Every finding on record at Nursing & Rehabilitation Center of Melbourne

Based on observation, interview, and record review, the facility failed to provide written notice, including the reason for the change, prior to changing residents' room for 4 of 4 residents reviewed for room changes, out of a total sample of 14 residents, (#1, #3, #5, and #6).Findings: 1.Review of resident #1's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 6/08/26. Her diagnoses included stage 4 pressure ulcer of the sacral region, chronic obstructive pulmonary disease, type 2 diabetes, difficulty walking, lack of coordination, and need for assistance with personal care. Review of the Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 7/31/26 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating she was cognitively intact. On 8/11/26 at 12:39 PM, resident #1 stated she had changed rooms multiple times and was waiting to be moved back to the East Wing. She explained when she returned from the hospital in June, she was placed in a different room. Resident #1 stated she did not receive written notification of the room change. Review of resident #1's medical record revealed she had resided in a room on the East Wing since 2/24/25. Following hospitalizations from 1/14/26 through 1/21/26 and from 5/11/26 through 5/20/26, she returned to the same room. Resident #1 was hospitalized again on 5/23/26 and, upon return to the facility on 6/08/26, was placed in a different room because her previous room was no longer available. On 6/23/26, resident #1 was transferred again to her current room in the [NAME] Wing. There was no documentation in the medical record identifying the reason for the 6/23/26 room change or evidence that written notification, including the reason for the change, was provided to the resident or resident representative prior to the move. Review of resident #1's medical record revealed a Social Services Progress Note dated 7/28/26 documenting a visit with the Social Services Director, Social Services Assistant (SSA), and the Unit Manager. The note documented the resident was requesting a room change to East wing. At this time there are no empty beds on the unit, we will see what we can do. 2. Review of resident #3's medical record revealed she was admitted to the facility on [DATE] with diagnoses including lack of coordination, Parkinson's disease, type 2 diabetes, and cerebrovascular disease. Review of the MDS quarterly assessment with an ARD of 6/05/26 revealed resident #3 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. On 8/11/26 at 10:35 AM, resident #3 stated while residing on another hallway, she was told a couple was moving in and wanted to be together and she was asked to move out. She indicated she did not want to move and was furious because she was already comfortable there. She stated she felt the couple was given priority over her and she was not given the option of remaining in the room. Review of resident #3's medical record revealed she changed rooms on 5/28/26. There was no Room/Roommate Change - Advance Notification form or written notification, that included the reason for the change, provided to the resident prior to the 5/28/26 move. Review of resident #3's medical record revealed a Social Services Progress Note dated 6/11/26 which documented the resident subsequently requested another room change because she could smell smoke from outside her window. The note documented, We discussed moving her she declined because we don't have a window bed at this time when one opens, we will move her. 3. Review of resident #5's medical record revealed she was admitted to the facility on [DATE] with diagnoses including osteomyelitis (bone infection), chronic obstructive pulmonary disease, gout, and neuromuscular dysfunction of the bladder. Review of the MDS quarterly assessment with an ARD of 5/06/26 revealed resident #5 had a BIMS score of 14 out of 15, indicating she was cognitively intact. On 8/11/26 at 12:17 PM, resident #5 stated she was verbally informed about her room changes and did not recall having received written notification. Review of resident #5's medical record revealed a Room/Roommate Change - Advance Notification form dated 2/17/26. The form documented the room change and notifications to the resident, representative, roommate and physician. The reason for the room change was documented as, Facility combining females in single rooms. The form was electronically signed by the Social Service Assistant (SSA). There was no evidence in the medical record that a copy of the written notification was provided to resident #5. Review of a second Room/Roommate Change - Advance Notification form dated 4/10/26 documented the room change and notifications to the resident, representative, roommate and physician. The reason for the room change was documented as, Resident transitioning to LTC [long-term care] room. The form was electronically signed by the SSA. There was no evidence in the medical record that a copy of the written notification was provided to resident #5. Review of resident #5's medical record revealed she changed rooms on 2/17/26, 4/10/26, and 6/17/26. There was no Room/Roommate Change - Advance Notification form in the medical record for the 6/17/26 room change. There was no evidence in the medical record that written notification was provided to resident #5. 4. Review of resident #6's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 1/17/26. Her diagnoses included non-pressure chronic ulcer of the right ankle, type 2 diabetes, chronic obstructive pulmonary disease, and chronic pain. Review of the MDS quarterly assessment with an ARD of 8/01/26 revealed resident #6 had a BIMS score of 13 out of 15, indicating she was cognitively intact. On 8/11/26 at 11:48 AM, resident #6 stated she had previously resided on other hallways. She explained the first move, from a private to a semi-private room, was requested by the facility. She further stated she requested another move because of roommate incompatibility and subsequently moved to the current room at the facility's request. Resident #6 stated she did not recall receiving paperwork regarding the room changes. Review of resident #6's medical record revealed a Room/Roommate Change - Advance Notification form dated 10/30/25. The form documented the room change and notifications to the resident, roommate and physician. The reason for the room change was documented as, Resident will be moving out of private room. The form was electronically signed by the SSA. There was no evidence in the medical record a copy of the written notification was provided to resident #6. Review of a second Room/Roommate Change - Advance Notification form dated 11/19/25 documented the room change occurred on 11/19/25 and the resident and roommate were notified on 11/18/25. The reason for the room change was documented as, Resident expressed desire to change rooms. The form was electronically signed by the SSA. There was no evidence in the medical record a copy of the written notification was provided to resident #6. Review of resident #6's medical record revealed she changed rooms on 10/30/25, 11/13/25, 11/18/25, and 12/02/25. There was no evidence of room change notification forms in the medical record for the room changes on 11/13/25 and 12/02/25. On 8/12/26 at 2:26 PM, the SSA stated the room change process could be initiated by the resident, family or facility. She indicated residents were verbally informed of room availability or changes and indicated there was a room change assessment that should be completed. The SSA recalled discussing the room change with resident #3 prior to the 5/28/26 move. She stated the resident initially did not want to move because her belongings were unpacked and arranged where she wanted them and recalled the resident was very upset about moving. The SSA confirmed there was no room change assessment, progress note, or other documentation regarding the initial discussion with resident #3's. She also confirmed there was no Room/Roommate Change - Advance Notification form for resident #3's actual room change on 5/28/26. The SSA reviewed resident #1's medical record and stated the resident's hospitalization extended beyond the bed hold period and, when she returned to the facility, her previous room was occupied. The SSA confirmed there was no room change form or documentation regarding resident #1's room change on 6/23/26. The SSA stated room change forms were completed on 2/17/26 and 4/10/26 for resident #5, but confirmed no copies were provided to the resident. She also acknowledged there was no form or written notification provided to resident #5 for the 6/17/26 room change. The SSA stated the room change forms were not signed by the residents or representatives and the residents did not receive copies of the forms. On 8/12/26 at 6:20 PM, the Administrator (NHA) stated room changes were discussed during morning and stand-down meetings, and staff communicated room changes with affected residents and their families. The NHA stated she was not aware of the written notification requirement or the lack of documentation for some of the room changes that occurred. Review of the facility's policy titled Change of Room or Roommate, revised 5/01/26, revealed an intent to conduct room and/or roommate changes when considered necessary by the facility or requested by the resident or resident representative. The policy documented, Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advanced notice of such a change as possible. The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understand and will include the reason(s) why the move or change is required.

Based on observation, interview, and record review, the facility failed to follow its grievance process related to a resident's room change request and concerns regarding call light response voiced during Resident Council meetings, for 2 out of 10 residents reviewed for grievances, (#1 and #4), and the Resident Council, out of a total sample of 14 residents. Findings: 1.Review of resident #1's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 6/08/26. Her diagnoses included stage 4 pressure ulcer of sacral region, chronic obstructive pulmonary disease, type 2 diabetes, difficulty walking, lack of coordination, and need for assistance with personal care. Review of the Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 7/31/26 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating she was cognitively intact. On 8/11/26 at 12:39 PM, resident #1 stated she had changed rooms multiple times and had been waiting to return to the East Wing. She became tearful while discussing her current room and stated she did not like the view from the window, could not see other residents or benches from the room, and did not feel good there. Resident #1 said, I pray to the Lord every single day to heal my body so I can get out of here, and became tearful again. Review of resident #1's medical record revealed a physician Progress Note dated 6/10/26 which documented, The patient reports she is upset that she is in a different room than when she was a resident prior, but otherwise feels well. Review of resident #1's medical record revealed a Psychiatry Progress Note dated 7/08/26 which documented, She says she is doing a little better but expresses wanting to move back to the other unit where her previous room was. She says she is coping well but is anxious to move. Review of resident #1's medical record revealed a Social Services Progress Note dated 7/28/26 which documented a visit with the Social Services Director (SSD), the Social Services Assistant (SSA) and the Unit Manager (UM). The note documented the resident was requesting a room change to East wing. At this time there are no empty beds on the unit, we will see what we can do. Review of resident #1's medical record revealed a Psychiatry Subsequent Note dated 8/05/26 which documented, When asked how she has been doing she states, 'not so good.' She endorses feeling more depressed and down. She has been wanting to move back to the unit she was on prior to going to the hospital. She states that her physical condition also makes her feel depressed. Review of the facility's Grievance Log for June, July, and August 2026 revealed no grievance documented for resident #1 related to her room change request. On 8/12/26 at 2:26 PM, the SSA confirmed the 7/28/26 Social Services Progress Note documented resident #1's request to return to the East Wing. She stated the SSD, SSA, and [NAME] Wing UM were working on the request and had spoken with the resident on 7/28/26. The SSA further stated resident #1 reported that her roommate's family tended to encroach upon her space. The SSA confirmed a grievance form was not completed and acknowledged one should have been initiated because the room and roommate situation was a concern for resident #1 as she was unhappy with her current room and roommate. The SSA stated the grievance would have remained open until the room change occurred. 2. Review of resident #4's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including major depressive disorder, bacterial infection, malignant neoplasm of the skin, and nicotine dependence. Review of the MDS annual assessment with an ARD of 6/30/26 revealed resident #4 had a BIMS score of 13 out of 15, indicating she was cognitively intact. On 8/11/26 at 10:46 AM, resident #4 stated call light response could take hours, particularly at nights and on weekends when management was not present. She indicated she had raised concerns regarding call light response during Resident Council meetings and had observed call lights remain unanswered for extended periods, sometimes for one to two hours. Resident #4 stated her roommate was bedbound and she sometimes had to locate staff to assist her roommate when the call bell went unanswered. Review of the facility's Grievance Log for May, June, July, and August 2026 revealed no grievance documented for resident #4 related to call light response concerns. 3. Review of Resident Council Minutes for June, July and August 2026 revealed repeated concerns regarding call light response. Review of Resident Council documentation for 6/11/26 revealed the Resident Council meeting was attended by 14 residents, including resident #4, and facility staff. The minutes documented residents reported Certified Nursing Assistant (CNAs) and nurses continued to use cellphones while providing care, particularly at night and CNAs were often sitting, using cellphones, and ignored call lights. A [NAME] Wing resident also reported being left on toilet for excessive amount of time. The minutes documented the [NAME] Wing UM was present and spoke to the resident's concern. Review of Resident Council documentation for 7/09/26 revealed the Resident Council meeting was attended by 13 residents, including resident #4, and facility staff. The minutes documented [NAME] Wing residents reported call light response time varied. An East Wing resident reported a call light used to request water was not answered at night and expressed concern that staff may be ignoring the call light because the resident's roommate frequently activated it. A grievance form related to linen availability was attached to the Resident Council documentation; however, that grievance was not included on the July Grievance Log. Review of Resident Council documentation for 8/06/26 revealed the Resident Council meeting was attended by 16 residents, including resident #4, and facility staff. Under Call Light Response Time, the minutes documented East Wing residents reported improvement, while [NAME] Wing residents reported response time continued to be a concern. On 8/11/26 at 3:22 PM, Certified Nursing Assistant (CNA) B stated not everybody answered call lights. CNA B explained when CNAs provided showers or resident care, they had no way of knowing a call light was activated. CNA B stated when residents told her they waited a long time for assistance, she apologized and told them, I am here to help now. She further stated she did not report those concerns to anyone else because other staff were on the floor and could see the call lights were not being answered. On 8/12/26 at 12:29 PM, the Activities Director stated the Activities Department assisted with Resident Council meetings, including taking meeting notes. She indicated when residents expressed concerns during Resident Council meetings, the grievance process was followed. On 8/12/26 at 4:10 PM, the SSA stated grievances identified during Resident Council meetings should be entered into the facility's Grievance Log, whether they involved a group or an individual resident. The SSA stated she did not know if staff were required to document concerns voiced during Resident Council meetings on grievance forms and forward them to the SSD. On 8/12/26 at 4:53 PM, the Activities Assistant stated he participated in monthly Resident Council meetings and took the minutes. He recalled a previous grievance regarding call light response time but stated it had been closed. He explained the residents decided as a group which topics would be opened as grievances and residents were reminded about the grievance process. He stated Resident Council meeting notes were shared by the Activities Director during management meetings. On 8/12/26 at 5:12 PM, the [NAME] Wing UM stated she attended Resident Council meetings and was aware of concerns regarding call light response. The UM stated the response had improved but always needs work. She stated she did not conduct formal call light audits but observed whether call lights were answered timely. The UM said, Call light response is a problem throughout the facility. She explained that if a resident complained about a specific situation, she filed a grievance; however, if residents voiced a general concern without specifics details, she educated staff and increased rounding. Regarding resident #1, the UM stated she was aware of the resident's request to change rooms and frequently checked on her. She stated resident #1 did not express any big complaints and did not appear extremely upset but was obviously still requesting the room change. On 8/12/26 at 6:20 PM, the Administrator (NHA) stated grievances were discussed during morning and stand down meetings. She indicated Resident Council minutes were discussed with the management team during stand-down or morning meetings and that call light audits had been conducted on different shifts. The NHA acknowledged the facility could do a better job capturing the concerns regarding call light response and ensuring they were followed through. Review of the facility's policy titled Resident and Family Grievances, revised 3/01/25, revealed the Grievance Official was responsible for overseeing the grievance process; receiving and tracking grievances through their conclusion; leading any necessary investigations; maintaining the confidentially of information associated with grievances; issuing written grievance decisions to residents; and coordinating with state and federal agencies related to specific allegations. The policy documented grievances could include verbal or written complaints made to a staff member or the Grievance Official and verbal complaints made during Resident or Family Council meetings. The policy further documented the staff member receiving a grievance would record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member in completing the form. The policy documented, The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. Review of the facility's policy titled Resident Council Meetings, revised 3/01/26, revealed the facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decision to the Council.

Based on observation, interview, and record review, the facility failed to ensure medications were secured and inaccessible to unauthorized persons for 1 of 2 medication carts observed on the East Wing. Findings: On 8/12/26 at approximately 11:30 AM, during an interview with Licensed Practical Nurse (LPN) A, the surveyor and LPN exited a resident's room and stopped beside her medication cart. As LPN A moved a binder from the top of the cart, a medication cup containing two capsules along with a bag of intravenous (IV) antibiotic medication were observed unsecured on top of the medication cart. LPN A immediately removed the medication cup and stated the two capsules were Amoxicillin she had obtained earlier from the automated dispensing machine for resident #9. LPN A confirmed the Amoxicillin had been left unsecured on top of the medication cart while she went into the resident's room. She explained resident #9 had been in her room earlier, and LPN A told the resident she would obtain the Amoxicillin and return to administer it; however, the resident left the unit to smoke. LPN A identified the bag of IV Cefepime lying on top of the medication cart as belonging to resident #6. She stated resident #6 had also left the unit to smoke. LPN A acknowledged medications were not supposed to be left unsecured outside the medication cart because another resident could access them and stated she had become distracted. Review of the automated dispensing machine report titled Transactions by Employee, C15, dated 8/12/26 and generated at 11:26 AM, revealed LPN A removed two capsules of Amoxicillin 250 milligrams for resident #9 at 8:45 AM. On 8/12/26 at 12:36 PM, the East Wing Unit Manager (UM) stated LPN A informed her she had left medications outside the medication cart. The UM indicated this was not acceptable and explained if the resident was unavailable, the nurse should discard the medications and retrieve them again when the resident was available. The UM stated she educated LPN A regarding the correct process and stated LPN A knew she should not do that. On 8/12/26 at 1:00 PM, the Director of Nursing (DON) stated nurses should not retrieve medications unless they were going to administer them immediately. The DON stated he was unaware LPN A had left medications outside the medication cart and confirmed medications were not to be left unlocked. Review of the facility's policy titled Medication Storage, revised 3/01/25, revealed all drugs were to be stored in locked compartments and only authorized personnel would have access to the keys to the locked compartments. The policy documented during a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to ensure medical records accurately reflected medication administration for 2 of 2 residents reviewed for medication documentation, out of a total sample of 14 residents, (#6 and #9).Findings: 1. Review of resident #6's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 1/17/26. Her diagnoses included non-pressure chronic ulcer of the right ankle, pain in right ankle and joints of right foot, type 2 diabetes, chronic obstructive pulmonary disease, and chronic pain. Review of the Minimum Data Set (MDS) quarterly assessment with an ARD of 8/01/26 revealed resident #6 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating she was cognitively intact. The MDS assessment documented resident #6 received an antibiotic during the last seven days, had intravenous (IV) access and received IV medication. Review of resident #6's physician orders revealed an order dated 7/09/26 for Cefepime IV Solution 2 gram (gm)/100 milliliters (ml) twice a day for 42 days for a right ankle/foot wound infection. On 8/12/26 at approximately 11:30 AM, a bag of Cefepime was observed lying on top of Licensed Practical Nurse (LPN) A's medication cart. LPN A identified the Cefepime as belonging to resident #6 and stated it was due at 8:30 AM but it had not yet been administered because the resident had left the unit to smoke. Review of resident #6's Medication Administration Audit Report dated 8/12/26 revealed Cefepime IV 2 gm/100 ml was documented as administered at 8:50 AM by LPN A. The documentation was entered at 10:52 AM on 8/12/26. Review of resident #6's Progress Notes entered by LPN A on 8/12/26 at 1:52 PM documented, Approximately 0840 AM writer attempted to give the med (medication) to the patient in the room, patient went to smoke prior writer administered the med, MD (physician) notified. On 8/12/26 at 3:50 PM, LPN A stated she did not have the IV medication with her when she entered resident #6's room to administer the resident's morning medications because the IV medication was in the medication room. She stated she administered the resident's oral medications and told resident #6 she would return to administer the IV medication. LPN A further stated she documented the IV medication as administered with the oral medications; however, when she returned with the IV medication, resident #6 was no longer in her room. LPN A acknowledged she had documented the Cefepime as administered before actually administering it and stated she was supposed to document medications at the time they were actually administered. 2. Review of resident #9's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, schizophrenia, generalized anxiety disorder, nicotine dependence, and chronic pain. Review of the quarterly MDS assessment with an ARD of 7/25/26 revealed resident #9 had a BIMS score of 13 out of 15, indicating she was cognitively intact. Review of resident #9's physician orders revealed an order for Amoxicillin 500 milligrams (mg) 1 tablet, twice daily for seven days, for tooth infection. On 8/12/26 at approximately 11:30 AM, a medication cup containing two capsules was observed on top of LPN A's medication cart. LPN A identified the capsules as Amoxicillin for resident #9 and stated she had obtained them earlier from the automated dispensing machine. LPN A further stated resident #9 had left the unit to smoke before she could administer the medication. Review of the automated dispensing machine report titled Transactions by Employee, C15, dated 8/12/26 and generated at 11:26 AM, revealed LPN A removed two Amoxicillin 250 mg capsules for resident #9 at 8:45 AM. Review of resident #9's Medication Administration Audit Report dated 8/12/26 revealed Amoxicillin 500 mg was documented by LPN A as administered at 8:47 AM. The documentation was entered at 8:49 AM that day. Review of resident #9's Progress Notes entered by LPN A on 8/12/26 at 1:38 PM, documented the newly prescribed antibiotic was not available and resident #9 was informed the medication needed to be obtained from the automated dispensing machine. The note documented when LPN A returned to the resident's room, the resident was no longer there and the physician was notified. An earlier entry at 8:47 AM, documented, Amoxicillin Oral Tablet 500 MG give 1 tablet by mouth two times a day for Tooth Infection for 7 Days pull from [name of automated dispensing machine]. On 8/12/26 at 3:33 PM, LPN A confirmed she had documented Amoxicillin as administered with resident #9's other morning medications although Amoxicillin had not been administered. She explained the medication had not yet been delivered by the pharmacy, and she had to obtain it from the automated dispensing machine. She indicated when she returned with the medication, resident #9 was no longer in her room. LPN A acknowledged it was her mistake to document the medication before actually obtaining it and administering it. She confirmed that documenting the medications for residents #6 and #9 as administered when they had not been administered was not accurate documentation. On 8/12/26 at 1:00 PM, the Director of Nursing stated medications were to be documented at the time they were administered. Review of the facility's policy titled Medication Administration, revised 5/02/25, revealed medications were to be administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. The policy documented nurses were to ensure the six rights of medication administration were followed, including the right time, and right documentation. The policy further instructed nurses to sign the Medication Administration Record after administration. Review of the facility's policy titled Maintenance of Clinical Records, revised 3/01/25, revealed the facility would maintain clinical records for each resident in accordance with acceptable standards of practice that reflected the current plan of care and the services provided. The policy documented medical records were to be complete and accurately documented.

Based on interview, and record review, the facility failed to ensure proper indwelling urinary catheter care and monitoring was provided to 1 of 3 residents reviewed for catheter, of a total sample of 5 residents, (#2).Findings:Review of the medical record revealed resident #2, an [AGE] year-old female was admitted to the facility from an acute care hospital on 2/02/26 with diagnoses that included anemia, elevated white blood cell count, and complicated urinary tract infection (UTI). The resident discharged home on 2/10/26. The most recent Five-day Minimum Data Set Assessment with an Assessment Reference Date of 2/09/26 noted resident #2 scored 10 out of 15 on the Brief Interview for Mental Status indicating moderate cognitive impairment. The assessment revealed there were no rejections of evaluation or care, the resident was dependent on staff to complete Activities of Daily Living (ADLs), there was an indwelling urinary catheter present, and she received high-risk anticoagulant, diuretic, opioid, and intravenous (IV) antibiotic medications during the look-back period. The Order Summary Report showed physician's orders for continued IV antibiotic medications of (2/03/26) Ceftriaxone 1 Gram once daily for UTI for 10 days, Cubicin 500 Milligrams every 24 hours for UTI for 7 days, and (2/05/26) Urinalysis/Culture and Sensitivity (UTI test). There were no orders or directions to monitor or care for an indwelling urinary (foley) catheter. A foley or indwelling urinary catheter is a thin, flexible tube inserted into the bladder to drain urine, and held in place by an inflatable balloon. The catheter tube connects to a collection bag to collect urine. Risks for foley catheter use are UTIs, bladder spasms, urethral damage, urine leakage and bleeding, (retrieved on 3/27/26 from www.clevelandclinc.org). An admission Note completed by Registered Nurse (RN) B on 2/02/26 noted that resident #2 had a foley catheter. The Care Plan Report did not include the presence, care, or monitoring of an indwelling urinary catheter, a UTI, or IV antibiotics. The nurses Admission/readmission Data Collection assessment completed by RN B on 2/02/26 was marked negative for the presence of an indwelling urinary catheter. On 3/16/26 at 3:40 PM, RN A explained nurses entered batch orders on admission when indwelling urinary catheters were present. The nurse stated, we need to watch for problems; it's noted on the Treatment Administration Record (TAR) to alert us for monitoring and to check. Review of resident #2's February 2026 TAR did not include any orders or directions for nurse care/monitoring of an indwelling urinary catheter. On 3/16/26 at 3:45 PM, RN B explained upon admission, nurses were expected to note indwelling urinary catheters in the records, notify the physician, and enter orders for nurses to monitor and provide care that is carried into the TAR from the orders. From that the nurses were alerted to check for signs of complications or infection to implement interventions or notify the physician. She checked resident #2's medical record and acknowledged she completed the admission and incorrectly documented there was no catheter in the assessment. Upon further review, the RN was unable to locate any orders for catheter care for resident #2. The nurse stated the catheter care orders should have been entered on admission and were missing. She said admission orders were re-checked by nurse managers the following day. On 3/16/26 at 2:25 PM, the Subacute Unit Manager recalled resident #2 had an indwelling urinary catheter and stated, she had it the whole time she was here. Later at 4:05 PM, the nurse manager explained she expected nurses to enter catheter orders upon admission to transcribe to the TAR for prompts so they could monitor it every shift. She explained this was important to avoid serious complications with the catheter. The Unit Manager said during daily clinical meetings, nurse managers re-checked admission orders for accuracy. She checked her handwritten meeting notes and found resident #2's catheter was discussed on 2/03/26. She checked resident #2's medical record and was unable to locate any orders or directions for nurses to monitor or care for the catheter and stated, we missed the orders. On 3/17/26 at 3:32 PM, the Director of Nursing (DON) explained he expected nurses to enter orders to monitor a catheter and document provided care on the TAR. The RN said he was not aware resident #2 had a catheter when she was admitted to the facility. He checked the medical record and found nurses' notes confirming the catheter and stated, I guess we missed that. Review of the facility's standards and guidelines titled Catheter Care and dated 3/01/25 noted the policy was intended to ensure that residents with indwelling catheters received appropriate catheter care every shift, and as needed.

Based on observation, interview, and record review, the facility failed to maintain a complete antibiotic stewardship program for 3 of 4 residents reviewed (#117, #81, and #21) of a total sample of 55 residents and failed to ensure linens and laundry were handled, stored, processed, and transported safely to prevent the spread of infection to the extent possible in accordance with accepted national standards of practice.1. Resident #117 was admitted to the facility on [DATE] from the hospital with diagnoses including chronic pressure ulcer of right ankle with necrosis of muscle, osteomyelitis, peripheral vascular disease, and type 2 diabetes. Review of an Infectious Disease Consult dated 10/28/25 revealed the resident was admitted to the facility with medication orders for Cefepime HCl intravenous 2 grams per 100 milliliters (ml) two times and Daptomycin-sodium chloride intravenous 700-0.9 milligrams per 100 ml once a day following a right lower extremity wound culture which tested positive for Methicillin-Resistant Staphylococcus Aureus (MRSA) and Pseudomonas. Methicillin-resistant Staphylococcus aureus or MRSA is a type of bacteria that's developed defense mechanisms or resistance to antibiotics. MRSA infections are hard to treat because very few antibiotics are effective against them (retrieved on 12/4/25 from https://my.clevelandclinic.org/health/diseases/11633-methicillin-resistant-staphylococcus-aureus-mrsa) Review of the resident's electronic medication administration record (EMAR) for Cefepime HCl for October and November 2025 revealed: On 10/28/25 at 10:00 PM, the MAR was noted to be 'blank' and no documentation of the medication being administered. On 10/29/25 at 6:00 AM, the MAR was noted to be coded '4' with a progress note reading 'not on hand' On 11/3/25 at 2:00 PM, the MAR was noted to be coded '4' with a progress note reading 'on order' On 11/5/25 at 2:00 PM, the MAR was noted to be coded '4' with a progress note reading 'not on hand. Pharmacy called. Will be in next batch delivery' 2. Resident #81 was admitted to the facility on [DATE] from the hospital with diagnoses including pneumonia, hemiplegia affecting left non-dominant side, cerebral infarction due to thrombosis, atrial fibrillation, sick sinus syndrome and cardiac pacemaker. Review of an Infectious Disease Consult dated 11/5/2025 revealed the resident was admitted to the facility with a large wound to his left gluteus with heavy drainage with concerns for an underlying abscess. A wound culture was ordered and intravenous antibiotics of Cefepime 2 grams per 100 ml two times a day for 7 days and Vancomycin 1 gram (gm) two times a day for 7 days to start after culture is obtained. Review of the resident's electronic medication administration record (EMAR) for Vancomycin 1 gram for November 2025 revealed: On 11/09/25 at 6:00 AM, the MAR was noted to be 'blank' and no documentation of the medication being administered. 3. Resident #21 was admitted to the facility on [DATE] from the hospital with diagnoses including lack of coordination, immunodeficiency, type 2 diabetes, chronic kidney disease stage 3B, and severe protein-calorie malnutrition. Review of the resident's EMAR for Amoxicillin 500 mg three times a day for a bacterial infection for 7 days revealed: On 11/17/25 in the morning, the MAR was noted to a code '5' and documentation of out of facility. On 11/17/25 in the afternoon, the MAR was noted to a code '5' and documentation of out of facility. On 11/18/25 in the morning, the MAR was noted to a code '4' and documentation of out of facility. On 11/19/25 in the morning, the MAR was noted to a code '5' and documentation of out of facility. On 11/19/25 in the afternoon, the MAR was noted to a code '5' and documentation of out of facility. On 11/20/25 at 10:08 AM, interview with the Infection Preventionist (IP) confirmed that one aspect of her job was to track and monitor antibiotic use throughout the building. The IP stated she did not realize the residents did not receive a full course of their antibiotics and had missed doses. She stated that she had oversight from the Director of Nursing (DON) and he never made her aware of the missed medications. On 11/20/25 at 10:21 AM, interview with the DON revealed they did not review missed medications during their daily morning meetings. His expectation was for the IP to track and monitor all the antibiotics in the building which included making sure the residents received full course of the antibiotics. He explained his expectation for when a resident's medication was unavailable was for the nurses to first check for the medication in the emergency medication supply and then notify the physician if the medication was still unavailable. He acknowledged that resident #21, #81 and #117 had missed doses of antibiotics and there was no documentation on those dates that the physician was notified. The facility's Infection control prevention and control policy revised 2/1/25 noted antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. The infection preventionist with oversight from the DON serves as the leader of the antibiotic stewardship program. 2. On 11/20/25 at 2:31 PM, a laundry room tour was conducted with Laundry Aide O. It was observed that the laundry room had two doors. There was an open door where laundry staff was observed folding clean laundry and a closed door directly to the right that was unlabeled and had laundry bins blocking the entrance. Laundry Aide O identified the closed door as the dirty room. Upon entering the room, two carts with linen and gowns were noted. Laundry aide O was unable to provide an explanation as to why these carts with clean linen and gowns were stored in the dirty area. The Laundry Aide stated that this was the way they always did it. The room had no space for staff to sort dirty laundry or linen and some of the laundry aprons that were hanging in the room were in disrepair. Laundry aide O agreed that clean and dirty laundry should remain separate from each other to prevent cross contamination. On 11/20/25 at 2:35 PM, the Housekeeping Assistant said the Housekeeping Director was on leave. She did not know dirty laundry had to be processed in a separate dirty room. She said the dirty room was used to store clean linen carts because they were lacking storage. She believed that because the linens were in bags, they were fine being kept in the dirty area. On 11/20/25 at 2:40 PM, the Maintenance Director said he was previously in charge of running the laundry department and had mentioned to staff they could not keep the clean linens in the dirty room because it was an infection control issue. On 11/20/25 at 4:28 PM, the Infection Preventionist (IP) said she was not aware laundry staff stored clean linens in the dirty laundry area. She acknowledged she did not do frequent observations of the laundry room to ensure staff were following infection control practices and said laundry staff were included in infection control education.

Based on observation and interview, the facility failed to ensure residents received meals at an appetizing temperature.Findings:On 11/18/25 at 9:35 AM, resident #9 said his food was always cold. He said he complained multiple times in the past, but things never changed. The resident stated, I just eat it.On 11/17/25 at 4:47 PM, resident #160 said her food was cold every day. She said she complained about it and the Kitchen Manager knew. The resident stated, this place doesn't want to get the warm plates; I eat what I can.On 11/20/25 at 11:42 AM, one of two carts (insulated) for the 500-unit resident lunch meal was delivered. At 11:44 AM, the second cart (not insulated) was delivered to the unit.On 11/20/25 at 12:10 PM, the last lunch meal tray was delivered to room [ROOM NUMBER]. At 12:11 PM, a sample tray with the lunch meal of fried chicken, rice, pinto beans, and corn bread was tested by two surveyors. The food was lukewarm and not at a palatable temperature, which was consistent with multiple resident complaints during the survey.On 11/20/25 at 12:05 PM, the Certified Dietary Manager said she was aware of resident complaints about cold food. She said the kitchen needed more insulated carts to help preserve warm food temperatures however they only received one and were required to use non-insulated carts to accommodate all the unit's meal trays.Review of the facility's standards and guidelines titled Administration of Facility dated 3/1/22 noted the facility provided systems to ensure it was administered in a manner that focused on attaining and maintaining the highest practicable physical, mental, and psychosocial well-being of each resident.

Based on observation and interview, the facility's Administration failed to provide resources and equipment to ensure meals were delivered at palatable temperatures. Findings:On 11/20/25 at 10:55 AM, the Certified Dietary Manager (CDM) said the kitchen utilized heat lamps on the steam table to assist with retaining warm food temperatures. She said the plates did not have metal inserts for heat retention. She said she was aware of ongoing resident complaints about cold food and had requested nine insulated carts to accommodate all three units but received only one new insulated cart. She said non-insulated carts that did not retain heat had to be used to manage all the trays for unit delivery.On 11/20/25 at 11:42 AM, one of two carts (insulated) for the 500 unit resident lunch meal was delivered. At 11:44 AM, the second cart (not insulated) was delivered to the unit. At 11:44 AM, Certified Nursing Assistant (CNA) A was observed distributing meal trays to resident rooms. On 11/20/25 at 11:52 AM CNA B said there was normally not enough help on the unit to deliver meal trays to residents. She said she was unable to remain on the unit to deliver resident lunch meals because she was assigned to go to the dining room to assist and she left to report to the dining room.On 11/20/25 at 11:59 AM, CNA A said the normal daily practice at lunchtime on the unit was that 1 CNA was responsible for delivering resident meal trays and assisting residents to eat.Unit 500 included 13 resident rooms with 26 total residents.On 11/20/25 3:09 PM, the Activities Assistant recalled over the past few months she received several complaints and grievances from residents about consistently cold food. She said that in approximately September 2025, a Food Committee was developed by the Activities Director because there were so many complaints.On 11/20/25 at 3:16 PM, the Activities Director recalled she initiated a Food Committee that met once monthly. She explained the residents complained that CNAs took too long to distribute trays once they were delivered from the kitchen. She said she received positive feedback from the residents who were on the rotation with the one new insulated cart who reported their food was hot. She said her point of contact was the CDM who told her new carts had been requested but only one was sent. She stated, It's been an ongoing issue with cold food. She noted that they had complaints about food temperatures not being warm every month during the Resident Council meetings; it was so time consuming; we started a Food Committee in June 2025.On 11/20/25 at 3:40 PM, the Nursing Home Administrator said the facility needed nine insulated carts. She explained they were trying to purchase two per month and had to work with the Regional Dietary person to get more and stated, that didn't happen. The NHA said they needed to work with Regional to obtain more carts.Review of the Facility assessment dated [DATE] noted the facility's kitchen appliances were all in good condition and have been replaced as needed. The Physical Equipment information outlined that each departmental manager or designee was responsible for assessing the condition of all equipment and determining what equipment was needed. The assessment read, . when equipment is needed, whether new or replacements, each department head follows procedures for obtaining purchase orders or capital expenditure authorizations for obtaining the needed equipment.

Based on interview and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Review of the facility's survey history revealed repeat deficiencies related to accuracy of assessments, quality of care and infection control during the current survey ending on 11/02/23. Past deficiencies revealed systemic concerns with similar findings on the previous recertification survey dated 11/2/23.On 11/20/25 at 6:15 PM, the Nursing Home Administrator (NHA) indicated repeat deficiencies regarding infection control, and quality of care were different from the issues from the previous survey. Their current Performance Improvement Plan (PIP) initiated from February 2025 and still ongoing included hand hygiene; glucometer disinfection; blood pressure monitoring/parameters/orders; point of care documentation; oxygen discontinuation and order accuracy. The NHA explained that they meet monthly and they would create PIPs from grievances, mock survey results and issues identified by department heads during round table discussions. She continued to explain she was not aware of the issues found during this survey, as being a current issue, but will begin facility wide all residents for trauma informed assessments. The Facility's policy on QAPI Monitoring revised 8/1/24 state It is the policy of the facility to systematically monitor performance indicators as part of the QAPI program.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected Pre-admission Screening and Resident Review (PASARR) results for 1 of 6 residents reviewed for PASARR of a total sample of 55 residents, (#94).Findings: Review of resident #94's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included mood disorder, schizoaffective disorder, bipolar type, anxiety, major depressive disorder, and intellectual disabilities.Review of resident #94's MDS Annual assessment with Assessment Reference Date (ARD) of 10/05/24 revealed question A1500 on Section A read, Is the resident currently considered by the state level II PASRR process to have serious mental illness (SMI) and/or intellectual disability (ID) or a related condition? The answered selected was NO.Review of resident #94's MDS Annual assessment with ARD of 10/06/25 revealed question A1500 on Section A was also answered NO.Review of resident #94's medical record revealed a Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report dated 4/19/23. The Outcome/Disposition section showed resident #94 met the state definition of SMI and ID and was appropriate for a Nursing Facility. The form showed Socialized Services were not deemed necessary, but it was recommended rehabilitative services of a lesser intensity were added to the comprehensive person-center nursing care plan.On 11/20/2025 at 1:12 PM, the MDS Lead stated she was responsible for the creation, updates and timely submission of resident assessments. She explained accuracy of assessment was important to create an appropriate care plan. She indicated the care plan was used by the interdisciplinary team to provide holistic care to the resident. The MDS Lead validated both of resident #94's MDS annual assessments dated 10/05/24 and 10/06/25 were answered incorrectly, and question A1500 should had been answered Yes, which would have prompted a response to questions A1510 and A1550 related to SMI and ID conditions.Review of the facility's policy titled MDS 3.0 Completion revised on 1/01/24 revealed an intent to assess residents using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan. The guidelines included conducting initial and periodic standardized assessments of each resident's functional capacity comprehensively and accurately.

Based on interview and record review, the facility failed to notify the State mental and intellectual disability authority after a significant change in the resident's mental condition for 1 of 6 residents reviewed for Pre-admission Screening and Resident Review (PASARR) of a total sample of 55 residents, (#94).Findings:Review of resident #94's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included mood disorder, schizoaffective disorder, bipolar type, anxiety, major depressive disorder, and intellectual disabilities.Review of resident #94's medical record revealed a Florida PASARR Level II Determination Summary Report dated 4/19/23. The Outcome/Disposition section showed resident #94 met the state definition of Serious Mental Illness (SMI) and Intellectual Disabilities (ID) and was appropriate for a nursing facility. The form showed Socialized Services were not deemed necessary, but it recommended rehabilitative services of lesser intensity be added to the comprehensive person-center nursing care plan. The form included, Should there be a significant change in his mental status, it is recommended that an additional Level II review be conducted.Review of resident #94's medical record revealed a SBAR (Situation, Background, Appearance, and Review) Communication Form dated 3/25/25 related to changes in behavioral symptoms. The form indicated a new order for a Haldol injection every 60 days for hallucinations/agitation.Review of resident #94's medical record revealed a SBAR Communication Form dated 4/07/25 related to disorganized thinking and hearing things. The Mental Status Evaluation section included increased confusion or disorientation, new or worsened delusions or hallucinations, and other symptoms or signs such as inability to pay attention. Review of a Certificate of Professional Initiating Involuntary Examination dated 4/07/25 revealed resident #94 became increasingly psychotic and paranoid over the past two weeks and was delusional and hallucinating, banging on other resident doors and making threats. The supporting evidence section included, Without higher level of care there is a significant concern pt (patient) may harm himself or others.Review of the Discharge Plan from the psychiatric facility dated 4/08/25 revealed treatment recommendations which read, Please follow all treatment recommendations . Please seek additional long term mental health programs and treatments as needed. Consider additional counseling to gain insight and develop healthy coping skills for ongoing stressors. Utilize the community resources listed below for additional treatment as needed.On 11/20/2025 at 1:12 PM, the Minimum Data Set (MDS) Lead stated her responsibilities included resident assessments and care plan meetings. She shared she attended daily clinical meetings which included discussions of changes in residents' conditions, discharges, admissions and readmissions. She explained the Social Services Director (SSD) was responsible for reviewing the PASARRs but she assisted this week because the SSD was out. She described how to complete a Level I PASARR and indicated some residents required a Level II. She stated this week she noticed resident #94 had a Level II in his medical record and she updated his care plan to reflect this information. She indicated she was not the MDS Lead back in April when resident #94 was [NAME] Acted. She recalled he exhibited auditory hallucinations, kept on banging on other resident doors, thought a female resident was his girlfriend, and refused medications. She stated he was evaluated by the psychiatrist, who determined he needed a higher level of care and was transferred to a psychiatric hospital for evaluation. He returned the next day and there were changes to his medications. She indicated she was not involved in the PASARR review process at that time and could not explain why the state mental authority was not informed of his change in mental status.On 11/20/2025 at 3:52 PM, the Director of Nursing (DON) stated the SSD was responsible for reviewing the PASARRs. He stated the PASARRs were reviewed for every admission during clinical meetings and if incorrect, re-processed. He recalled back in April resident #94 was more aggressive, followed by psychiatry and changes of medications were made. He stated since there were no changes to resident #94's diagnoses as identified in the PASARR, there would not have been a need to re-do the PASARR. The DON confirmed a new PASARR was not completed at that time.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 out of 1 resident of a total sample of 55 (#164).Resident #164 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, nicotine dependence, cigarettes, uncomplicated dependence on supplemental oxygen and chronic pain syndrome. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed resident #164 was cognitively intact with a brief interview of mental status score (BIMS) of 15 out of 15.Review of the smoking assessment listed resident #164 as a safe smoker on 4/15/24 it also included the verbiage smoking is always supervised; the smoking attendant holds cigarettes and lighter.A review of the social services notes on 11/5/25 at 4:00PM stated It has been reported that a strong cigarette odor has been coming from resident #164's bathroom. She has previously been caught smoking inside the facility, causing her smoking privileges to be revoked. Smoking policy reviewed, including no smoking within the facility. Resident verbalized understanding and stated she would not be smoking within the facility.On 11/17/25 at 5:30 PM, she was observed in the facility's parking lot smoking, and she had an oxygen concentrator attached to her wheelchair.On 11/19 at 3:06 PM, the receptionist was asked if she was aware of resident #164 smoking in the parking lot while having her oxygen tank at the back of her wheelchair and stated, we talk to her, but she don't listen . administration is aware. On 11/19/25 at 3:31 PM, both the nursing home administrator (NHA) and the Director of Nursing (DON) said that resident #164 had the right to leave the premises and if she chose to abandon all rules they could not stop her from leaving the premises. They said that there was no supervision provided after the front door and whenever a resident signs out on leave of absence (LOA) the intent is that they leave the property. They explained resident #164 lost her smoking privileges on 11/5/25 but had orders for LOA and residents on LOA have no restrictions. They added, the doctor determined that resident #164 had a BIMS of 15 without restrictions, she was her own responsible party and they would not revoke her LOA. On 11/19/25 at 4:24 PM, CNA G, the smoking attendant in the smoking patio said that resident #164 does not come out here to smoke, instead she goes in front and the facility was not holding any supplies except a vape. CNA G said, when resident #164 would come here, she would leave her wheelchair and oxygen and walk outside to smoke, they have to leave the oxygen tank inside. A review of resident #164's Plan of Care initiated 5/1/24 revealed that she was a smoker and required supervision while smoking however, nowhere did the care plan address her non compliance with facility's rules for smoking nor did it address her behaviors of smoking in her room, smoking with oxygen nearby nor smoking in the parking lot while having the oxygen tank on her wheelchair. On 11/20/25 at 9:40 AM, the MDS coordinator said she updated Care plans quarterly and as needed. For resident #164, she explained she was not aware of her smoking with the oxygen in parking until yesterday nor was she aware that her smoking privilege was revoked for smoking in her room . if she knew, she said that she would have updated the care plan.On 11/20/25 at 11:11AM the DON said that he did not oversee care plans and it was the responsibility of the MDS coordinator and would have expected the care plan to be updated. On 11/20/25 at 2:20 PM, the NHA said she was not aware that resident #164's care plan did not reflect noncompliance with smoking policy and thought it should have been updated.The facility's policy on Comprehensive Care Plans revised 3/1/25, stated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview, and record review, the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders for 1 out of 2 residents, (#164), failed to ensure medications were administered and provided per physician orders to prevent missed doses in accordance with professional standards of practice for 1 of 1 residents, (#99), reviewed for quality of care, out of a total sample of 55 residents. Resident #99, a [AGE] year-old male, was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included acute transverse myelitis in demyelinating disease of central nervous system, generalized anxiety disorder, and major depression. Review of resident #99's admission Minimum Data Set assessment dated [DATE], revealed he had a Brief Interview of Mental Status score of 13 out of 15, which indicated intact cognitive function. He had no rejection of care behavior and received scheduled pain medications for occasional pain that affected his sleep and daily activities. He required partial to moderate assistance for Activities of Daily Living and utilized a wheelchair for mobility. On 11/17/25 at 12:28 PM, resident #99 said he was concerned about missing some doses of a new medication, Gabapentin, that had just been prescribed for pain on 11/14/25. He said the medication was prescribed to be given three times per day and he had last received it on 11/16/25 at around lunch time. He explained that on 11/15/25 he received his first three doses and then on 11/16/25, after his second dose, the nurse told him he had run out of the medication. He was not sure if the nurse had reordered the medication, but he said he never received his third dose that night. He said he received his morning medications, but the Gabapentin had not been included, and he knew what it looked like. According to WebMD, Gabapentin was commonly used to treat and prevent seizures in people with epilepsy, but it was also prescribed to treat nerve pain or neuralgia. (https://www.webmd.com/drugs/2/drug-14208-8217/gabapentin-oral/gabapentin-oral/details; retrieved 11/25/25). Resident #99's progress notes revealed he was seen by the Nurse Practitioner on 11/14/25 and she noted he had complained of difficulty ambulating and was compliant with his medications. She ordered Gabapentin to be started on that day for nerve pain. A nursing note entered on 11/16/25 at 4:42 PM, by Registered Nurse (RN) L noted Gabapentin was on order from the pharmacy. Review of resident #99's medication orders, revealed an order dated 11/15/25 for Gabapentin 100 milligram (mg) tablets three times per day for pain related to myelitis. Further review of the Medication Administration Record for November 2025 revealed the following: on 11/15/25 he received three doses of Gabapentin, 11/16/25 he received two doses, but the third dose was documented as refused, and 11/17/25 the nurse documented he had received the morning dose. On 11/17/25 at 11:54 AM, the resident's assigned nurse, Registered Nurse (RN) M said resident #99 had received his morning dose of Gabapentin but would not be receiving the second dose because he had run out of it. She stated that the blister pack only had one pill left but was unable to show me the empty pack because she had discarded it already. She noted that he would miss his second dose of the medication because she was unsure when the pharmacy would deliver the medication. She was asked if the facility had a medication dispensing system (Pyxis) where they kept extra medication and she said they did but it mostly had narcotics. She confirmed she had not asked her supervisor or Director of Nursing (DON) if the medication was available in the Pyxis. At 1:27 PM she stated she was able to take the Gabapentin out of the Pyxis machine and administered it to resident #99. She said she was not aware that this medication was kept in the Pyxis. On 11/17/25 at 1:30 PM, resident #99 confirmed he received his second dose of the Gabapentin and reiterated that he absolutely did not receive his morning dose. On 11/19/25 at 12:47 PM, a phone interview with RN J revealed that he had been the nurse assigned to resident #99 on 11/15/25. He stated that he worked a double shift on 11/15/25 from 7:00 AM to 11:00 PM and had noticed there was a new prescription for Gabapentin three times per day for resident #99. He explained there was a full blister pack of the medication, which was usually 25 tablets and had administered all three doses to the resident during his shift. He said there was still medication left when he left that night. RN J stated that in the event a resident ran out a medication he would check the Pyxis to see if the medication was available to prevent the resident from missing a dose until the pharmacy delivered the medication but if it was not available in the Pyxis, he would let the doctor know and document in the resident's medical record. On 11/19/25 at 1:29 PM, Licensed Practical Nurse (LPN) K said in a phone interview that he worked with resident #99 on 11/16/25 during the 7:00 AM to 3:00 PM shift. He confirmed there was enough Gabapentin for resident #99 and he administered both doses during his shift. He said he did not recall the medication being low after he administered the second dose. He stated the pharmacy usually sent a full blister pack of medications that were to be given routinely but, in the event, a medication was missing, he would check the Pyxis to see if it was available until the pharmacy delivered to prevent the resident from missing a dose. On 11/19/25 at 3:00 PM, RN L said in a phone interview that she had worked at the facility for over two years. She confirmed she worked on 11/16/25 from 3:00 PM to 11:00 PM and was assigned resident #99. She said that when she went to administer his evening medications, she noticed that he had run out of the Gabapentin but had not been told by the previous nurse during report. She asked the resident if he was aware that he had no more medication, and she alleged he told her that the first shift nurse had told him he would not have any more medication after his second dose and that it needed to be reordered. RN L said she put in an order with the pharmacy and documented in the resident's chart that the medication was on order but did not mean to document that the resident refused the medication in the medication administration record. She did not attempt to get the medication from Pyxis because she had forgotten her code and did not let a supervisor know. She agreed that she should have let a supervisor know but she was being, lazy and said she did not usually work on that unit, so she did not know the resident well. When asked if she believed it was appropriate to not give medication when it was available to give, she said no and that she should have either attempted to get it from Pyxis or alerted the doctor about the missed dose and documented it in the resident's record. On 11/20/25 at 11:52 AM, during a phone interview with the facility's pharmacy provider, it was revealed that they delivered medications to the facility several times a day. He confirmed that the first time Gabapentin had been delivered to the facility for resident #99 was on 11/18/25 at 5:21 AM, and said there had been no prior deliveries of this medication prior to that date. Review of pharmacy invoices from 11/1/25 through 11/20/25, revealed there had been no deliveries of Gabapentin for resident #99 prior to 11/18/25. A review of all medications dispensed from Pyxis from 11/1/25 through 11/20/25, revealed that Gabapentin had not been dispensed prior to 11/17/25 for resident #99. On 11/20/25 at 2:21 PM, the DON was made aware that resident #99 had been administered Gabapentin starting on 11/15/25 but had then run out of the medication by 11/16/25. He was told that the pharmacy had no record of delivering Gabapentin for resident #99 until 11/18/25 and there was no evidence that the staff was taking the medication from Pyxis prior to 11/17/25. He said he was unsure where the nurses were getting Gabapentin from and said it was not common practice for staff to take medications from other residents. He clarified that the pharmacy never sent more than seven tablets of medication and that it needed to be reordered weekly. He confirmed that all nurses had access to Pyxis and there was no code to enter because it was set up with their fingerprint. He said nurses were given access to Pyxis during orientation and they were told which medications were available but could ask a supervisor if they did not know. He expected staff to follow up with the pharmacy to ensure the medication would be delivered and if it was not delivered on time and it was not in the Pyxis, they needed to let the doctor know about the missed dose as well as document in the resident's medical record. Resident #164 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, nicotine dependence, uncomplicated dependence on supplemental oxygen and chronic pain syndrome. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed resident #164 was cognitively intact with a brief interview of mental status score (BIMS) of 15 out of 15. Review of the medical record showed resident #164 was prescribed Xanax 0.5 mg twice daily for anxiety at 6 AM and 1 PM and Gabapentin 600 mg three times a day for neuropathy. On 10/18/25 at 10:55 AM, resident #164 stated the facility runs out of Xanax and Gabapentin and she had missed doses of those medications. She later stated that on the days she missed her Xanax, she was more anxious than usual. A review of the medication administration record (MAR) revealed resident #164 did not receive Xanax 0.5 mg on 11/16, 11/17, 10/13, 10/14, 10/15, 10/16. The MAR also revealed resident #164 did not receive Gabapentin 600 mg on 10/5 and 10/6 which was then discontinued and not restarted until 10/9. A review of the nurses' medication administration notes revealed on 10/17/25 at 7:03 AM, for Xanax 0.5 mg On Order and at 4:29 PM script needed, script signed and sent to pharmacy. On 10/18/25 at 12:10 PM, RN C said that she recalled resident #164 missing one dose on her shift and explained that she could not retrieve it from the Pyxis because the pharmacy requested a script. She explained the psych nurse had sent it, but the pharmacy said they never received it. RN C confirmed she wrote the note on 11/17/25 at 4:29 PM, and that the [NAME] Wing Unit Manager (UM) usually reviewed the medications for reordering. On 11/20/25 at 10:19 AM the [NAME] Wing UM was made aware of the number of times resident #164 did not receive Xanax 0.5 mg and Gabapentin 600 mg. She reviewed the MAR and confirmed the times the medications were not administered and was asked if she could find the related administration progress note for the days they were missed. The [NAME] Wing UM later said she was unable to produce associated progress notes for the missed does and only found three. She stated her expectation was for nurses to communicate to her if they were having any issues with the process of reordering medications so she could assist with reordering. She explained that she educated the nurses on calling the pharmacy and checking the Pyxis system. On 11/20/25 at 11:11AM, the DON was made aware of the missed doses of Xanax and Gabapentin for resident #164 and stated that his expectation was that nurses would go to the Pyxis for the medication, call the pharmacy, call the doctor and document.

Based on observation, interview, and record review, the facility failed to obtain timely dressing change orders for a peripherally inserted central catheter (PICC), failed to timely change the PICC dressing, failed to obtain timely intravenous (IV) flush orders, and failed to administer the IV flushes in accordance with accepted standards of practice for 1 of 1 residents reviewed for IV antibiotics in a total sample of 55 residents (#52).Findings: Review of resident #52's medical record revealed he was originally admitted on [DATE] and readmitted to the facility on [DATE] from an acute care hospital. His diagnoses included a displaced fracture of the right femur, sepsis, methicillin-resistant Staphylococcus aureus (MRSA), and urinary retention. Sepsis is a life-threatening medical emergency caused by your body's overwhelming response to an infection. (Retrieved from www.clevelandclinic.org on 12/08/25). MRSA is a type of bacteria that many antibiotics don't work on. MRSA most often causes skin infections, but it can also cause serious illnesses that are hard to treat. (Retrieved from www.clevelandclinic.org on 12/08/25).Review of resident #52's admission Minimum Data Set assessment with Assessment Reference Date of 10/02/25 revealed a Brief Interview for Mental Status score of 14, indicating intact cognition. The MDS assessment noted no rejection of care or evaluations necessary to achieve health and well-being goals. A review of resident #52's physician's orders revealed a PICC was ordered and inserted on 10/25/25 to administer IV antibiotics related to a right hip surgical infection. The IV antibiotics ordered on 10/24/25 included Vancomycin 1 gram (gm) twice daily for seven days and Cefepime 1 gm/50 milliliters (ml) three times daily for seven days. Cefepime was discontinued on 10/28/25. An order for Vancomycin 1 gm was restarted on 10/28/25 until 11/02/25, and again from 11/03/25 to 11/13/25. A new order for Vancomycin 1250 milligrams (mg)/250 ml IV once daily was initiated on 11/14/25. Review of resident #52's physician's orders also revealed a PICC dressing change and IV flush orders were not obtained until 11/17/25, twenty-one days after resident #52 returned from the hospital on [DATE]. The orders indicated to change the PICC dressing weekly with Tegaderm every Monday day shift and to flush the IV line with 10 ml of normal saline before and after each medication administration every shift. Review of resident #52's comprehensive care plan revealed a focus for antibiotic therapy related to the right hip infection was initiated on 11/05/25. A focus for IV therapy, including interventions for IV site care and dressing changes, was initiated on 11/17/25, more than 3 weeks after he began receiving IV antibiotics. Review of resident #52's Progress Notes revealed a note dated 11/17/25 which read, IV midline dressing noted to be missing on PCC (PointClick Care) review. No signs of infection or complications observed at insertion site. MD (physician) contacted and informed of missing dressing order. Order obtained for weekly and PRN (as needed) dressing changes. IV midline dressing changed by new order using aseptic technique. Dressing secure and intact. Patient tolerated procedure well. No immediate complications noted. Continue to monitor IV site for signs of infection or dislodgement. Will continue to follow plan of care.Review of the Medication Administration Record showed the PICC dressing change documented as completed 11/17/25 at 11:19 AM.On 11/17/25 at 4:04 PM resident #52 stated he had been receiving IV antibiotic for approximately four weeks to treat his right hip infection. He displayed his left upper arm (LUA) which revealed a single lumen PICC with a non-intact and soiled dressing dated 11/09/25. He stated the PICC line dressing had not been changed in more than a week.On 11/17/25 at 4:14 PM, Licensed Practical Nurse (LPN) N confirmed resident #94 received IV antibiotics and stated the wound care nurse was usually responsible for changing IV dressings. At 4:21 PM, LPN N assessed resident #52's LUA, confirmed the dressing was dated 11/09/25 and acknowledged the dressing was not intact. LPN N stated the dressing was dirty and needed to be changed. She said she needed to check the computer to determine if there was an order dressing changes and the required frequency. After reviewing the medical record, LPN N stated an order had been entered that day to change the dressing every 72 hours. She explained timely dressing changes were important to help protect the resident from infection. On 11/17/25 at 4:29 PM, the Director of Nursing (DON) assessed resident #52's LUA, confirmed the dressing was dated 11/09/25, and noted the presence of dried blood on the dressing. He stated the type of dressing used, which included gauze, required changes every 72 hours. The DON confirmed orders to change the IV dressing and flush the IV line were entered on 11/17/25, and there were no previous orders for IV line care. The DON also reviewed the progress notes and acknowledged there was no documentation of IV dressing changes or flushes. He stated all nurses were expected to assess IV lines and obtain PICC care orders on admission or at the time of insertion if the line was placed at the facility.On 11/20/25 at 10:29 AM, the East Wing Interim Unit Manager (UM) stated orders to maintain IV lines needed to be obtained for any resident admitted with them. She indicated the nurses were responsible for maintaining the IV lines by ensuring patency, confirming the dressing was clean and intact, and administering medications as ordered. She explained they used batch orders that should be entered upon admission or when the IV line was placed. The UM stated these orders should have been reviewed during their morning clinical meetings to ensure accuracy. She explained resident #52 was in the hospital from [DATE] to 10/27/25 and she reviewed his medical record on 11/17/25, noticing there were no orders for IV dressing changes or flushes. She stated she obtained the orders at that time and could not explain why this issue was not identified earlier. She acknowledged the progress note written on 11/17/25 contained inaccurate details regarding the dressing observation and change documented as completed as 11:19 AM. She stated after obtaining the dressing order, she believed a previous order had fallen off and did not recall checking whether an earlier order existed. She explained during review of the hospital discharge packet, they would have seen resident #52 had a PICC line and, if orders were not present, the physician would have been contacted for IV line care orders. Review of the facility's PICC/Midline/CVAD Dressing Change policy revised on 3/01/25 revealed PICC dressings were to be changed weekly or when soiled to decrease the risk of infection and cross-contamination. The policy specified physician orders would include the type of dressing and frequency of changes, and completion of the procedure would be documented.Review of the facility's Intravenous Therapy policy revised on 3/01/25 revealed the intent for staff to adhere to accepted standards of practice regarding infusion practices.

Based on observation, interview, and record review, the facility failed to identify and provide ongoing monitoring of identified past trauma for 2 of 2 residents reviewed for Trauma Informed Care, of a total sample of 55 residents, (#25, #84).Findings: 1. Review of the medical record revealed resident #84, a [AGE] year-old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included: Alcohol Abuse, Adult Failure to Thrive, Moderate Dementia with Anxiety, Other Psychoactive Substance Abuse, Anxiety Disorder, Convulsions, Weakness, and Post Traumatic Stress Disorder (PTSD). The most recent Comprehensive Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/16/25 noted during the look-back periods, resident #84 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. Cognitive Patterns were assessed with continuous/non-fluctuating behaviors of inattention and disorganized thinking. The Mood Interview (PHQ-2 to 9) noted the resident felt down, depressed or hopeless for several days, and the Behavior section noted there were no behavioral changes or rejections of evaluation or care. The assessment indicated the resident required moderate staff assistance to complete Activities of Daily Living (ADLs), used a manual wheelchair, and did not walk. The resident had active diagnoses of Non-Alzheimer's Dementia, Seizure Disorder, Anxiety Disorder, Depression, Alcohol and Other Psychoactive Substance Abuse, Weakness, Homelessness, and Post Traumatic Stress Disorder (PTSD). The Care Planning Decisions signed on 10/19/25 did not include Psychosocial Well Being. The Comprehensive MDS admission Assessment with an ARD of 10/19/22 noted Active Diagnoses included PTSD however did not include anxiety disorder or depression. The Electronic Health Record (EHR) showed a diagnosis of Major Depressive Disorder, Recurrent, Moderate was added on 1/23/23 noted as, during stay. The Comprehensive Care Plan Report's focus included: (10/24/24) self-care impairment and required staff assistance for all ADLs, (12/20/22, revised 5/24/23) self-care deficits with history of PTSD, (11/24/22, revised 10/16/25) risk for restlessness, hypervigilance, and mood alterations related to anxiety disorder with an intervention to monitor behaviors and attempt to determine the underlying cause, (12/23/22, revised 10/16/25) risk for mood alterations, isolation feeling of doom related to depression that requires medication, (11/24/22, revised 7/25/24) potential for psychosocial well-being problems related to ineffective coping skills/substance use disorder. The Care Plan did not include a Focus for individualized PTSD/Past Trauma. On 11/18/25 at 1:46 PM, resident #84 was observed sitting in a wheelchair beside his bed alone, with the privacy curtain drawn. On 11/19/25 at 1:20 PM, resident #84 was observed sitting in a wheelchair in the same location with the privacy curtain drawn. The resident was unable to recall his past life history and answered he did, this and that prior to living in the facility. Unsuccessful attempts were made to interview resident #84's court appointed guardian by telephone on 11/19/25 at 1:20 PM and 3:28 PM, and on 11/20/25 at 9:05 AM. On 11/19/25 at 1:22 PM, Certified Nursing Assistant (CNA) E said she knew resident #84 well and he was frequently on her assignment. She said the resident was occasionally irritable, but she was unaware of his history or any unique findings about him. On 11/19/25 at 1:09 PM, Registered Nurse (RN) C said she knew resident #84 well, and he was frequently included in her assignment. The nurse explained she was unaware of any special mental health needs or concerns, he mostly preferred to stay alone in his room, and he was quiet and didn't speak much. On 11/19/25 at 1:45 PM, the [NAME] Wing Unit Manager said she knew resident #84 well, he preferred to be alone and kept to himself. She said the resident did not have any special mental health issues or concerns. Review of Social Services Progress Notes dated from 11/24/22 to 10/30/25 revealed there were no entries that addressed care and services for resident #84's diagnosis of PTSD. The EHR included one Community Life Progress Review (Activities) dated 4/12/24 and one Activities Quarterly Participation Review dated 10/13/25 that did not note any awareness for resident #84's PTSD. The medical record did not include a Social Service Department Social History and Initial Assessment required by the facility soon after the resident's admission on [DATE], nor any Social Services ongoing quarterly monitoring/assessments. In an interview on 11/19/25 at 12:10 PM, the Social Services Assistant explained the Social Services Director was responsible for completing resident initial admission assessments and updates quarterly and thereafter. She said the Social Services Director was not at work and unavailable during the survey. She checked resident #84's medical record and was unable to locate any Social Services evaluations. On 11/1925 at 1:49 PM, the Activities Assistant said he knew resident #84 well. He recalled over time, the resident had become more withdrawn from any group activities and had only seen him once in the previous month for an ice cream. He stated he was unaware of any special needs or any history of trauma. On 11/20/25 at 3:27 PM, the Community Life Director (Activities) said she was unaware of any residents in the facility who had PTSD and if she did, she would have created a special program for them. On 11/20/25 at 8:51 AM, the Director of Nursing (DON) explained the Social Services Department was responsible for completion of discipline specific assessments on admission, every quarter thereafter, and as needed for every resident. He said the assessment was important to identify any special psychological/psychosocial needs and PTSD trauma required a separate care plan for triggers, so staff were aware. At 10:47 AM, the DON said he checked resident #84's medical record and was unable to locate any Social Services assessments. He said he could not explain why they were not completed, and the Social Services Director was not available for an interview. Review of the facility's standards and guidelines dated 3/01/25 and titled Trauma Informed Care outlined that the facility screened residents to identify trauma history and asked about triggers or stressors that may prompt recall using tools that included social/history assessments. The policy noted the facility used trigger specific interventions to decrease and mitigate exposure, and those interventions were included in the individualized care plan. The facility's undated job description titled Social Worker indicated the position was responsible for completing discipline specific assessments that contributed to residents attaining or maintaining their highest practicable well-being. 2. Resident # 25 was readmitted to the facility on [DATE] with diagnoses which included unspecified fracture of the right femur, pulmonary embolism, schizoaffective disorder, major depressive disorder and PTSD. Review of the quarterly MDS assessment with assessment reference date (ARD) of 9/28/25 revealed resident # 25 had BIMS Score of 9 out of 15 which indicated he had moderate impaired cognition, was dependent on staff for activities of daily living and transfers. The assessment also showed that the Psychiatric /Mood disorders included depression, schizophrenia and PTSD. A review of resident #25's Care plan revealed the resident had impaired cognitive function/dementia or impaired thought processes related to dementia/PTSD initiated on 12/27/22 and revised 4/1/25 with no specific interventions addressing PTSD or the triggers. A review of the practitioner's progress notes on 11/13/25 by Psychiatric Nurse Practitioner revealed an excerpt from Assessment and Plan which addressed PTSD for resident #25 .PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology. Care Plan for PTSD diagnosis: Trauma: Told to notify provider and staff if triggers present Triggers: Denies Care Plan: Told to notify provider and staff if triggers present . On 11/18/25 at 10:30 AM resident #25 was observed in bed with his eyes closed. On 11/19/25 at 4:10 PM, the resident's assigned nurse LPN O said the resident was confused at times, had schizoaffective disorder and stayed in bed. She had never seen visitors or family but knew he had a guardian. She explained he was incontinent, had no wounds, medicated for anxiety and pain and that he can be resistive to care at times with certified nursing assistants (CNAs). The LPN did not explain any mental health issues. On 11/19/25 at 4:15 PM, the resident's assigned CNA P stated the only thing that stood out about the resident was he did not like his private area touched during care. On 11/20/25 at 9:40 AM in the presence of the MDS coordinator, the Psychiatric Nurse Practitioner (NP) said that most days resident #25 was unable to explain anything and on other days, he was actively psychotic. The Psychiatric NP explained resident #25 would say things like, the homosexuals are coming and she said that it should be care planned. She explained she could not determine what trauma the resident faced and the exact circumstances but she had told the team about rape and addressing triggers for resident #25. The MDS coordinator could not find anything addressing resident #25's PTSD or any history of rape. On 11/20/25 at 3:38 PM, the Assistant Director of Nursing acknowledged resident #25's care plan should reflect interventions to address triggers based on his trauma.

Based on interview and record review, the facility failed to follow their grievance process related to preferences for 2 of 2 resident reviewed for grievances, (#1, #3). Findings 1.A review of the medical record revealed that resident # 3 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, major depressive disorder, unspecified psychosis and schizoaffective disorder. According to the Annual assessment of the Minimum Data Set with the assessment reference date of 9/30/25, the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which means he was cognitively intact, and was dependent on staff for hygiene care. On 10/8/25 at 10:06 AM, resident # 3 who was selected from the facility's grievance log was observed being wheeled into the shower room. At 10:50 AM, resident #3 was observed coming out of shower room and answered only yes to everything is okay, staff treated him well him well and could not remember filing a grievance. On 10/8/25 at 1:47 PM the Social Services Director (SSD) was asked about the grievance filed on 9/12/25 for resident # 3 and presented the form. She explained that resident # 3 complained about waiting a long time to get out of bed in the morning and that a staff member kept turning off the call light. She continued to explain that since then, the staff have been educated on call lights and customer service and that the resident had no concerns thereafter. On examination of the form, it showed that the grievance was not resolved from 9/14/25 when the family was informed. The SSD confirmed that the form was incomplete and showed the grievance was not resolved and she acknowledged that it was her fault the form was not signed nor completed. The facility's policy on Resident and Family Grievances dated 1/1/23 stated in section 12 that the facility will make a prompt efforts to resolve grievances. 2. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses including dislocation of right ankle, type 2 diabetes, bipolar disorder irritable bowel syndrome with diarrhea and obesity. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 out of 15 which indicated intact cognition. On 10/9/25 at 10:22 AM, resident #1 stated that there was an incident when he requested a shower on a night that was not his scheduled shower night. He stated that the Certified Nursing Assistants (CNA) told him his shower night was the following day and refused to give him a shower. He stated the nurse instructed the CNAs to give him a shower that night and that they were very upset. Review of the grievance log for September 2025 was reviewed and revealed that resident #1 was not listed on the log. Review of a Grievance form dated 9/23/25 filed by resident #1 read, resident reports staff refused to give resident a shower. After resident spoke with nurse, nurse had 3 CNAs assist the resident with shower. After shower, resident reports he was left soiled until a CNA changed him at 7am on 9/24. The person completing this form is indicated as the SSA and the person assigned to investigate the concern was the social service department and the Director of Nursing (DON). The Grievance official follow-up section read, statements obtained from DON (3 CNAs and nurse on 11-7). More frequent interviews with resident regarding care. Resident voices no concerns and room change provided at request. Psych services and follow up provided by outside vendor. The section for the grievance official's signature was blank. The date resolved was 9/24/25. Documents attached to the grievance form included a handwritten statement that has no date or employee name on it. Statement read during second shift on 9/23/25 she was asked by the assigned CNA for resident #1 to witness her offering the resident a shower to which the resident refused. The resident responded that he did not say he wanted a shower. The resident refused to transfer into the shower chair and wanted to remain in his wheelchair. The resident continued to express his displeasure during the entire shower. After the shower, the resident returned to his room and transferred back into his bed. He was then dried and dressed. The second statement attached to the grievance was a phone interview with the assigned nurse taken by the DON dated 9/23/25. The nurse stated he did not hear or witness anything related to the incident but he did know that the resident received a shower that night. On 10/8/25 at 11:45 AM, the Social Service Assistance (SSA) stated she is the person who handled resident #1's grievance since the Social Service Director (SSD) was on leave at that time. SSA and SSD confirmed that the resident's grievance was not on the grievance log and that it should be listed. SSD acknowledged that she did not review the grievance when she came back from leave. On 10/8/25 at 12:17 PM, the SSA stated that she handed this grievance off to the DON since it had to do with nursing. She stated that grievances are distributed to each department depending on the issue. SSA stated that the DON interviewed the staff and that she only dealt with the resident. On 10/8/25 at 12:33 PM, the DON confirmed that he handled the grievance for resident #1 since it was a nursing issue. The DON acknowledged that the handwritten statement attached to the grievance did not have an employee signature nor a date/time. The DON stated that the statement was from a CNA who was involved in the incident. The DON confirmed that there were no other employee statements from the CNAs including the assigned CNA. DON stated that he tried to call the assigned CNA to get a statement, but she did not respond. The DON acknowledged that the assigned CNA is still a employee of the facility and works regularly. On 10/8/25 at 1:12 PM, the Nursing Home Administrator (NHA) stated that it was the first time she had reviewed resident #1's grievance. She acknowledged that the grievance was lacking and required more information. She stated that there should have been more to the grievance and that there was room for improvement. The NHA stated that typically at the end of each week the management meet as a team and discuss grievances. She acknowledged that the grievance for resident #1 was not reviewed and somehow got missed. Facility policy titled resident and family grievances dated 1/1/23 revealed the facility will support each resident's right to voice grievances without discrimination, reprisal or fear of discrimination. The grievance official will keep the residents appropriately apprised of progress towards resolution of the grievances. In accordance with resident rights, the resident will obtain a written decision regarding his or her grievance at the conclusion of the investigation.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to appropriately implement enhanced barrier precautions (EBP) during high-contact care activity for 1 of 6 residents (#5) requiring EBP on the Specialized Subacute Unit (SSU). The facility had a total of 20 residents who required EBP in a census of 154 residents. The facility capacity is 167 beds.On 10/08/25 at approximately 10:50 AM the light above the door to resident #5's was illuminated to indicate the resident was calling for assistance. Certified nursing assistant (CNA)- A was observed to obtain and don a mask from a caddy (container) hanging on the door across the hallway and she entered the room. She was overheard to say to the resident, I will be right back to help you get dressed. The resident was in a private room.A sign on the door to resident #5's room read STOP. ENHANCED BARRIER PREAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. A container for personal protective equipment (PPE) for gowns and gloves was not observed on the door. (photographic evidence obtained)At 11:20 AM, after knocking and gaining permission to enter, two staff members, CNA - A and another person who identified herself as a CNA and private sitter, were observed in the resident's room. They were wearing facial masks and gloves. Neither staff member was wearing a gown. They both said they had just provided bathing and dressing for the resident and were preparing to use the mechanical lift to transfer the resident out of bed to the wheelchair to go to therapy. When asked about their knowledge of EBP they both said they are to wear masks and gloves when providing care because the resident has a catheter for his urine. When asked about any requirement to wear a gown, both replied and said they understood they did not need to wear a gown during care. When asked if they are to wear a gown when emptying the urine drainage bag, they both replied, no gown, just gloves and mask. Both CNAs were asked if they were aware of the sign posted on the door to the room. They said they saw it, but they thought they did not have to wear a gown to provide care.On 10/08/25 at 11:30 AM, in an interview with RN-B who was the nurse assigned for the section of the unit that included resident #5, she was asked to explain her knowledge of EBP and how it was to be implemented. She stated staff wear PPE depending on the type of disease the resident has. She checked the electronic medical record and verified that resident #5 required EBP since his most recent admission to the facility on [DATE]. She stated he had a suprapubic urinary catheter, and staff are to wear a mask and gloves when they provide care. When asked when staff would need to wear a gown, she stated they only wear a gown if a resident is on airborne precautions. She confirmed resident #5 was not on airborne precautions.Per Centers for Disease Control and Prevention (CDC) (www.cdc.gov) airborne precautions are used for patients known or suspected to be infected with pathogens transmitted by the airborne route ( e.g. tuberculosis, measles, chicken pox).In an interview on 10/08/25 at 4:39 PM, the Infection Preventionist (IP) stated she also had the job duties for the Assistant Director of Nursing and Staff Development. She described how EBP should be implemented according to the CDC guidelines for Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs). She stated staff have been educated by her for the use of PPE for residents requiring EBP in March 2025 and April 2025. She provided evidence of such education. RN B was listed on the attendance record. The IP was informed of the findings involving staff members caring for resident #5 as they occurred earlier that day. She confirmed the actions and responses by staff regarding EBP and resident #5 were incorrect. She was asked if she had any process surveillance regarding appropriate use of PPE and EBP and she replied she did not. The facility provided a list of residents currently requiring EBP on the SSU dated 10/08/25 with a time of 14:11 (2:11 PM). During the interview the IP acknowledged the list was inaccurate. Two additional residents were not included on the current order listing report, and she confirmed those two residents required EBP.Record review for resident #5 revealed orders dated 6/27/25 for Enhanced Barrier Precautions per CDC guidelines and facility protocol for Suprapubic catheter and History of MDRO. The care pan report with a revision date of 8/04/25 listed a focus for EBP related to catheter. Another area on the care plan report listed a focus that resident #5 needed assistance with grooming, bathing and personal hygiene due to inability to care for himself and he has a private daily sitter. The goal indicated that staff will provide activities of daily living (ADL) care through the next review.The facility policy titled Enhanced Barrier Precautions listed the date implemented as 4/01/24. The policy contained the statement of the facility to implement EBP for the prevention of transmission of MDROs. The policy included a definition, EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and glove use during high contact resident care activities. The Policy Explanation and Compliance Guidelines included the following:.All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions.Implementation of EBP: Make gowns and gloves available immediately near or outside of the resident's room.The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.

Based on interview and record review, the facility failed to respond to grievances identified by resident council. Findings: During Resident Council meeting on 11/01/23 at 3:30 PM, members of Resident Council verified they met monthly. The members stated several grievances had been voiced regarding laundry, linen, nurse staffing, staff speaking other languages and dietary. The residents in attendance agreed the same concerns were voiced month after month without a resolution. The group expressed no one ever responded to the grievances and informed them of what was done. The resident council members were not aware of any grievances that had been filed on behalf of Resident Council. Review of Resident Council minutes from May 2023 through October 2023 revealed several repeat grievances concerning staff not speaking English, staff on cell phones, quality of linen and various dietary concerns. On 11/01/23 at 5:00 PM, the Activity Director stated she attended every Resident Council meeting along with her assistant. She explained the Resident Council agreed to have an open invitation to any management staff member who wanted to attend. She stated residents were encouraged to express grievances during Resident Council and she noted those under the appropriate department. The Activity Director stated she provided a copy of the Resident Council minutes to the Resident Council President and to the facility Administrator. She explained she brought up the issues in morning report and each department was supposed to address those issues. She acknowledged she did not fill out any grievance forms for resident council. The Activity Director acknowledged resident council members reported they did not feel like anyone was listening to them. On 11/01/23 at 5:22 PM, the Social Services Director (SSD) stated the Administrator was the primary grievance officer. She stated social services received the grievances and the grievances were shared with department heads in morning meetings. She explained the Administrator assigned the grievances to department heads to handle. The SSD stated grievances could include concerns about food, staff not speaking English, complaints about call lights, customer service and quality of care. She explained any grievance from Resident Council would be brought to social services and a grievance form was completed. The SSD reviewed the Grievance Log and verified there were no grievances submitted on behalf of Resident Council. She acknowledged there would be no way to show what was done to resolve the issue without a grievance and follow-up. On 11/01/23 at 5:47 PM, the Administrator verified she was the primary grievance officer. She explained her expectation was for the Activity Director to bring concerns from Resident Council to daily department head meeting which would then be assigned to the appropriate department to be addressed. She acknowledged they did not complete a grievance form. The Administrator explained the facility had completed grievance forms for Resident Council in past but was not sure why that stopped. She was unable to produce the facility's response to Resident Council grievances. Review of the facility's policy and procedure for Grievances Program revealed that a grievance would be documented on the facility Grievance Report, listed on the facility Grievance Tracking Log and investigated accordingly. The document indicated the grievance decision would be documented on the grievance form and include dates, summary statement of resident's grievance, and summary of findings, statement confirming or not confirming grievance, correction actions as indicated, and the date that the written decision was issued to the person filing the grievance.

Based on interview and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 resident reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, out of a total sample of 63 residents, (#53 and #96). Findings: 1. Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anemia, gastrointestinal hemorrhage, unspecified mood affective disorder and personal history of transient ischemic attack. Review of resident #53's financial record revealed she began Medicare Part A skilled nursing stay on 4/01/23 with last covered day on 4/28/23. She had Medicaid as her primary payer effective 4/29/23. A SNF Beneficiary Protection Notification Review revealed resident #53 received a Notice of Medicare Non-Coverage (NOMNC) at the end of her Medicare Part A stay but did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). 2. Resident #96 was admitted to the facility on [DATE] with diagnoses including acute metabolic acidosis, adult failure to thrive, dysphagia and atherosclerotic heart disease. Review of resident #96's financial record revealed he began Medicare Part A skilled nursing stay on 6/01/23 with last covered day on 7/31/23. He had Medicaid as his primary payer effective 8/01/23. A SNF Beneficiary Protection Notification Review revealed resident #96 received a NOMNC at the end of his Medicare Part A stay but did not receive a SNF ABN. Review of residents discharged from a Medicare Part A stay in the last six months revealed there were 57 residents who discharged from a Medicare Part A stay without using all available days and remained in the facility. On 11/02/23 at 3:58 PM, the Social Services Director (SSD) explained she was not aware that a resident who discharged from a Medicare Part A stay with days remaining and stayed in the facility required a SNF ABN to be provided. She acknowledged she had not provided a SNF ABN to any of the 57 residents who remained in the facility following a Medicare Part A stay without exhausting their benefit days. The facility's policy and procedure for Resident Right - Medicaid/Medicare Coverage/Liability Notice read, If the Facility provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related stand claim appeal rights.

Based on interview, and record review, the facility failed to notify the State Long Term Care Ombudsman in writing, by phone, or in person for a facility-initiated emergency transfer/discharge for 2 of 2 residents reviewed for [NAME] Act and 1 of 3 residents reviewed for hospitalization out of a total sample of 63 residents, (#561, #562 and #626). Findings: 1. Review of the medical record revealed resident #561 was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. His diagnosis included type II Diabetes, hypertensive heart disease with heart failure, mood disorders, history of traumatic brain injury, suicidal ideation, and anxiety disorder. The Minimum Data Set (MDS) Discharge-Return Anticipated assessment with assessment reference date of 3/16/22 revealed resident #561 had severely impaired cognitive skills for daily decision making. Review of the resident's medical record revealed the physician's progress note dated 3/16/22 indicated the resident was emergently transferred to the hospital due to the immediate risk of harm to self and others. The facility-initiated transfer met the criteria for [NAME] Act. Further review of the medical record indicated that the resident's Guardian was notified, however there was no evidence in the medical record that the State Long Term Care Ombudsman was notified of the emergency transfer. On 10/31/23 at 12:53 PM, the Social Service Director (SSD) stated the resident's Guardian was notified immediately of the resident's transfer, but the Ombudsman was not notified in writing, by phone, or in person. She did not know why the resident's discharge did not populate to the discharge report to be faxed monthly to the Ombudsman. The SSD acknowledged the facility did not contact the Ombudsman by phone or in person for [NAME] Act transfers. On 11/1/23 at 12:26 PM, the Director of Nursing (DON) stated the facility's process for facility-initiated emergency transfers was to contact the Ombudsman by fax monthly and they did not contact the Ombudsman by phone or in person. On 11/1/23 at 1:27 PM, the SSD confirmed the resident's name did not appear on the facility's March discharge report that was faxed to the Ombudsman and that she had not phoned or spoken in person to the Ombudsman regarding the emergency transfer. 2. Review of the medical record revealed resident #562 was admitted to the facility on [DATE] from the hospital. Her diagnosis included spinal stenosis, cardiomyopathy, major depressive disorder, anxiety disorder, schizoaffective disorder-depressive type, and mood (affective) disorder. The MDS Quarterly assessment with assessment reference date of 8/14/22 revealed the resident's cognition was intact with a Brief Interview Mental Status (BIMS) score of 15 out of 15. Review of the resident's medical record revealed the progress note dated 10/27/22 indicated the resident was emergently discharged to the hospital due to violent behaviors that posed harm to self and other residents in the facility. There was no documentation in the medical record that indicated the State Long Term Care Ombudsman was notified of the facility-initiated discharge. On 10/31/23 at 12:53 PM, the Social Service Director (SSD) stated the Ombudsman was not notified in writing, by phone, or in person of the [NAME] Act. She did not know why the resident's discharge did not populate to the discharge report to be faxed monthly to the Ombudsman. The SSD acknowledged the facility does not contact the Ombudsman by phone or in person for [NAME] Act discharges. On 11/1/23 at 1:27 PM, the SSD confirmed the resident's name did not appear on the facility's October discharge report that was faxed to the Ombudsman and that she did not phone or speak in person to the Ombudsman regarding the emergency transfer. The SSD acknowledged that the Ombudsman should have been contacted regarding the emergency [NAME] Act transfer. 36489 3. Review of the medical record revealed resident #626 was admitted to the facility on [DATE] with diagnoses including quadriplegia, heart disease, osteomyelitis or bone infection, chronic kidney disease, and muscle wasting. Review of the Minimum Data Set (MDS) Discharge-Return Anticipated assessment with assessment reference date of 6/18/23 revealed resident #626 had an unplanned discharge. A Hospital Transfer Form dated 6/18/23 at 3:40 AM, indicated the resident was transferred to the hospital for evaluation and treatment of a change in condition. Review of the facility's policy and procedure for Notice Requirements Before Transfer/Discharge (undated) revealed the facility would send copies of transfer/discharge notices to the Office of the State Long-Term Care Ombudsman. On 11/02/23 at 12:25 PM, the Social Services Director (SSD) provided a copy of paperwork she faxed to the Ombudsman's office in July 2023 with the names of residents who were discharged from the facility in June 2023. Review of the Admission/Discharge To/From Report from 6/01/23 to 6/30/23 revealed resident #626's name was not included on the form. The SSD validated the resident's name was missing from the list. In addition, the SSD explained she was not able to find the fax confirmation sheet to prove the list was received by the Ombudsman's office. On 11/02/23 at 3:19 PM, the SSD stated she was still not able to figure out why resident #626's name was not on the list of discharged residents. She confirmed although she was responsible for sending the list to the Ombudsman's office once monthly, she did not review the document thoroughly before transmittal. She said, I trust the list is accurate. The SSD acknowledged there had to be a reason why resident #626's name did not show up. Closer review of the document revealed the list had a filter applied that specified, No Discharges selected. The document listed only admissions for June 2023 and was dated 11/02/23 rather than July 2023. The SSD stated she searched but did not find the fax confirmation sheet. She acknowledged the facility was unaware notification to the Ombudsman was not made as required. In response to a request for verification of notification, an email received on 11/06/23 from the Office of State Long-Term Care Ombudsman revealed the office had no documentation regarding the facility's transfers and discharges for June 2023.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive device for hot fluids during dining for 1 of 3 sampled residents which resulted in actual harm, (#1). Findings: Review of resident #1's medical record noted she was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], dementia, [CONDITION(S)] disorder, dysphagia, cognitive communication deficit and mixed receptive-expressive language disorder. Review of resident #1's admission Minimum Data Set assessment dated [DATE] showed her cognitive status was not able to be assessed due to inattention that fluctuated and continual disorganized thinking. The assessment showed she did not have any impairment with upper extremity (shoulder, elbow, wrist, hand) and no impairment with lower extremity (hip, knee, ankle, foot). Review of Nutritional Evaluation dated 03/09/22 by the Registered Dietician showed the resident was able to feed self and was on regular diet with mechanical soft texture and thin liquids with no chewing or swallowing concerns. Review of the Change of Condition form showed resident #1 sustained a burn to her right forearm and right abdomen on 4/3/22 at 8:45 AM. It indicated there was redness with blister to the right forearm and redness to the abdomen. The form noted the resident was crying and observed rubbing the area. She described the pain as burning with intensity of 7 out of scale of 1-10. Interventions at the time included an ice pack and pain medication. Review of the Director of Nursing's (DON) written statement dated 04/03/22 at 9 AM, read, The resident reported she spilled coffee on her blanket covering her arm. The resident reported she tried to stick a straw in the hole in the lid of the coffee cup. The resident reported when her arm started to hurt, she did not know why her arm was hurting until the CNA showed her the coffee had spilled on the blanket and her arm. The resident expressed she did not want hot liquids again. The resident's husband expressed she should not have hot liquids until the center could obtain a coffee cup with a spout to reduce leaking. Review of the Wound Physician's Note dated 04/12/22 documented resident #1 was being seen for [CONDITION(S)] to her right upper arm and abdomen. The right upper arm had full thickness burn measuring 3.0 centimeters (cm) x 1.0 cm x 0.3 cm with scant serous drainage, and debridement performed. The right side of the resident's abdomen had full thickness burn measuring 2.5 cm x 2.5 cm x 0.3 cm with scant serous drainage, and debridement performed. Treatment included Silvadine 1% topically daily to both areas. Review of Certified Nursing Assistant (CNA) F's written statement dated 04/03/22 read, It was 8:45 AM when I heard the resident screaming. When I asked her what was wrong, she said she wanted a wash cloth because the coffee burned her. When I returned with the wash cloth and proceeded to clean her up, I discovered a red area on her inner arm and her right side so I notified the nurse right away. The resident said she was trying to put a straw in the cup which had a lid on it. On 05/24/22 at 2:30 PM, CNA F stated on 04/03/22, resident #1 called out and told me she had spilled her coffee and burned herself. CNA F recalled a brown coffee cup with lid with hole was sitting upright on the meal tray and the coffee cup was empty. CNA F explained the resident had on a short sleeved blouse and noted a large reddened area on her right mid-arm. When I went to clean the resident up, I noticed a red mark on her right side. After I cleaned the resident up, I notified the nurse, (Registered Nurse, RN D). On 05/22 at 3 PM, RN E stated she was the nurse assigned to resident #1 on 04/03/22. She recalled on 04/03/22, the CNA came to get me to tell me that resident #1 had spilled hot coffee on herself and was burned. I assessed the resident and she was anxious and had a speech problem. She had [CONDITION(S)] to the inner aspect of her right forearm and right side of her abdomen. She was rubbing her arm which caused a blister to break open. RN E said she notified the physician, the Nursing Supervisor and the DON. She recalled the resident was crying, complained of pain and she administered pain medication. On 05/24/22 at 11 AM, the resident's husband said he was informed several weeks ago that his wife had spilled hot coffee on herself and she had [CONDITION(S)] to her right arm and abdomen. The [CONDITION(S)] were bad, and the Wound Physician was seeing her. He explained his wife was in a coma for 3 months from a brain bleed before coming to this facility for rehabilitation. He reported she used her left hand to eat but but was very shaky and spilled food and liquids on herself. Review of resident #1's plan of care revealed a Baseline Care Plan which was not dated or signed that read, Therapy Screen - Special Cup - Hot Liquid Spill. A Care Plan for nutritional problem included interventions for no hot liquids until special cup was obtained and resident was to be supervised at mealtimes until further notice. The care plan showed the resident sustained burn on 04/03/22. There was no follow up on the care plan to indicate if a special cup was obtained for the resident. Review of the CNA Kardex provided by the DON revealed no documentation of resident #1's assessed need for supervision during meals and use of special cup for hot liquids to prevent spills and [CONDITION(S)]. Review of the Occupational Therapy Transitional Evaluation and Plan of Treatment with certification period 03/09/22-04/07/22 noted the resident's gross and fine motor coordination were severely impaired. The plan included baseline short-term goal that resident will feed self seated at bedside in wheelchair with contact guard, adaptive/assistive devices and minimal assistance from staff. On 05/24/22 at 10:40 AM, resident #1 was observed in bed wearing pink pants and a white short sleeved top. The right shoulder of her blouse had a large brown stain from the base of her neck to the upper area of her right arm. Resident #1 said the stain was from liquids spilling out the right side of her mouth. Three cups were observed on the resident's overbed table. One was a bright blue plastic no spill cup, one was a bright green no spill cup and the third was a bright pink thermal container with a flip top spout for drinking with weighted bottom. She explained she had the cups because she had spilled hot coffee on her right arm and right side several weeks ago and sustained [CONDITION(S)]. She explained she had a stroke three months ago and was not able to move her right arm or right leg. When I spilled hot coffee on my right arm, I was not able to feel it because I don't have any feeling in my right arm. It was not until I felt the burning pain to my right side and I screamed for help. Resident #1 recalled the hot coffee was in a brown coffee cup with a lid and when she tried to insert a straw through the sipping area of the lid, the cup tipped and hot coffee spilled on her skin. On 05/24/22 at 10:25 AM, CNA A said the resident ate independently, I am not aware she used any special cups for drinking and we don't need to stay with the resident during meals. The CNA was not aware the resident needed supervision during meals. On 05/24/22 at 12:35 PM, resident #1 was observed in her room sitting in her wheelchair with her husband at bedside. Her lunch tray was on the overbed table with a glass containing milk and a small plastic glass containing iced tea. The resident stated, I don't have very good control over my mouth on the right side and I drool. There was no staff member supervising the resident during lunch as per the care plan. At this time, the West Wing Unit Manager entered the room with a pink thermal container which contained hot coffee for the resident. She said the resident was currently using the special weighted cup for hot fluids to prevent [CONDITION(S)]. The Unit Manger placed the cup in front of the resident then left the room. She did not provide supervision while the resident ate lunch. On 05/24/22 at 12:40 PM, the Dietary Manager stated the kitchen was responsible for sending the specialty cups to the residents on their meal trays. Observation of resident #1's lunch meal ticket revealed no documentation of the resident's need for any specialty cup. The Kitchen Manager stated he was not aware resident #1 used a no spill cup for liquids. She may not have an order for the no spill cup. On 05/24/22 at 2:35 PM, resident #1 was in her room sitting in her wheelchair eating cake brought in by her husband. She had a spoon in her left hand and her left arm was observed with quick jerking movements as she attempted to place the spoon with cake into her mouth. Cake crumbs were visible on her shirt and pants. On 05/24/22 at 3:10 PM, Occupational Therapist (OT) C stated resident #1 had been evaluated for Occupational Therapy services on 03/10/22. She said initially, the resident had a clear unweighted cup but she was impulsive and spilled the fluids so we switched to a clear weighted cup. This was before she had the burn incident. The OT explained the clear weighted cup being used was not appropriate for hot liquids so they obtained another weighted cup specifically for hot coffee use after the burn incident. OT C stated, The weighted cup for hot liquids would prevent spills and [CONDITION(S)]. OT C explained that she did not know if the CNA's were made aware the resident was to use the weighted cup for hot liquids. On 05/24/22 at 3:45 PM, a meeting was held with the Administrator, DON and Assistant DON. The Administrator and DON stated the facility had conducted a thorough investigation and the root cause of resident #1's coffee [CONDITION(S)] was the result of resident #1 trying to put a straw into the lid of the coffee cup. The DON stated on 04/03/22 at 8:45 AM, CNA F responded to the resident screaming. She said the CNA noticed the brown coffee cup with lid was in the bed and coffee was dribbling out of the cup. She indicated when CNA F removed the wet bed covers from the resident, she noticed reddened areas on the resident's right forearm and right side. The DON stated on 04/03/22, she arrived at the facility and had interviewed resident #1 and her husband together. The resident explained that when she tried to put a straw in the opening of the brown coffee cup lid, the coffee cup tipped over and spilled on her skin causing [CONDITION(S)]. The DON reported a re-enactment of the event had been conducted with resident #1 and she was unable to insert a straw into the sipping area of the coffee cup lid. The Administrator said that resident #1 only had use of her left arm and she was not able to stabilize the coffee cup in order to insert the straw into the cup. The DON was not able to identify what type of cup was assessed for resident #1's use before the burn incident and she was not aware if the cup was non-spill or could be used for hot liquids. The DON stated resident #1 was on therapy services and working with a double handle weighted cup prior to the incident. The DON explained the weighted cup was implemented after the burn incident because the resident was impulsive and lifted her beverage cup to her mouth too quickly. The Administrator and DON could not explain why a weighted cup and/or any other assistive device to assist resident #1 when drinking hot coffee was not used before the incident. The Administrator and DON were informed of the discrepancies in the resident's assessments. The Registered Dietitian's note dated 03/07/22 assessed resident #1 as independent with eating, and the admission MDS assessment dated [DATE] noted no impairment in movement of resident's upper extremities. They were informed the resident's current care plan did not specify what type of special cup was needed and the CNA Kardex contained no documentation of the special cup or the need for resident to be supervised at mealtimes until further notice as listed in the care plan. The DON and Administrator did not provide any clarification of the above discrepancies. The Administrator stated, The root cause of resident #1's coffee [CONDITION(S)] was due to the facility not providing the resident with the proper cup for hot liquid use and as a result the resident was burned. Review of the Facility assessment dated [DATE] documented the facility accepts and is able to care for residents with diagnoses including Impaired Cognition, Depression, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]) and Stroke. Services and care are based on the resident's needs with Activities of Daily Living (eating), Mental Health and Behavior (anxiety, cognitive impairment, depression) and Nutrition (assistive devices). Resident care is person centered making sure the staff caring for the residents are competent and have information from the resident's care plan.

Based on observation, interview and record review, the facility failed to provide adequate supervision and determine appropriate safety interventions based on a thorough elopement risk evaluation, and failed to maintain a secure environment by implementing front desk procedures to ensure vulnerable residents did not exit the facility without supervision, for 1 of 11 residents at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was reasonable likelihood he could have fallen, become lost or been hit by a car. On 4/19/21 at approximately 9:15 AM, the facility failed to prevent a resident with significant cognitive impairment from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts until law enforcement located him approximately three hours later, wandering in a busy commercial district over six miles away. The facility failed to ensure resident #1 was adequately supervised and failed to monitor the front lobby door to ensure vulnerable residents did not exit the facility without supervision. There was a total of 11 residents who were identified as at risk for elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy. The Immediate Jeopardy began on 4/19/21 and was removed on 4/23/21. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more that minimal harm that is not Immediate Jeopardy. Findings: Resident #1 was [AGE] years old, admitted to the facility on [DATE] with a primary diagnosis of dementia with behavioral disturbance. His secondary diagnoses included anxiety, [CONDITION(S)] disorder, altered mental status (AMS), and [CONDITION(S)]. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 4/05/21 revealed resident #1 was admitted to the hospital for AMS and dementia. The document indicated he lacked decision making capacity, required a surrogate, and walked without an assistive device. He was alert but disoriented and could follow simple instructions. Review of the hospital record revealed resident #1 was hospitalized on [DATE] under the Baker Act. This law permits involuntary examination of a person who is believed to be mentally ill, refuses voluntary examination and without care or treatment will suffer neglect and/or cause harm to self or others (retrieved on 4/28/21 from the Florida Department of Children and Families website.www.myflfamilies.com). The Report of Law Enforcement Officer Initiating Involuntary Examination dated 3/24/21 revealed resident #1 met the criteria for involuntary examination. He was neither able to respond to basic questions nor care for himself. The document indicated a psychiatric nurse confirmed the instability of resident #1's mental status and reported he was aggressive with his sister. A written statement by the psychiatric nurse indicated she had been working with resident #1's family . to get him mental health care and safe placement. He wanders daily / bus riding. She wrote he was at risk for safety. Review of the medical record revealed an Admission/Readmission Data Collection form dated 4/05/21. The document indicated resident #1 was alert, oriented to person only, had memory problems and experienced hallucinations. Section N2. Elopement Risk Evaluation revealed inaccurate findings that were inconsistent with the hospital record and findings already documented within the admission assessment. The elopement evaluation inaccurately showed resident #1 was not cognitively impaired, did not have poor decision-making skills, had not demonstrated exit-seeking behavior, did not wander oblivious to safety needs, had no history of elopement or ability to exit the facility. The admission nurse Registered Nurse (RN) B determined resident #1 was not at risk for elopement based on the responses to the evaluation questionnaire. In RN B's Admission Nurse's Note at the end of the form, he described resident #1 as confused, very demented and required close monitoring. On 4/06/21, resident #1 was assessed by a psychiatric Advanced Practice Registered Nurse (APRN) for medication management related to anxiety. The progress note revealed resident #1 was a poor historian, had a significant history of dementia, and was oriented to person only. The note read Patient is preoccupied with discharge home . often wanders the halls . has been redirected several times, but due to short term memory impairment does not retain information. The psychiatric APRN noted resident #1 had no insight into the reason for his admission to the facility and described him as cognitively impaired, anxious, with circumstantial and disorganized thought processes, and poor short-term and long-term memory. The psychiatric APRN's assessment indicated resident #1 had poor concentration, insight, and judgement and a diagnosis of adjustment disorder with anxiety. Review of the nursing progress notes dated 4/06/21, showed resident #1 was restless and wandered throughout the hallway and on 4/07/21 he was angry, confused, and unable to follow commands. An Initial Evaluation by a psychologist dated 4/07/21 revealed resident #1 was confused, dodged questions, and tried to conceal his significant cognitive impairment. The document indicated resident #1 exhibited loose associations, tangential thought process and impaired insight and judgement. The evaluation read, He is too impaired to meaningful participate in psychotherapy. Review of the medical record revealed a second Elopement Risk Evaluation dated 4/08/21, completed by the Short Stay Unit (SSU) Unit Manager (UM). The evaluation again inaccurately indicated resident #1 was not cognitively impaired and did not have a history of elopement. The document indicated he wandered oblivious to safety needs and resident is determined to be AT RISK for elopement. The evaluation was not signed by the SSU UM. Instructions on the form directed staff to report all residents at risk for elopement to the Director of Clinical Services (DCS), initiate a prevention protocol immediately and document the risk in the resident's care plan. Review of physician's orders and the Medication Administration Record (MAR) for April 2021 revealed resident #1 was placed on 15- minute checks from 4/08/21 to 4/19/21. The MAR showed resident #1 exhibited behaviors including agitation, combativeness, resisting care and wandering on 14 of 33 shifts. Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 4/12/21 revealed resident #1 had limited ability to express his ideas and wants and responded adequately to simple, direct communication only. Resident #1's Brief Interview for Mental Status (BIMS) score was 0, indicating severe cognitive impairment. He displayed continuous inattention and disorganized thinking and had trouble falling asleep and concentrating on several days. The MDS assessment revealed resident #1 wandered daily and the behavior placed him . at significant risk of getting to a potentially dangerous place. such as outside the facility. The document indicated resident #1's wandering behavior also significantly intruded on the privacy and activities of others. Resident #1 required supervision for transfers and walking and had unsteady balance but was able to stabilize without staff assistance. He did not use a mobility device such as a walker or wheelchair and did not have a wander alarm device. Review of resident #1's Care Area Assessment (CAA) worksheets revealed areas of concern triggered by assessment findings in the MDS assessment which included cognitive loss and behavioral symptoms. The CAA for Cognitive Loss / Dementia dated 4/18/21 included triggered conditions of a BIMS score of less than 13, presence of inattention and disorganized thinking and daily wandering. In an analysis of these findings done by the Director of Social Services (DSS), she wrote, He is actively exit seeking without express destination expressed. Referral has been sent to a secure facility. Should it be rejected, additional referrals will be sent to facilities that can provide better security for his safety. The CAA worksheet indicated care plan considerations should include minimizing risk by providing frequent observation of resident #1's whereabouts. The CAA worksheet for Behavioral Symptoms dated 4/18/21 revealed a triggered condition of resident #1's daily wandering. The document indicated he was ambulatory and actively exit seeking. The behavior was deemed serious and the document read, Resident is immediate threat to self - IMMEDIATE INTERVENTION REQUIRED. The DSS noted resident #1 was at risk for elopement and was in danger due to his inability to identify safety risks. The CAA worksheet indicated care plan considerations should include minimizing risk by keeping a close watch on resident #1 due to his exit seeking behavior. Review of nursing progress notes revealed resident #1's wandering behaviors increased in frequency and severity over time. On 4/11/21, a progress note indicated resident #1 was angry, ambulated with an unsteady gait and required re-direction. On 4/14/21 he wandered around the nurses' station and continued to require re-direction. On 4/16/21, a nursing note revealed resident #1 was anxious, confused, continued to wander in the hallways and staff were unable to re-direct him at times. On 4/17/21, resident #1's assigned nurse noted he was confused, wandered in and out of rooms continuously, and refused to be re-directed. On 4/18/21 a nursing note revealed resident #1 remained on 15-minute checks but continued wandering all over the unit. In a Nursing Progress Note dated 4/19/21 at 4:39 PM, the DCS wrote a late entry regarding an incident that occurred earlier that day at 10:00 AM. The progress note revealed staff responded to an overhead announcement about a missing resident. The receptionist informed the DCS she had opened the front lobby door for resident #1, who she thought was a visitor. Law enforcement was notified, and they located and returned resident #1 to the facility later that afternoon at 12:35 PM. The note revealed that on return to the facility, resident #1 was confused, having flight of ideas and rambling conversation. The facility placed an electronic wandering device on his wrist and initiated 1:1 supervision at that time. Review of the medical record revealed a Baseline Care Plan and Summary dated 4/05/21 that included a care plan for Falls/Safety/Elopement. The interventions addressed resident #1's fall risk and environmental safety but did not note a risk for elopement. The document was updated on 4/08/21 to reflect implementation of 15-minute checks but did still did not address risks related to wandering and elopement. The baseline care plan read Resident desires other(s) to be part of care planning. However, the document revealed there was no review of the care plan with resident #1's representative until 4/22/21, three days after he eloped from the facility. Despite the significant assessment findings and recommendations on the CAA worksheets, the facility did not develop care plans with interventions to prevent resident #1 from wandering to unsafe areas or eloping. A care plan for elopement risk and wandering related to impaired safety awareness was eventually initiated on 4/20/21, the day after resident #1 eloped from the facility. On 4/23/21 at 9:23 AM, resident #1 was seated on the bed in his room with Certified Nursing Assistant (CNA) C nearby providing 1:1 supervision. Resident #1 stood and moved quickly towards the door once it opened and required immediate re-direction. He was alert but disoriented, and only able to provide his name. Resident #1's speech was rapid and repetitive with periods of incoherent rambling words. He became frustrated at not being able to communicate his thoughts and recited verses of poetry instead. CNA C described resident #1 as very, very confused. He doesn't really understand. On 4/23/21 at 9:29 AM, the West Wing UM confirmed resident #1 had been transferred to her unit after his elopement on 4/19/21. She explained resident #1 was very confused, and said, There are brief moments of lucidity [MEDICATION(S)] up to 2 to 3 minutes . I would say he would not be safe in the community because of his cognitive state. He would not be safe crossing the street. The West Wing UM stated although resident #1 might be physically able to walk without assistance, he might not make safe decisions and could step into the path of traffic. On 4/23/21 at 9:40 AM, receptionist A recalled on the day of resident #1's elopement she was seated in the front lobby at her desk. She stated at about 9:15 AM, resident #1 walked through the lobby past her desk, and headed towards the front door. She stated he repeated his name a few times and said, I'm all set. I'm done. Receptionist A stated she opened the front lobby door as resident #1 approached it and he exited the facility alone, turned right and walked away from the facility. Receptionist A explained resident #1 looked like a visitor because he was well-dressed in jeans, a long sleeve button-up shirt and a baseball cap. When asked why she felt he was a visitor, receptionist A said, Residents would have walkers or wheelchairs. Those are the top two things I would look for. Receptionist A acknowledged she was educated on hire to follow the facility's visitation procedure including asking visitors to sign in and out on a log. She stated she was not sure why she did not follow this procedure. Receptionist A stated later that morning, resident #1's assigned nurse arrived in the lobby to use the overhead paging system to announce a missing resident. Receptionist A said, After she announced the name, I remembered what the man said his name was and I realized then that he was not a visitor. She explained the nurse and the DCS provided her with a photograph of resident #1 and she confirmed she let him out the front door. Receptionist A stated she was at her desk in the front lobby when law enforcement representatives returned resident #1. She recalled they reported resident #1 was found in the downtown area near a restaurant, close to railroad tracks and a major highway. In an interview on 4/24/21 at 9:52 AM, the Business Office Manager (BOM) stated her duties included training and supervision of receptionists. She explained after a general orientation to the facility, new receptionists shadowed an experienced receptionist to learn the job responsibilities including visitor and front door monitoring procedures. The BOM stated the facility did not have a system in place to validate that new receptionists were knowledgeable of all safety procedures to prevent elopement prior to working without supervision. On 4/23/21 at 10:11 AM, the DCS stated a 15-minute check on 4/19/21 showed resident #1 was last observed by nursing staff at 9:00 AM. The DCS could not explain why assigned nursing staff did not notice resident #1 was missing for the scheduled 15-minute checks at 9:15 AM, 9:30 AM and 9:45 AM. He confirmed the police eventually found resident #1 walking in the historic [NAME] downtown district. The DCS said, It is an assumption that he took a bus. When he returned, he told the nurse he was beat tired because he had a bus ride today. The DCS stated during the search, resident #1's sister informed the facility her brother often used to ride buses to the downtown area. The DCS explained this was the probable scenario since there was currently no fee for use of the transit system. On 4/23/21 at 11:02 AM, Physical Therapist (PT) D recalled on 4/19/21 resident #1 was not in his room when she checked at about 8:15 AM. She said, I was wondering where he was, and someone told me he was walking around. PT D stated at about 8:30 AM she informed the SSU UM she could not find resident #1 for his therapy session. PT D stated the SSU UM told her resident #1 was in the facility so she continued on to her next appointment. PT D stated at about 9:30 AM, she decided to look for resident #1 more thoroughly. When she still could not locate him, she informed his assigned nurse that neither she nor the other therapists had been able to find resident #1. PT D stated resident #1 was sometimes anxious and agitated, had limited conversation, and could not follow higher thought processes or complicated sequences of instructions. PT D confirmed resident #1's cognitive issues and poor decision making would make him unsafe if unsupervised outside the facility. In a telephone interview on 4/24/21 at 9:14 AM, PT D explained she was aware of resident #1's potential risk for elopement prior to the incident based on the hospital record included in his chart. She stated during the initial PT evaluation at the time of admission, she read that resident #1 had a history of getting away from his family and jumping on buses. On 4/23/21 at 12:40 PM, RN B acknowledged he completed resident #1's initial elopement evaluation on admission. RN B explained if a resident was cognitively impaired he obtained information from the hospital record. RN B validated he did not attempt to contact resident #1's family to obtain accurate information regarding any previous history of wandering, exit-seeking behaviors and elopements. RN B reviewed the admission elopement evaluation and noted the errors related to resident #1's cognitive impairment, poor decision making and ability to exit the facility. In interviews on 4/23/21 at 1:19 PM and 3:52 PM, the DSS validated she completed the section on the MDS regarding resident #1's daily, dangerous wandering behavior. The DSS said, At first he wandered around his immediate room area and then he was just everywhere on the unit. She recalled eventually he started exiting the unit. The DSS stated on 4/08/21, three days after resident #1's admission, she sent a referral for placement to another nursing facility with a secure, locked unit. The DSS validated she completed CAAs worksheets that referred to resident #1's exit-seeking behavior and increased potential for elopement. She acknowledged her assessment would suggest additional interventions were necessary to ensure resident #1's safety. The DSS stated resident #1's behaviors were discussed regularly in daily clinical meetings of the interdisciplinary team (IDT) and secure unit placement was a team decision. However, she could not explain why the IDT felt resident #1's behavior was significant enough to require a secure unit, but not warrant a careful review of his elopement evaluations, closer supervision, addition of his photograph and demographic information to the elopement risk binder or placement of an electronic wander device. The DSS stated she did not initiate a care plan as directed by the assessment findings nor inform the DCS of her concerns. She said, Usually I would have put in a care plan immediately for something like this. Obviously, I dropped the ball. I can't say why. Maybe I was interrupted. I don't even have an excuse. Review of the policy and procedure Plans of Care revised on 9/25/17 revealed the IDT would develop and implement an Individualized Person-Centered baseline plan of care . to ensure residents' care needs were met. Review of the job description for the Admissions and Social Service Coordinator (undated) revealed the duties and responsibilities of the DSS included meet with appropriate facility staff concerning resident issues . ensure all documentation complies with applicable regulations. 4/24/21 at 8:52 AM, in a telephone interview with the SSU UM, he stated he re-evaluated resident #1's elopement risk three days after admission due to his significantly increased confusion. He acknowledged his evaluation contained erroneous information regarding resident #1's cognitive impairment. He confirmed he never attempted to obtain information from resident #1's family members related to past wandering behaviors and elopement incidents. The SSU UM stated although the instructions on the evaluation form indicated resident #1 was at risk for elopement he did not initiate a new care plan. He explained 15-minute checks were initiated because to his knowledge resident #1 wandered only on the SSU and was therefore not truly at risk for elopement. However, the SSU UM recalled on the day resident #1 eloped, he saw him walking in the hallway near the therapy gym and re-directed him to return to the SSU. The SSU UM recalled previous IDT discussion regarding transferring resident #1 to a facility with a secure, locked unit, but he could not explain why such a high-risk resident did not have more appropriate safety interventions in place. The SSU UM stated on the morning resident #1 eloped, the IDT discussed placement of an electronic wander device, but it was not done. Review of the policy and procedure Elopement/Wandering Risk Guideline revised on 8/01/20 revealed a purpose to evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions. The document directed staff to evaluate residents on admission and again 7 days after admission. For an identified elopement risk, staff should obtain a photograph of the resident and create an Elopement Risk Alert. The procedure indicated the facility would develop and implement individualized interventions based on the level of risk. Review of the job description for Unit Manager - RN (May 2010) revealed duties and responsibilities included conducting and accurately documenting a thorough collection of data regarding residents' status on admission and throughout their stay. The UM was expected to participate in IDT meetings and assist in the development and implementation of an individualized treatment plan for each assigned resident. On 4/24/21 at 10:01 AM, in a telephone interview with resident #1's daughter, she described her father's extensive history of [CONDITION(S)], dementia, and impulsive, erratic behavior. She recalled an incident 7 years ago when he drove on the wrong side of the highway with his young grandson in the car and got lost in a nearby city that was previously familiar to him. She stated her father was an angry person who was sometimes physically aggressive. Resident #1's daughter stated during her father's recent stay at her home, he left and got lost on more than one occasion. She said, Some strangers picked him up and called me from my number in his phone. He did not know me at times and made up stories about himself . He would usually just jump on the bus and take off. Resident #1's daughter stated the facility did not contact her when her father was admitted regarding information on his previous medical history and behaviors. Resident #1's daughter said, He needs to be in a lockdown facility. He needs to be able to walk outside or walk around freely or else he will be angry and try to leave. On 4/24/21 at 11:25 AM, during a review of a map of the downtown area with the Executive Director she indicated resident #1 was found by law enforcement by a sports bar near the railroad tracks in the downtown area. The map showed the distance from the facility was 6.7 miles. Review of the county transit system's bus route map revealed there was a bus stop on the 4-lane street in front of the facility. Resident #1 could either have taken one bus to the end of its route and walked about a mile to the downtown area or transferred to another bus to get directly to the busy commercial area (retrieved on 4/24/21 from www.321Transit.com). On 4/24/21 at 12:00 PM, resident #1's probable elopement route was re-traced. He exited the facility's front lobby door and turned right, walked through the parking lot, and left the property. The facility is located along a busy 4-lane street that intersected nearby with a heavily trafficked 6-lane road. The facility and bus stop faced a large department superstore with a constant flow of vehicles entering and leaving the parking lot. Resident #1 traveled a total of 570 feet from the facility's front door to the bus stop. Based on the facility's timeline and the posted schedule for bus route 24, resident #1 would have been at the bus stop when the eastbound bus arrived at 9:30 AM. On 4/24/21 at 12:25 PM, observation of the downtown area revealed a dense commercial area with offices, restaurants, bars, and stores. The narrow main street was filled with slow-moving traffic and there was street parking along the sidewalks. Near the sports bar where resident #1 was found, three roads converged at a railroad track in a complicated intersection. The main street through the downtown area ended at a major 6-lane highway approximately 1000 feet away. Historical weather data revealed on the morning resident #1 eloped, 4/19/21, the temperature at 8:53 AM was 70 degrees Fahrenheit (F) with light rain and fog. An hour later at 9:53 AM, it was 71 degrees F and foggy, and at 11:53 AM, the temperature was 76 degrees F. with broken clouds (retrieved on 4/23/21 from www.timeanddate.com). Review of the Facility Assessment Tool reviewed by the Quality Assurance and Performance Improvement (QAPI) committee on 1/28/21, revealed the facility accepted and could care for residents with psychiatric and mood disorders including [CONDITION(S)], hallucinations, delusions, impaired cognition, [CONDITION(S)], anxiety, and behaviors that needed intervention. The document indicated the facility provided person-centered care including identification of hazards and risks for residents. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 4/19/21 at 10:00 AM, resident #1 was discovered to be missing and the facility implemented its elopement policy and procedures. * On 4/19/21 at 12:35 PM, resident #1 returned to the facility by local law enforcement. He was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 had an electronic monitoring device applied and he was placed on 1:1 supervision. *On 4/19/21, resident #1 was re-evaluated for elopement risk and a comprehensive care plan was initiated due to his increased risk. * On 4/19/21, receptionist A received 1:1 re-education regarding following the facility's front door monitoring procedures to ensure no residents were permitted to leave the facility without authorization. * On 4/20/21, the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting and conducted a root cause analysis of the elopement. The QAPI committee including the Medical Director approved the Performance Improvement Plan and created audit tools. *From 4/20/21 to 4/21/21, the facility re-evaluated all residents' elopement risk and there were no newly identified concerns. A quality review audit of the 11 residents who were at risk for elopement revealed no concerns related to their electronic wandering devices, care plans and physicians' orders. *On 4/21/21, the elopement binders were updated with resident #1's demographic information. * From 4/19/21 to 4/24/21, re-education was provided for nurses regarding completing elopement risk evaluations accurately and reporting residents identified at risk to the UMs and DCS. During this period, staff were educated on the facility's elopement procedures. Reconciliation of in-service attendance sheets with the facility's staff roster revealed 162 of 182 staff members received education, a total of 89%. * From 4/19/21 to 4/24/21, the facility completed 8 elopement drills to cover all 3 shifts with satisfactory staff response documented on elopement drill worksheets. * Interviews were conducted from 4/23/21 to 4/24/21 with 21 staff members (5 CNAs representing all shifts, 1 Patient Care Assistant, 3 of 5 receptionists, 5 RNs, 3 Licensed Practical Nurses, 3 therapists and 1 dietary aide). Staff interviews revealed they were knowledgeable of the elopement policy and procedures and supervision of residents at risk for elopement. The resident sample was expanded during the survey to include 7 additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #3, #5, #7, #9, #11, #13 and #15.

Based on observation, interview, and record review, the facility failed to follow accepted standards of clinical practice for wound assessment, documentation, and treatment of [REDACTED].#2). As a result of this failure, resident #2 developed avoidable pressure ulcers to the left and right heel. Cross Refer to F314 Findings: European Pressure Ulcer Advisory Panel; National Pressure Ulcer Advisory Panel; Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. treatment of [REDACTED]. Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. 2. With each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications). 2.1 Address signs of deterioration immediately. 3. Assess and document physical characteristics, including: Location, Category/Stage, Size,Tissue type(s), Color, Periwound condition, Wound edges, Sinus tracts, Undermining, Tunneling, Exudate, Odor Conducting Skin and Tissue Assessment 1. In individuals at risk of pressure ulcers, conduct a comprehensive skin assessment: As soon as possible but within eight hours of admission (or first visit in community settings) As part of every risk assessment Ongoing based on the clinical setting and the individual's degree of risk Prior to the individual's discharge. 1.1 Increase the frequency of skin assessments in response to any deterioration in overall condition. 1.2 Document the findings of all comprehensive skin assessments. Prevention of pressure ulcers 1. Conduct a structured risk assessment as soon as possible (but within a maximum of eight hours after admission) to identify individuals at risk of developing pressure ulcers. 2. Repeat the risk assessment as often as required by the individual's acuity. 3. Undertake a reassessment if there is any significant change in the individual's condition. 4. Include a comprehensive skin assessment as part of every risk assessment to evaluate any alterations to intact skin. 5. Document all risk assessments. 6. Develop and implement a risk based prevention plan for individuals identified as being at risk of developing pressure ulcers. Caution: Do not rely on a total risk assessment tool score alone as a basis for risk based prevention. Risk assessment tool subscale scores and other risk factors should also be examined to guide risk-based planning. Florida Board of Nursing, Nurse Practice Act, 464.003 (3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and the promotion of wellness, maintenance of health, and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to subscribe such medications and treatments, (3) the supervision and teaching of other personnel in the theory and performance of any of the above acts. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Section M Skin of the Admission/Readmission Data Collection form, dated 5/03/17 revealed resident #2 was admitted with an area of skin impairment on the buttocks. The form had no description of the area of concern highlighted on the buttocks of the body diagram, and no information documented in the sections for General Skin Condition and Current Skin Treatments. The section for Foot Problems and Care did not identify any observations regarding resident #2's heels. The Admission Nurse's Notes section of the data collection tool revealed resident #2 had a .stage 3 pressure (ulcer) 6 x 12 (centimeters) in her buttocks . On 5/31/17 at 12:55 PM licensed practical nurse (LPN) G stated she performed the re-admission data collection for resident #2 on 5/03/17. LPN G confirmed she documented in the nurse's note that resident #2 had a stage 3 pressure ulcer. When asked if she assessed and staged wounds, she acknowledged staging wounds was outside her scope of practice. LPN G stated she should have described the area of impairment instead of staging the wound. She explained she received the information on the stage of the sacral wound in verbal report, but could not provide written supporting documentation. Resident #2 had a Wound Care initial exam 5 days later, on 5/08/17. The assessment findings indicated resident #2 had an unstageable sacral pressure ulcer with measurements 9.0 x 9.0 centimeters (cm), not a stage 3 wound measuring 6 x 12 as documented by the admitting nurse. The Wound Care progress note revealed resident #2 also had an unstageable left lateral heel pressure ulcer, an intact dry purple blister with measurements 4.0 x 3.5 cm that was not identified in the admission data collection. Review of daily nurses' notes from 5/04/17 to 5/08/17 revealed no documentation of a left heel pressure ulcer. Following this initial exam on 5/08/17, resident #2 received weekly visits from the Wound Care Advanced Registered Nurse Practitioner (ARNP) on 5/15/17, 5/22/17 and 5/30/17. Review of the Nursing Assessment and Treatment forms completed by the Wound Care ARNP revealed assessments, interventions, and treatment orders for resident #2's unstageable wounds to the sacrum and the left lateral heel. The interdisciplinary team (IDT), comprised of the Director of Clinical Services (DCS), Assistant DCS (ADCS) and the East Wing Unit Manager (UM) accompanied the wound care ARNP during Wound Rounds on 5/15/17, 5/22/17 and 5/30/17. The Interdisciplinary Progress Notes revealed documentation of observations, measurements, and treatment orders for unstageable wounds to resident #2's sacrum and left heel, but did not identify any areas of concern on the right heel. The associated Pressure Ulcer Record forms for assessments completed during the wound rounds revealed wound measurements were recorded by the wound team. The forms indicated the unstageable sacral pressure ulcer was present on admission, but the unstageable left lateral heel pressure ulcer was acquired after admission. On 5/31/17 at 12:35 PM the UM stated, to her knowledge, resident #2 currently had a left heel wound and no wounds on the right heel. The UM explained she was a member of the facility's wound team that rounded once weekly. She stated resident #2 was seen during wound rounds yesterday, on 5/30/17, and the team was not aware of a new pressure ulcer on her right heel. On 5/31/17 at 12:37 PM an observation of resident #2's bilateral heels was conducted with the UM and the ADCS, and they confirmed there was an unstageable dark purple pressure ulcer, about 3 cm in diameter on the right heel. Resident #2's legs were on an off-loading heel elevator cushion located under her knees rather than under the lower legs. The ADCS confirmed resident #2 needed to be repositioned to ensure appropriate placement for pressure relief. The UM stated she had never seen this right heel pressure ulcer and was not informed of its development. She explained nurses were expected to notify her, the DCS, the physician and the resident's responsible party of any newly identified areas or worsening areas of skin impairment. She stated nurses were expected to complete a Situation, Background, Assessment and Recommendation (SBAR) communication form to document findings, notifications and immediate interventions for any change in a resident's condition. On 5/31/17 at 12:42 PM a review of resident #2's medical record was conducted with the UM and the ADCS. Weekly skin checks, scheduled for Thursdays on the 7:00 AM - 3:00 PM shift, were documented on a Skin Evaluation sheet. On 5/25/17 the weekly evaluation indicated resident #2 had an unstageable area to the right heel with measurements of 3.4 x 2.5. The entry did not include required detail of whether the area was open, new, or previously identified. The evaluation was dated, but not signed. The UM explained LPNs were not permitted to stage wounds, rather, it should have been reported so a Registered Nurse could assess the area. Review of the Medication Administration Record [REDACTED]. The entry was dated, but not initialed or signed. Documentation on the MAR indicated [REDACTED]. The UM confirmed the use of SKIN-PREP required an order, and validated there was no corresponding order to support this entry. The UM validated there was no SBAR communication form or nurse's note regarding contacting a physician for orders or notifying a supervisor of the newly identified pressure ulcer to the right heel. The manufacturer's product overview revealed SKIN-PREP is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films. (http://www.smith-nephew.com/professional/products/advanced-wound-management/skin-prep/). Review of the Policy and Procedure (P&P) for Skin Evaluation revised 4/01/2017, revealed A Licensed Nurse will complete a total body evaluation on each resident weekly .paying particular attention to .pressure injury .reddened areas and skin problems. The procedure instructed nurses to document observations on the skin evaluation form and initiate the appropriate form, such as Pressure Injury Record for pressure areas. The procedure directed The evaluating nurse must date and sign each review .will initiate the appropriate form. For pressure areas complete the Pressure Injury Record . Review of the P&P for Change In Resident Condition effective 11/30/2014, revealed the primary nurse was expected to communicate any change in a resident's condition to the nurse manager or supervisor as it occurs and notify the physician and family as soon as possible. In addition, the information should be placed in the 24-hour report. The procedure directed nurses to document assessment findings and the details of notification, and instructed supervisors to communicate with the minimum data set (MDS) Coordinator as a change in condition .may warrant a reassessment. The facility's Best Practices-24 Hour Report (12/20/16) guide revealed the 24-hour report was used to communicate .clinical information, unusual occurrences, changes in condition, changes in plan of care . This method of communication was devised to maintain the continuum of safe patient care and should be reviewed during daily clinical meetings. The best practices included documentation, by exception, on each shift on care areas such as admissions, change in condition, and new or changed wounds (pressure or non-pressure). However, review of 24 Hour Report / Change of Condition Report forms dated 5/17/17 to 5/23/17 and 5/25/17 revealed no entries regarding a newly acquired pressure ulcer on resident #2's right heel. Review of Daily Skilled Nurse's Note forms dated 5/04/17 to 5/30/17 revealed nurses documented on resident #3 at least three times daily, once each shift, but did not record any observations or assessments related to resident #2's right heel. On 5/31/17 at 1:27 PM the DCS confirmed changes in skin condition should be documented by nurses on a SBAR communication form followed by notification of the physician, family, and manager or supervisor, then addressed on the appropriate grid or form. The DCS confirmed the newly identified dark purple area on resident #2's right heel was an unstageable pressure ulcer. She explained SKIN-PREP was a preventative measure and a standard of care therefore, did not require a physician's orders [REDACTED].#2 revealed an order dated 5/08/17 for prep to left lateral heel every shift. The facility's Pressure Ulcer Protocol At-A-Glance protocol provided guidance for nurses in identification, staging and treatment of [REDACTED]. The protocol read that suspected DTI should be coded as unstageable, and product selection should be made according to physicians order . On 5/31/17 at 1:36 PM the Lead Minimum Data Set (MDS) Coordinator stated she met with the UM after Wound Rounds yesterday, 5/30/17, and discussed resident #2's sacral and left heel pressure ulcers. The MDS Coordinator confirmed the UM did not report a newly identified pressure ulcer on the right heel, as a result she did not revise the care plan. She explained LPNs do not stage wounds, rather they should inform the physician, the UM and follow the facility's pressure ulcer protocol. The MDS Coordinator explained in addition to herself, any nurse could initiate a care plan for a newly identified area of skin impairment. She stated care plans were updated based on assessment findings, so resident #2's right heel pressure ulcer would not have been addressed on a care plan since there was no documentation or report from nursing staff. On 6/01/17 at 10:52 AM LPN E stated on 5/21/17 she observed a new dark purple area, about 2.5 cm in diameter, on resident #2's right heel. LPN E described the surrounding tissue as pink and blanchable at that time, and stated she applied SKIN-PREP to the right heel. When asked if SKIN-PREP was a preventative measure or a treatment, LPN E stated it was both. She confirmed there was no order for SKIN-PREP to the right heel, and explained she carried packets of SKIN-PREP in her pockets and used it on residents as needed. LPN E said, It's regular care, just like washing your face. LPN E acknowledged she did not document the newly identified right heel pressure ulcer or notify the physician or the UM at that time. LPN E confirmed the dark purple pressure ulcer worsened between 5/21/17 when she first noticed it, and 5/25/17 when she did a scheduled weekly skin evaluation. She confirmed during this time the wound increased in size and the surrounding tissue was darker, but she still did not report it to the physician or the UM. LPN E stated resident #2's heel did not get like that overnight and other nurses and certified nursing assistants (CNAs) should have seen the change while providing care. LPN E acknowledged she did not follow the facility's process of reporting a newly identified area of skin impairment to the physician and the UM, and stated she should have obtained an order for [REDACTED].

Based on observation, interview, and record review, the facility failed to prevent the development of avoidable pressure ulcers and failed to ensure necessary care and services were provided for identification and treatment of [REDACTED].#2). The facility's failure to provide necessary care and treatment to prevent new pressure ulcers resulted in actual harm. Resident #2 developed pressure ulcers to both heels that were not identified or treated until after they progressed to unstageable ulcers. Cross refer to F281 and F520 Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Section M Skin of the Admission/Readmission Data Collection form, dated 5/03/17 revealed resident #2 was admitted with an area of skin impairment on the buttocks. The form had no description of the area of concern highlighted on the buttocks of the body diagram, and no information documented in the sections for General Skin Condition and Current Skin Treatments. The section for Foot Problems and Care did not identify any concerns regarding resident #2's heels. The Admission Nurse's Notes section of the data collection tool revealed resident #2 had a .stage 3 pressure (ulcer) 6 x 12 (centimeters) in her buttocks, dressing change. Review of the clinical record revealed a physician's orders [REDACTED].#2 for the coccyx wound. Resident #2 was seen by the Wound Care Advanced Registered Nurse Practitioner (ARNP) on 5/08/17. The Wound Care progress note for this initial exam revealed she had an unstageable pressure injury located on the sacrum, that measured 9 x 9 centimeters (cm), not a stage 3 wound that measured 6 x 12 cm as documented on the admission data collection form. In addition, the wound care ARNP identified an intact purple blister, unstageable pressure injury obscured full-thickness skin and tissue loss on the left lateral heel that measured 4 x 3.5 cm. The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure injury as localized damage to the skin and underlying soft tissue . as intact skin or an open ulcer . The updated staging system (April 2016) revealed a stage 3 pressure injury occurred when there was full-thickness skin loss and fat, and visible slough (yellow or white mucous-like tissue) or eschar (black or brown tissue firmly adhering to the wound bed or edges). In a stage 4 pressure injury there was full-thickness skin and tissue loss with exposed muscle, tendon or bone. In an unstageable pressure injury, the extent of skin and tissue loss could not be confirmed because the area was covered by slough or eschar. A Deep Tissue Injury (DTI) was described as an area of persistent purple discoloration or a blood-filled blister (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). Review of physician's orders [REDACTED].#2's sacral wound care orders were changed. There were orders to initiate Skin prep (L) (left) lateral heel (every) shift and Therapy eval for off loading device for (L) (left) heel, approp. (wheelchair) cushion for sacral wound. Low air mattress. Following the initial exam, resident #2 received weekly visits from the Wound Care ARNP on 5/15/17, 5/22/17 and 5/30/17. Review of the Nursing Assessment and Treatment forms completed by the Wound Care ARNP revealed assessments, interventions and treatment orders for resident #2's unstageable wounds to the sacrum and the left lateral heel. The interdisciplinary team (IDT), comprised of the Director of Clinical Services (DCS), Assistant DCS (ADCS) and the East Wing Unit Manager (UM) accompanied the wound care ARNP during Wound Rounds on 5/15/17, 5/22/17 and 5/30/17. The Interdisciplinary Progress Notes revealed documentation of observations, measurements and treatment orders for unstageable wounds to resident #2's sacrum and left heel, but did not identify any areas of concern on the right heel. The associated Pressure Ulcer Record forms for assessments completed during these rounds revealed wound measurements were recorded by the wound team. The forms indicated the unstageable sacral pressure ulcer was present on admission, but the unstageable left lateral heel pressure ulcer was acquired after admission. The Minimum Data Set (MDS) prospective payment system 14-day assessment, with assessment reference date (ARD) of 5/17/17 revealed resident #2 required extensive assistance of one person for personal hygiene, and extensive assistance of two people for bed mobility. Resident #2 was assessed as being at risk of developing pressure ulcers and had unhealed pressure ulcers. She had one unstageable pressure ulcer with dimensions of 8.0 x7.0 x0 cm with slough, and one unstageable deep tissue injury. Review of resident #2's clinical record revealed a care plan for impaired skin integrity of the left lateral heel, initiated on 5/08/17 and revised on 5/22/17. The goal was the wound would show signs of healing and remain free from infection through the next review on 7/18/17. Interventions included treatments as ordered, float heels and weekly skin checks. There was no care plan to address any preventive measures or interventions for potential skin impairment to the right heel. The Medication Administration Record [REDACTED]. The entry was not signed or initialed and review of physician's orders [REDACTED]. The Skin Evaluation form dated 5/25/17 documented findings from resident #2's weekly skin check of a (R) heel unstageable 3.4 x 2.5 area on 5/25/17. This right heel area was previously unidentified in the medical record. On 5/31/17 it was brought to the attention on the nursing leadership team, and they confirmed it was a new unstageable pressure ulcer. On 5/31/17 at 9:03 AM during observation of sacral wound care with licensed practical nurse (LPN) F, dark purple areas were observed on resident #2's heels, approximately 4-5 cm in diameter on the left heel and 3-4 cm in diameter on the right heel. The peri-wound tissue was light pink on the left heel and dark pink on the right heel. On 5/31/17 at 12:35 PM the unit manager (UM) stated, to her knowledge, resident #2 had a left heel wound and no wounds on the right heel. The UM explained she was a member of the facility's wound team that rounded once weekly. She stated resident #2 was seen during wound rounds yesterday, on 5/30/17, and the team was not aware of a new pressure ulcer on her right heel. On 5/31/17 at 12:37 PM an observation of resident #2's bilateral heels was conducted with the UM and the ADCS, and they confirmed there was an unstageable dark purple pressure ulcer, about 3 cm in diameter on the right heel. Resident #2's legs were on an off-loading heel elevator cushion located under her knees rather than under the lower legs. The ADCS confirmed resident #2 needed to be repositioned to ensure appropriate placement for pressure relief. The UM stated she had never seen this right heel pressure ulcer and was not informed of its development. She explained nurses were expected to notify her, the DCS, the physician and the resident's responsible party of any newly identified areas or worsening areas of skin impairment. She stated nurses were expected to complete a Situation, Background, Assessment and Recommendation (SBAR) communication form to document findings, notifications and immediate interventions for any change in a resident's condition. On 5/31/17 at 12:42 PM a review of resident #2's medical record was conducted with the UM and the ADCS. Weekly skin checks, scheduled for Thursdays on the 7:00 AM - 3:00 PM shift, were documented on Skin Evaluation sheets. The weekly evaluation dated 5/25/17 that indicated resident #2 had an unstageable area to the right heel with measurements of 3.4 x 2.5 was brought to the attention of the UM and ADCS. The entry did not include any detail of whether the area was open, new or previously identified. Review of the MAR indicated [REDACTED]. The UM confirmed the use of SKIN-PREP required an order, and validated there was no corresponding order to support this entry. The UM validated there was no SBAR communication form or nurse's note regarding contacting a physician for orders or notifying a supervisor of the newly identified pressure ulcer to the right heel. The manufacturer's product overview revealed SKIN-PREP is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films. (http://www.smith-nephew.com/professional/products/advanced-wound-management/skin-prep/). On 5/31/17 at 1:27 PM the DCS confirmed changes in skin condition should be documented by nurses on a SBAR communication form followed by notification of the physician, family, and manager or supervisor, then addressed on the appropriate grid or form. The DCS confirmed the newly identified dark purple area on resident #2's right heel was an unstageable pressure ulcer. She explained SKIN-PREP was a preventative measure and a standard of care therefore did not require a physician's orders [REDACTED].#2 revealed an order dated 5/8/17 for SKIN-PREP to left lateral heel every shift. The facility's Pressure Ulcer Protocol At-A-Glance protocol (undated) provided guidance for nurses in identification, staging and treatment of [REDACTED]. The protocol read that a suspected DTI should be coded as unstageable, and product selection should be made according to physicians order . On 5/31/17 at 1:36 PM the lead MDS Coordinator stated the care plan for resident #2's left heel pressure ulcer was last updated on 5/22/17. She explained care plans were reviewed quarterly, and also updated regularly with information obtained from daily review of new orders or reports from nursing staff. The MDS Coordinator stated she met with the UM after wound rounds yesterday, 5/30/17, and discussed resident #2's wounds. She confirmed the UM did not mention a newly identified pressure ulcer to the right heel. On 6/01/17 at 10:52 AM LPN E stated she was regularly assigned to care for resident #2 and was familiar with her skin conditions. LPN E explained she returned to work on 5/21/17 after approximately 2 weeks' leave and noticed resident #2 had a new dark purple area, about 2.5 cm in diameter, on her right heel. LPN E described the surrounding tissue as pink and blanchable at that time, and stated she applied SKIN-PREP to the right heel. When asked if SKIN-PREP was a preventative measure or a treatment, LPN E stated it was both. She confirmed there was no order for SKIN-PREP to the right heel, and explained she carried packets of SKIN-PREP in her pockets and used it on residents as needed. LPN E said, It's regular care, just like washing your face. LPN E acknowledged she did not document the newly identified right heel pressure ulcer or notify the physician or the UM at that time. LPN E confirmed the dark purple pressure ulcer worsened between 5/21/17 when she first noticed it, and 5/25/17 when she did a scheduled weekly skin evaluation. She confirmed during this time the wound increased in size and the surrounding tissue was darker, but she still did not report it to the physician or the UM. LPN E stated resident #2's heel did not get like that overnight and other nurses and certified nursing assistants (CNAs) should have seen the change while providing care. LPN E acknowledged she did not follow the facility's process of reporting a newly identified area of skin impairment to the physician and the UM, and stated she should have obtained an order for [REDACTED]. Review of the policy and procedure for Change In Resident Condition effective 11/30/2014, revealed the primary nurse was expected to communicate any change in a resident's condition to the nurse manager or supervisor as it occurs and notify the physician and family as soon as possible. In addition, the information should be placed in the 24-hour report. The procedure directed nurses to document assessment findings and the details of notification, and instructed supervisors to communicate with the MDS Coordinator as a change in condition .may warrant a reassessment. The facility's Best Practices-24 Hour Report (12/20/16) guide revealed the 24-hour report was used to communicate .clinical information, unusual occurrences, changes in condition, changes in plan of care . This method of communication was used to maintain the continuum of safe patient care and should be reviewed during daily clinical meetings. The best practices included documentation, by exception, on each shift on care areas such as admissions, change in condition, and new or changed wounds (pressure or non-pressure). However, review of 24 Hour Report / Change of Condition Report forms dated 5/17/17 to 5/23/17 and 5/25/17 revealed no entries regarding a newly acquired pressure ulcer on resident #2's right heel. The Daily Skilled Nurse's notes from 5/10/17 to 5/30/17 revealed no documentation of concerns related resident #2's right heel. On 6/01/17 at 1:12 PM the UM stated her expectation was all CNAs would complete a Skin Care Alert form for each resident at least twice weekly on his/her assigned shower day, and for any new areas of skin impairment observed during care. She stated CNAs should always report findings to the assigned nurse. The UM acknowledged she reviewed weekly skin evaluation forms completed by nurses, but did not review the CNA Skin Care Alert forms. On 6/01/17 at 2:05 PM CNA B stated she noticed a new area of purple discoloration on resident #2's right heel about 2 weeks ago, but could not recall the date. CNA B explained a therapist was present at the time. She said, I told (LPN E) and she knew about it. CNA B explained she did not document this newly identified area on a skin care alert form, although she was assigned to resident #2 on her shower days, because the nurse was already aware of it. Review of the facility's Pressure Ulcer Prevention At-A-Glance protocol revealed CNAs should inspect skin every shift and as needed. Review of unit's 7-3 Shower Book revealed instructions for CNAs to fill out paper (skin care alert form) for every shower and put in binder under the day. The unit manager will check daily. If not done corrective action will be taken. On 6/01/17 at 2:53 PM the physical therapist (PT) explained she observed a new, black area on resident #2's right heel during a therapy session on 5/23/17. The PT stated she immediately reported it to the assigned nurse, LPN E, and recalled discussing resident #2 in the therapy department's scheduled weekly meeting the following day, 5/24/17. The PT stated a CNA was present during the therapy session, but could not recall her name. Review of a Physical Therapy Treatment Encounter Note (TEN) dated 5/23/17 revealed the PT worked with resident #2 while a CNA provided perineal care. The note indicated the PT identified breakdown on bilateral heels, and LPN E and the CNA informed her they were already aware of the issue. Review of employee time clock records revealed the PT, CNA B and LPN E worked on 5/23/17, as indicated in the PT progress note dated 5/23/17. Review of the policy and procedure Skin Evaluation revised 4/01/17, revealed A Licensed Nurse will complete a total body evaluation on each resident weekly .paying particular attention to .pressure injury .reddened areas and skin problems. The procedure instructed nurses to document observations on the skin evaluation form and initiate the appropriate form, such as Pressure Injury Record for pressure areas.

Based on record review and interview, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) committee to develop and implement plans of action to prevent, identify and treat avoidable pressure ulcers for 1 of 3 residents reviewed of a total of 5 residents with pressure ulcers (#2). As a result of this failure resident #2 developed two avoidable pressure ulcers. Cross Refer to F314 and F281. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's clinical record revealed she developed a left heel unstageable pressure ulcer after admission to the facility. Resident #2 was seen during weekly wound rounds by nursing leadership staff, and had weekly assessments done by the wound care Advanced Registered Nurse Practitioner (ARNP). In addition, skin checks by certified nursing assistants (CNAs) during baths or showers were scheduled twice weekly, on Tuesdays and Fridays. Assigned nurses completed daily skilled nurses' notes every shift (3 times daily) from 5/03/17 to 5/30/17, and completed treatments to the left heel every shift. However, the clinical record contained no documentation by nursing staff of any skin impairment or concerns related to the right heel until 5/25/17, and no evidence of notification to the physician for treatment orders. On 6/01/17 at 5:27 PM a meeting was held with the facility's Executive Director (ED), Director of Clinical Services (DCS), Assistant Director of Clinical Services (ADCS) and the Regional Director of Clinical Services (RDCS). The administrator explained the QAA committee consisted of himself, the medical director, department heads and unit managers. He stated the committee usually met once monthly, but after deficiencies found during the recertification/relicensure survey in January 2017, including F281, F314, and F520, meetings were held weekly until the first week of May, then changed to biweekly. The ED explained corrective plans were in place to address all deficiencies from the previous survey in which deficiencies were found to comprise immediate jeopardy to resident health. He said the QAA committee did on-going system evaluation and monitored with audit tools. He acknowledged the QAA committee was ultimately responsible for monitoring the effectiveness of the corrective actions. Review of the current plan of correction indicated the Quality Assurance/Performance Improvement (QAPI) committee would .take corrective action to achieve compliance in skin care management, coordination and communication of services and medical record documentation. The DCS and ADCS stated an audit of each newly admitted resident's chart was done on the next clinical day after admission. They explained the leadership team, headed by the DCS, used the Physicians Order Sheet, Medication Administration Record [REDACTED]. The DCS stated the chart audit system was developed to identify areas of weakness in documentation and assessment. The ADCS stated exercises that simulated admitting a resident revealed a couple nurses had difficulties with the admission process and needed re-training in that area. The RDCS explained unit managers (UMs) were responsible for reviewing all weekly skin evaluations and the associated skin care alert forms for each resident. She explained UMs reviewed and validated nurses' skin check findings on the day after scheduled skin evaluation. The RDCS confirmed resident #2's pressure ulcers on the heels should have been identified if staff had followed the process. She confirmed skin sheets should be used by certified nursing assistant (CNAs) every time there is a skin concern. She stated the QAA committee monitored the development of new skin issues by using the UMs' audits of the skin evaluations. The RDCS stated the DCS was ultimately responsible for ensuring compliance by reviewing the weekly skin evaluations for accuracy, and comparing them to findings from the previous week. The RDCS, DCS, and ADCS stated they would perform a root cause analysis to identify how this situation occurred with resident #2. The RDCS, DCS and ADCS acknowledged the QAA committee had not identified the use and review of skin care alert forms as an essential part of daily monitoring of residents' skin conditions. They acknowledged there was no specific system for CNAs to document skin conditions observed during care as some document new areas only, some document on every shower day and some not at all. The QAA committee members confirmed reviews of the weekly skin assessment for resident #2 were not done by the UM and DCS in a timely manner. After resident #2 acquired a left heel pressure ulcer that was not identified until it was unstageable, the current action plan was not reviewed and revised. As a result, resident #2 acquired another unstageable pressure ulcer to her other heel.

Based on record review and interview, the facility failed to keep residents free from neglect by failing to provide care and services for treatment of [REDACTED].#258). Resident #258 did not receive the necessary treatment and care to prevent a painful pressure ulcer and infected wound for 15 days. As a result of this neglect, the resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis). The failure to prevent neglect resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Findings: Cross Reference to F281, F309, F314 Resident #258 was a [AGE] year-old female who was admitted to the nursing home on 11/29/16 for surgical aftercare. She fell at home, sustained a right hip and right elbow fracture, and was hospitalized from [DATE] to 11/29/16. The hospital record revealed that the resident had an open reduction internal fixation (ORIF) surgical repairs to the right hip and right elbow resulting in 3 incisions with staples, right hip, right thigh, and right elbow. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) The admitting registered nurse (RN) N, on the 3-11 shift, noted the resident's [DIAGNOSES REDACTED]. The admitting nurses note dated 11/29/16 documented the resident had blister on the coccyx, the right upper extremity was in a soft cast and sling, and the right hip had 8 staples and 3 staples (in the right thigh). The resident had an abrasion to the right posterior thigh. The note did not contain any observation or description of the right elbow. The note indicated dressing care was done, but a review of the treatment order handwritten on the physicians order sheet and the treatment record revealed it was written for the left hip, not the right. Review of the physicians orders' and treatment records for November and December revealed inconsistent and inaccurate evidence of any treatment to the right hip, right thigh, and right elbow. Review of the physicians orders' and treatment record for November and December revealed the blister pressure wound on the coccyx did not receive any treatment and the right thigh abrasion did not receive any treatment in December. On 1/27/17 at 4 PM RN N, the resident's admitting nurse, stated that there was as soft cast on the arm and that she could not look at/observe the right arm surgical wound because she did not have a doctor's order to do so. The nurse stated that the resident did not have any admission orders [REDACTED]. When the nurse was asked what she does if residents do not have wound treatment orders at admission, she then said that the dressing should be removed to look at the wound/surgical sites regardless of whether or not they had treatment orders upon admission. She stated that she would ask the physician how the wound should be treated, but she did not recall if she called the physician for wound treatment orders for resident #258. She said that she did not remove the soft cast to the right elbow because it was a fresh post-operative wound and she thought it was not to be removed until the resident is seen for the follow up appointment. She could not explain why she removed the dressings to the post-operative wounds on the right hip, but not the right elbow. The Daily Skilled Nurse's Notes noted, 12/07/16, 7-3 pt. (patient) has been crying out in pain. On 12/08/16, 7-3 pt. yelling out in pain . pt cont. (continued) to moan with pain. 12/09/16, c/o (complaint of) pain. 12/10/16, Late entry - pt. crying out in pain, medicated . no relief . 12/11/16, 7-3 p.t crying out in pain . grabbing at right hip . medicated . pt. cont. to cry out . pt. again crying out in pain. 3-11 pt. seems unhappy. 12/12/16, 7-3 - late entry. Pt. has been crying out in pain, medicated .increased yelling out in pain. 12/13/16 at 2:30 AM, Pt. crying and holding elbow stating, it hurts. 4 AM pt. conts.(continues) To voice pain in right elbow. 7-3 - late entry. Pt crying out in pain . pt not showing any relief. 12/15/16, 7-3 pt. crying out in pain. Medicated .pt. cont. to cry out in pain. On 12/14/16 the resident went to a follow up appointment at the Orthopedic Surgeons office. The surgeon's notes indicated the staples to the right elbow were removed and the resident returned to the nursing home. The orthopedic surgeon noted, 'elbow surgical wound open/pressure sore, s/p (status/post) ORIF R (right) elbow, R hip. The surgeon gave the following orders: 1. Hyperbaric treatment R elbow 2. Wound VAC (vacuum assisted closure) R elbow wound 3. PT (physical therapy) with ROM (range of motion) only Rt elbow 4. No splint on R elbow 5. PT R hip - WBAT (weight bearing as tolerated) 6. Daily PT/OT (occupational therapy) There was no evidence that the orthopedic surgeon's orders pertaining to the right elbow were followed by the nursing home staff after the resident returned from the appointment with the orthopedic surgeon. Treatment instructions to change dressing to right elbow and clean with [MEDICATION NAME] were written and signed off as completed on 12/13/16 the day before the appointment with the surgeon, but the surgeon noted the dressing and splint the residents right elbow had not been changed at all during the time the resident was in the nursing home until he saw her on 12/14/16. There were still no physician's orders for treatment to the right hip and thigh incisions as of 12/14/16. Instructions to clean right hip staples with normal saline, place Xeroform and cover with border gauze was handwritten on the Medication Administration Record [REDACTED]. The medical record revealed a wound care physician note with the same instructions for treatment, but they were never written as treatment orders and they were intended for the right posterior thigh, not the right hip. Other handwritten instructions for treatment to the right elbow either did not have a corresponding physician's order or they were documented incorrectly. Handwritten instructions on the medication record read remove staples to right hip, place steri strips, but had no corresponding physician's order. They were initialed as completed, but the staples were not removed. On 12/15/16 the resident was transferred to the hospital. The nursing home transfer form noted that the resident was lethargic, altered mental status, labored breathing and the right elbow surgical site was open. Nurse's note dated 12/15/16 at 7:30 PM read, Received return call from MD (medical doctor) r/t (related to) labs. MD states sodium is very high. Described resident's current condition. New order to send resident out 911. Resident appears lethargic, labored breathing and AMS (altered mental status) (MD aware) completed transfer paperwork and called 911. Hospital assessment dated [DATE] at 21:55 (9:55 PM) noted that the resident appeared to be uncomfortable, unkempt and uncooperative. The resident smelled of urine and foul odor. The resident presented with a right elbow open wound with exposed metal hardware. The site was red and hot to touch. The resident still had staples to her right hip and thigh. On 12/16/16 Hospital staff met with the resident's family. Per the family, resident had some dementia but was pretty independent at home. The resident used a front wheeled walker for ambulation and could complete most activities of daily living without assistance. The resident was only in the nursing home for rehabilitation a for recent hip and right upper extremity injury. The resident's admitting [DIAGNOSES REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis) [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . (Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.) MRSA is a bacteria that is resistant to many antibiotics. (www.cdc.gov/mrsa) Bacteremia is the presence of bacteria in blood. (McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.) On 12/19/16 the right elbow wound measurements were 3.0 centimeters (cm) x 2.0 cm x 1.4 cm. Hospital staff noted full thickness wound, with exposed hardware entire wound bed. No granulation noted. Moderate serous yellow drainage noted on dressing upon removal. No odor. Peri-wound with [MEDICAL CONDITION] and [DIAGNOSES REDACTED] and the resident/patient was moaning with palpation. Further review of the hospital record revealed that a wound vac to the right elbow was used to treat the wound. The wound vac was the same treatment ordered by the surgeon on 12/14/16, but it was not initiated as ordered in the nursing home. On 12/20/16 the hospital consult note read, Orthopedic consultation report noted from (orthopedic surgeon): History of Present Illness: The patient is known to (orthopedic surgeon) from previous admission with s/p (status [REDACTED]. She was seen in our office on Wednesday with X-rays. The patient had been in rehab at (nursing home). She was accompanied in the office by her family. The patient has severe dementia. When her dressing from the elbow was removed it was found that this had not been changed and the patient had been still wearing splint. She acquired a pressure wound to the R elbow. None of her staples had been removed. (orthopedic surgeon) saw the patient in the office. All staples were removed (to right elbow) and sterile dressing placed. Orders were written for (nursing home) for wound care and wound vac placement and PT/OT (physical therapy/occupational therapy). The patient presented yesterday to the ER (emergency room ) and was subsequently admitted and (orthopedic surgeon) was reconsulted. Photos on chart to support findings, report called into DCF (Department of Children and Families) . DCF is the program responsible for investigating allegations of neglect. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for end of life services and pain management. On 1/25/17 at 3:25 PM the Unit Manager (UM) F stated that on 12/13/16 the resident #258 had drainage from the right elbow area. The UM said she called the attending physician and obtained orders to clean the right elbow wound with [MEDICATION NAME]. She said the doctor told her to remove the soft cast and she observed a stage III pressure wound. A stage III pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). She indicated the staples were intact and that the pressure wound was not on a staple or the surgical suture lines. Her recollection of the events on 12/13/16 contradict the evidence from the surgeon who noted the dressing and splint had not been changed on 12/14/16. The hospital admission note indicated the resident had a right elbow open wound and exposed metal hardware. This type of wound is not a stage III, but it is classified as a stage IV pressure ulcer, Full thickness tissue loss with exposed bone, tendon or muscle. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). The UM F stated she called the Wound Care Physician (WCP) and informed the WCP of the stage III pressure wound. The UM pointed to the second telephone order dated 12/13/16 with time ordered written as 11:32 AM. She stated that the order was from the WCP. The WCP treatment order dated 12/13/16 was for the Xeroform to the staples and Maxsorb to the pressure sore on the right elbow. The order included to remove the soft cast and apply the new treatment. The UM F was aware that the resident had a follow up appointment with the Orthopedic Surgeon on 12/14/16. The UM F stated that the surgeon wanted a wound vac to the right elbow, but this was not followed. The medical record was further reviewed by UM F and she stated that the resident did not have admission orders [REDACTED]. When asked how she could complete the weekly skin checks without observing the right elbow and checking the surgical wound for signs/symptoms of infection without removing the soft cast, the UM replied, I don't know how you would monitor it if you don't look at it. On 1/25/17 at 4:45 PM the Director of Nursing (DON) discussed resident #258 and the facility's investigation of the issue. The DON stated the resident was discussed during the morning clinical meeting on 12/13/16. It was reported that the resident had some drainage from the right elbow and UM F called the physician for treatment orders. She said the resident was admitted on [DATE] and had an admission order for orthopedic follow up appointment in 1 week. This information was listed in the discharge instructions, but it was not written in the admission physicians order sheet on 11/29/16. She said there was an issue about getting authorization from the Orthopedic Surgeons office, for insurance purposes, before the resident could be seen for the follow up appointment. The DON stated that the facility staff had been working on getting the authorization since admission, but were unable to make the appointment as directed in the discharge instructions. The DON stated that she found admission orders [REDACTED]. She stated that these orders were from the orthopedic surgeon. Review of the admission orders [REDACTED]. The DON was not aware if these orders were present at the time of the resident's admission. One of the orders noted wound drainage - call provider. The DON stated that the facility did not have an order to remove the soft cast until 12/13/16. The DON could not explain why neither the nurses, nor the physician or nurse practitioners observed the resident's elbow or obtained a treatment order from the attending physician. She stated, I can't tell you why, I can only speak about what happened from 12/13/16 forward. I am not going to comment for other staff or what they should have done. I will only comment from 12/13/16. The DON did not discuss how the documentation on 12/13/16 contradicts the notes and observations from the orthopedic surgeon on 12/14/16 indicating the splint was not removed and the dressing was not changed from 11/29/16 until the resident saw the surgeon on 12/14/16. The DON did not investigate why the resident was not receiving wound care to the right elbow and the circumstances that caused a 15-day delay for assessment and wound care to the resident's surgical areas. She said that the facility could not get authorization from the orthopedics surgeon's office so that the resident could have a follow up appointment. She said that the facility was not to be blamed for the resident's lack of wound care to the right elbow and that the fault should be placed upon the orthopedic surgeon's office for delay in the follow up appointment. On 1/26/17 at 1:43 PM the WCP was interviewed at the nursing home. The WCP reviewed the telephone orders and her notes that were in the medical record. The WCP recalled observing the elbow wound on 12/15/16, after the resident had the follow up visit with the surgeon. She stated she was responsible for only treating the wound to the posterior thigh, not any of the surgical sites. The staff asked her to look at the elbow wound to determine if the resident needed a wound vac. The WCP told the facility staff that the resident did not need a wound vac and that the resident should go back to the orthopedic surgeon to have the wound surgically closed. A telephone order dated 12/13/16 timed at 11:32 AM, was discussed with the WCP. The order was for the Xeroform to the staples and Maxsorb to the pressure sore on the right elbow. The order included to remove of the soft cast and apply the new treatment. The WCP stated she never gave that order. She stressed that she would have never gave an order to remove the orthopedic surgeon's soft cast and provide treatment to a surgical site. The WCP stated she did not sign the telephone order dated 12/13/16 and that she always signs her orders. Observation of the telephone order revealed that it had not be signed by a physician. The WCP stated she would have told the staff to contact the orthopedic surgeon for an order to remove the soft cast and provide treatment. On 1/27/17 at 4:40 PM the resident's attending physician was interviewed via phone. He said did not recall looking at the right elbow, but he said he looked at the right hip. He stated there were admission orders [REDACTED]. This contradicts the orders on the physicians order sheets for November and December in which there are not any orders for treatment to the right hip. The attending physician stated that orthopedic surgeons can be very picky on how wounds are to be treated. He said, we wanted to contact the surgeon about how to treat the right elbow wound, but I do not know if the nursing home staff were able to get through to him. The attending physician stated he did not give any orders for the right elbow. He stated that he was an internist not a wound care doctor. He said he thought that there was a report that the resident had drainage to the right elbow. He stated, I am not 100%, but I don't think they called me about it. I don't recall them telling me it was pressure wound. The attending physician stated that he might have ordered a treatment, but told the nursing home staff to contact the wound care doctor. A second interview was conducted with UM F on 1/27/16 at 6:10 PM. She recalled the events that she said took place on 12/13/16. She stated that the 11 PM-7 AM nurse observed the drainage from the right elbow. The UM stated that she arrived at the facility at 5:00 AM and looked the right elbow wound. She said that the attending doctor gave her an order to remove the soft cast and cleanse the right elbow area with [MEDICATION NAME]. After she cleansed with [MEDICATION NAME] she took measurements of the pressure sore. Several minutes into the interview the UM attempted to clarify her statements. She stated that the attending doctor was on the phone when she removed the soft cast and he told her to paint the entire wound with [MEDICATION NAME]. When asked if she informed the Attending Doctor of the pressure wound, the UM stated, He didn't know there was a pressure wound because I hadn't removed the dressing yet. The UM stated that on 12/13/16 she also spoke with the WCP and received orders for Xeroform to the staples and Maxsorb for the pressure sore to the right elbow. The UM stated that the WCP asked her to stage the pressure wound. The UM clarified how she documented the telephone orders for 12/13/16. She stated the first telephone for the 12/13/16 was from the Attending Doctor to paint the right elbow with [MEDICATION NAME]. The second telephone order dated 12/13/16 with the time ordered as 11:32 AM has orders from both the WCP and attending doctor in the same order. The UM sated the Xeroform and Maxsorb treatments to the right elbow were from the WCP, then below the treatment order on the same telephone order she documented the attending physician's order to remove the soft cast. When asked about conflicting order from the WCP and Orthopedic Surgeon, the UM stated that the Medical Director should have been called. Further review of the medical record together with the facility staff interviews it was determined that no one on resident #258's care team attempted to contact the Medical Director to obtain orders for treatment or clarify the conflicting physicians' orders. Review of the Nursing Home Federal Report initiated on 12/20/16 confirmed the facility did not consider the lack of care and treatment to the surgical wounds, pain, and pressure ulcer prevention as neglect. Their investigation found neglect did not occur as related to setting up an appointment. It did not address any concerns regarding the care and treatment of [REDACTED].

Based on record review and interview, the facility failed to ensure that residents had physician orders for immediate care upon admission to address wound care needs for 1of 12 sampled residents reviewed for wounds (#258). Resident #258 did not have admission orders [REDACTED]. The resident became septic, was hospitalized and then transferred to a hospice house for end of life care. The failure to provide physician's orders for immediate care for resident #258 resulted in Immediate Jeopardy starting on 11/29/16. Immediate Jeopardy was ongoing as of 1/28/17. Findings: Resident #258 fell at home injuring her right arm and right hip. The resident was admitted to the hospital on [DATE] where she had a surgical repair of the right hip and right elbow. On 11/29/16, the resident was admitted to the nursing home for rehabilitative services. Her [DIAGNOSES REDACTED]. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) The physician's order sheet dated 11/29/16 to 11/30/16 noted she did not have any orders for treatment to the right elbow. Orders were present for daily wound care to the left hip, but the resident's surgical wounds were not on the left hip, they were on the right. Orders were also present for a posterior left thigh abrasion, but the abrasion was on the right thigh. The admitting nurse, registered nurse (RN) N documented on the Admission Data Collection form that the resident had an abrasion to the right posterior thigh, staples to the right hip, a blister to the coccyx and a bruise to the left arm. The nurse's admission note dated 1/29/16 for the 3 PM-11 PM shift indicated that the resident's right upper extremity was in a soft cast and a sling. The nurse documented that she cleansed the blister on the coccyx and applied barrier cream, but there were no orders for treatment to the coccyx. There were no orders for splint and sling to the right arm. Hospital discharge instructions that came with the resident to the nursing home indicated that the resident was to follow with the orthopedic surgeon in one week. Other instructions in the hospital records dated 11/24/16 indicated the resident's pain was under control at that time and the staples to the ORIF to the right hip and right elbow were to be taken out by rehab (facility) in 10-12 days. These orders were not included in the admission physicians order sheet in the facility. The Minimum (MDS) data set [DATE] noted that the resident had a stage II pressure sore upon admission. A stage II pressure ulcer May also present as an intact or open/ruptured blister. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). On 1/27/17 at 4:00 PM, the admitting nurse, RN N, stated that the resident did not have any wound care orders at admission. When asked where she got orders to treat the right hip and posterior thigh, the nurse stated she did not remember. Review of the record revealed there were no physician orders for treatment to the right hip and right posterior thigh. On 1/25/17 at 3:25 PM, the Unit Manager (UM) responsible for resident #258 stated that the resident did not have any treatment orders for the right elbow surgical wound upon admission. The resident was in the facility for 15 days without any treatment orders for the right elbow incisions, dressing, splint, or sling. The UM stated the resident had a follow up with the orthopedic surgeon on 12/14/16 and returned to the facility with treatment orders. The orthopedic surgeon noted, Elbow Surgical wound open/pressure sore. On 12/15/16, the day after the resident was seen by the orthopedic surgeon, the resident was transferred to the hospital. The nursing home transfer form dated 12/15/16 noted that the resident was lethargic and had altered mental status with labored breathing. The hospital assessment dated [DATE] at 9:55 PM noted that the resident appears to uncomfortable, unkempt and uncooperative. The resident smelled of urine and foul odor. The resident presented with a right elbow open wound with exposed metal hardware. The site was red and hot to touch. The hospital admitting [DIAGNOSES REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. It is difficult to predict, diagnose, and treat. Patients who [MEDICAL CONDITION] have an increased risk of complications and death. www.cdc.gov. Center for Disease Control and Prevention Online. 16 Sept. 2016. [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier. MRSA is a bacteria that is resistant to many antibiotics. www.cdc.gov Center for Disease Control and Prevention Online.) Bacteremia is the presence of bacteria in blood. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. On 12/20/16 the hospital consult note read, Orthopedic consultation report noted from (orthopedic surgeon): History of Present Illness: The patient is known to (orthopedic surgeon) from previous admission with s/p (status [REDACTED]. She was seen in our office on Wednesday with X-rays. The patient had been in rehab at (nursing home). She was accompanied in the office by her family. The patient has severe dementia. When her dressing from the elbow was removed it was found that this had not been changed and the patient had been still wearing splint. She acquired a pressure wound to the R elbow. None of her staples had been removed. (orthopedic surgeon) saw the patient in the office. All staples were removed (to right elbow) and sterile dressing placed. Orders were written for (nursing home) for wound care and wound vac placement and PT/OT (physical therapy/occupational therapy). The patient presented yesterday to the ER (emergency room ) and was subsequently admitted and (orthopedic surgeon) was reconsulted. Photos on chart to support findings, report called into DCF (Department of Children and Families) . DCF is the program responsible for investigating allegations of neglect. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for end of life services and pain management. On 1/25/17 at 4:45 PM, the director of nursing (DON) stated that the resident was to have a follow up appointment with the orthopedic surgeon after she was admitted to their facility, but there was a delay because the nursing home could not get authorization from the orthopedic surgeon's office. She indicated that their investigation demonstrated facility's due diligence in setting up an appointment and meeting the resident's needs. When asked about lack of admission treatment orders for the right elbow surgical sites, splint, and sling, the DON stated, I am not going to answer for other staff or what they should of done. Review of the facility's policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Policy: A Clinical Nurse shall transcribe and review all physician orders in order to affect their implementation: -admission orders [REDACTED]. Transcribe all orders from the transfer form to the facility admission physician order for [REDACTED]. -The Attending physician shall review and confirm the orders. The nurse shall document the date, time, physician's name and that the orders were confirmed on the order form: i.e. 12/01/98 11:00 AM Dr. Brown; Green, RN. -Routine Orders: The order shall be repeated back to the physician for his/her verbal confirmation. The order sheet shall be signed as follows: T.O. Dr. Brown/D. Green, RN 12/01/98 11:00 AM. The order must then be transcribed to all appropriate areas (MAR, TAR, etc.). The nurse shall sign off the orders upon completion or verification of transcription as follows: noted D. Green, RN, 12/01/98 11:45 AM. Nursing staff failed to follow their policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Nursing staff failed to transcribe all orders from the transfer form to the Facility Admission Physician order for [REDACTED]. The nurse did not document the date, time, physician's name or that she had verified the orders with a physician on the facilities order form. The nurse also did not obtain orders for the residents wound care for her elbow or coccyx.

Based on observation, interview, and record review, the facility failed to provide nursing care to meet professional standards of quality for 1 of 12 sampled residents reviewed for wounds (#258). Resident #258 did not receive quality nursing treatment and care for surgical wounds and prevention of a painful, infected pressure ulcer. As a result of the lack of professional nursing judgement and failure to follow nursing policies and procedures and care plans, the resident required hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her elbow. The resident was diagnosed with [REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The failure to provide quality nursing care and judgement according to standards of nursing practice resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Cross Reference to F224, F271, F309, F314 Findings: The Florida Statutes Chapter 464 The Nurse Practice Act. (ss. 464.001-464.027) defines the Practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a)The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b)The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (c)The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection. American Nurses Association Standards of Practice include: Standard 1. Assessment - The registered nurse collects comprehensive data pertinent to the healthcare consumer's health or the situation. Standard 2. Diagnosis - The registered nurse analyzes the assessment data to determine the [DIAGNOSES REDACTED]. Outcome Identification - The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. Standard 4. Planning - The registered nurse develops a plan of care that prescribes strategies and interventions to attain expected outcomes. Standard 5. Implementation - The nurse implements the interventions identified in the plan. Standard 5A. Coordination of Care Standard 6. Evaluation - The registered nurse evaluates progress toward attainment of outcomes. (Scope and Standards of Practice-Nursing 2nd Edition, American Nurses Association, 2010 Edition.) Resident #258 was admitted to the nursing home on 11/29/16 with [DIAGNOSES REDACTED]. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) On 11/29/16 the Admission Data Collection form, Section M/Skin, the admitting nurse, RN N, did not indicate that the resident had a right elbow surgical incision/soft cast in a sling, but later in her Nurse's Notes on the same document she wrote, RUE (right upper extremity) soft cast and sling Blister coccyx cleaned and covered with barrier cream. The nurse documented an abrasion to the right posterior thigh. RN N, did not provide a description of the wounds, presence of redness or drainage, the amount of staples, or the condition of the wounds/incision. Review of the facility's policy and procedures (P&P) for Admissions Assessment, effective 1/27/16, noted the following: Upon admission and/or readmission to the facility, the nurse shall complete a Data Collection Form to facilitate the beginning and/or revisions of the plan of care. Procedure: . Pertinent information shall be collected by physical review, interviews with resident and family and review of the resident's available medical records. A complete head to toe review must be done on the resident during the admission process. RN N failed to follow this policy, when she did not complete a head to toe review to include all resident #258's surgical wounds, pressure wounds, and other alterations in skin integrity. Review of the P&P for Physician Orders/admission orders [REDACTED]. Policy: A Clinical Nurse shall transcribe and review all physician orders [REDACTED]. -admission orders [REDACTED]. Transcribe all orders from the transfer form to the facility admission physician order [REDACTED]. -The Attending physician shall review and confirm the orders. The nurse shall document the date, time, physician's name and that the orders were confirmed on the order form: i.e. 12/01/98 11:00 AM Dr. Brown; Green, RN. -Routine Orders: The order shall be repeated back to the physician for his/her verbal confirmation. The order sheet shall be signed as follows: T.O. Dr. Brown/D. Green, RN 12/01/98 11:00 AM. The order must then be transcribed to all appropriate areas (MAR (medication administration record), TAR (treatment administration record), etc.). The nurse shall sign off the orders upon completion or verification of transcription as follows: noted D. Green, RN, 12/01/98 11:45 AM. The admission data collection for did not contain any information that RN N called the physician to confirm the orders or obtain any and all wound care orders necessary for resident #258. She documented a treatment to the blister on the coccyx, but there were no orders for treatment to the coccyx. The resident did not have orders for treatment to the coccyx at any time during her 16 days in the nursing home. The resident did not have orders for the wound on her right elbow, right thigh and hip, or right thigh abrasion. On 01/27/17 at 4:00 PM, staff RN N stated she did not unwrap or assess the resident's arm. She stated she did not have any wound care orders for the resident's right hip, thigh, coccyx, or elbow when the resident came to the facility, and she did not call the attending physician for orders. She said, The Unit Manager (UM) should have gone through and made sure everything was there (in the Medical Record). Many times they (residents) will come in with orders, and we write those orders and follow up appointments on the Medication Administration Record [REDACTED]. One of the unit nurses or charge nurses should have followed up on it. RN N, failed to follow the P&P for Pressure Ulcer Record and Non-Pressure Skin Condition Record. RN N should have initiated a Non-Pressure Ulcer Record, per policy, upon resident #258's admission on 11/29/16, to include the surgical wounds to her right hip and right elbow, as well as any other non-pressure areas. Review of the P&P for Pressure Ulcer Record and Non-Pressure Skin Condition Record, Effective Date 11/30/14, noted the following: Pressure Ulcer Record Policy, Effective Date 11/30/14 .document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is healed. Procedure: Residents will have a Pressure Ulcer Record completed for each skin impairment that is related to Pressure. - Mark the pressure area on the body description identifying the site. - Enter the date - Enter the stage of the pressure ulcer - Enter the size of the pressure ulcer - length x width x depth in centimeters - Enter the tissue type and color - Enter the wound edges and drainage - Enter the peri-wound information - Licensed nurse to sign the appropriate area RN N failed to follow this policy. She did not document the resident's pressure ulcer to the coccyx on the Pressure Ulcer Record upon admission. No other licensed nurses documented the coccyx pressure ulcer per the P&P at any time during her 16 days in the facility. The Non-Pressure Skin Condition Record, Effective Date 11/30/14 read, .document the presence of skin impairment/new skin impairment not related to Pressure when first observed and weekly thereafter. This includes skin tears, surgical sites, etc. Procedure: - Residents will have a Non-Pressure Skin Condition Record completed for each skin impairment that is not related to Pressure. - Enter the initial identification information. - Mark the area on the body description identifying the site. - Enter the date, size, drainage information description of the wound edges and the per-wound area. - Enter the size of the non-pressure ulcer skin condition - length x width x depth in centimeters - Each week the non-pressure skin condition is to be evaluated and the information recorded until healed. The licensed nursing staff failed to follow the P&P for non -pressure skin conditions for the surgical wounds on her right elbow and right hip and right thigh abrasion upon admission. In an interview with RN N, on 1/27/17 at 4 PM, she was asked about the handwritten the orders for the wound care to the resident's left hip/thigh and left posterior thigh abrasion and she stated she could not remember. A review of the physician's orders [REDACTED].#258's left hip/thigh and left posterior thigh abrasion. The orders do not contain an order date or time. A review of the Physician Telephone Orders sheets revealed there were no telephone orders for wound care. RN N did not acknowledge the orders incorrect. The resident's wounds were on the right hip and thigh, not the left. Interviews with RN/Unit Manager (UM) F were completed on 01/25/17 at 3:25 PM and a second interview on 01/27/16 at 6:10 PM. UM F stated when the resident came into the facility she did not have wound care orders. UM F reviewed the medical record, and stated that RN N did not assess the resident's surgical wounds. She said newly admitted residents are reviewed the following morning by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and the UMs. It includes a review of the medical records to determine what needs to be completed and follow up if orders are missing. UM F confirmed they had an order to follow-up with the Orthopedic surgeon, but no orders for the right elbow surgical wound. The review by the DON, ADON, and UM did not result in any follow up with a physician regarding the care and treatment for [REDACTED]. Interviews with RN/Unit Manager (UM) F were completed on 01/25/17 at 3:25 PM and a second interview on 01/27/16 at 6:10 PM. Resident #258's Care Plan was reviewed with UM F. On the care plan, under Skin/Wound: Right Elbow Open Reduction Internal Fixation (ORIF), it read, Administer treatments as ordered & observe for effectiveness. Observe Skin areas around casts, splints, adaptive devices; remove as needed to check skin condition, and weekly skin checks. The UM confirmed nurses did not follow the plan of care. She said they should have called the physician for instructions regarding the care of the surgical wound on the resident's right elbow. She confirmed the initial assessment and weekly assessments were not documented per facility policy and procedure and the care plan. UM F stated the facility was having difficulty getting a follow-up appointment with resident #258's orthopedic surgeon, and told the attending physician several times that the resident did not have wound care orders, but he did not give any wound care orders for the resident. She said the attending physician had come into the facility multiple times to see the resident, but he did not remove any of the resident's dressings on her right elbow. UM F confirmed she should have called the Medical Director when she couldn't get wound care orders for the resident, but she never called him. She said she spoke with the DON and ADON about the resident not having wound care orders, but she cannot remember the date. Review of the medical record revealed conflicting and contradictory information regarding the care and treatment for [REDACTED]. Interviews with UM F were completed on 01/25/17 at 3:25 PM and on 01/27/16 at 6:10 PM. She said 11 PM-7 AM nurse, Licensed Practical Nurse (LPN) T told her the resident had drainage from her arm on 12/13/16, and asked UM F to come into the facility and evaluate the resident's arm. UM F said she did not know why the LPN called her and did not follow the care plan for Skin/Wound, Notify physician for change in condition. UM F said she assessed the elbow wound when she came into the facility at 5 AM on 12/13/16. She said the staples were intact, but there was also a Stage III pressure wound. The wound was on the residents elbow, but not on the surgical line. UM F said she called the attending physician for orders, and he told her to remove the resident cast and look underneath, paint the wound with [MEDICATION NAME], and order X-rays. A review of the Nurses Progress Notes dated 12/13/16 6:20 AM, stated, Resident in bed c/o (complaint of) pain, drainage not to R elbow & odor. MD notified, new order to clean area with [MEDICATION NAME] now and cover, xray 2 views for R (right) elbow & r hip s/p surgery. Area to R elbow cleaned as ordered . Another note from UM F dated 12/13/16 at 11:32 AM stated, notified MD of new order from wound doctor for Xeroform and Maxsorb to open area remove soft cast & reapply after treatment applied. UM F confirmed these were her notes and the orders to remove the soft cast and treat the resident's elbow with Xeroform and Maxsorb came from the Wound Care Physician. A review of the Physician's Telephone Orders form for 3 orders dated 12/13/16 was completed with UM F. Two of the orders did not include the time. One of the orders included a time for 11:32 AM to remove the soft cast and apply new treatment to right elbow. This contradicts the previous information provided by UM F in which she said the spoke with the attending physician at 6:20 AM. The orders were written as follows: 1. 12/13/16: 2 view R (right) elbow Xray. 2 view R hip Xray. Indication: Pain/ s/p (status [REDACTED]. 2. 12/13/16: Clean area with [MEDICATION NAME] to R Elbow Now. Wound Consult. It was signed by UM F, did not include the time ordered and it was not signed by the physician. 3. 12/13/16 at 11:32 AM: New order from wound doctor. Apply Xeroform to staples & Maxsorb to open area to R Elbow. Remove soft cast apply new treatment to R Elbow and reapply soft cast. It was not signed by the physician. UM F said she did not know why she didn't include the time in the orders, and confirmed that they should have been timed. She stated the order to remove the cast was not from the Wound Care Physician, as she wrote it on the order. She said the attending physician told her to remove the cast and use the [MEDICATION NAME]. She said that she wrote the order from the attending physician and wound care physician together as one order. An interview with the Wound Care Physician (WCP) on 01/26/17 at 1:43 PM, she stated she only saw the resident #258 twice while the resident was admitted . The first time was when she was consulted on 12/07/16 and was asked to look at a blister the resident had developed on the back of her right thigh. The WCP denied speaking with UM F on 12/13/16. She reviewed Telephone Order dated 12/13/16 for the right elbow, which UM F stated came from the WCP. The WCP stated, That is not my order, I did not give that order. The TAR for December listed handwritten instructions for treatment to the right hip as follows: Clean R (right) hip staples with NS (normal saline), pat dry. Place Xeroform and cover with border gauze Q (every ) day & PRN (as needed) 12-07-16. The record shows the treatment was not completed 12/09/16 and 12/14/16. A wound care note dated 12/07/16 was the identical treatment, but it was for the right posterior thigh. It read, Wound #1 Right, Posterior Thigh Blister; Wound Cleansing & Dressing: Clean wound with Normal Saline, pat dry, apply Xeroform gauze and dry drsg daily and prn. Review of the physician's orders [REDACTED]. Other instructions for treatments in December 2016 are conflicting and other evidence as follows contradict the treatments. The treatments for December are written on a record that reads Medication Administration Record rather than Treatment Administration Record. 12/13/16: Change Dressing to R (right) elbow now. Clean with [MEDICATION NAME]. It was initialed as completed by UM F on 12/13/16. 12/14/16: Change dressing to R elbow clean with [MEDICATION NAME], apply Maxsorb to open area elbow. It is initialed as completed on 12/15/16. Review of the physicians order timed for 11:32 AM revealed the order was written by UM F on 12/13/16. The order was not transcribed accurately to the treatment record. As stated above in the interview with the WCP, she denies ever giving that order for treatment to the right elbow. Remove Staples to R hip. Place Steri-strips is initialed as being completed on 12/15/16. This entry was not dated and there was no evidence of a physician's orders [REDACTED]. In an interview with the Attending Physician (AP) on 01/27/17 at 4:40 PM, he confirmed he remembered the resident and had looked at resident #258's right hip surgical wound, but not the right elbow. He stated he did not remember the facility calling him about the wound on 12/13/16. He confirmed the order on 12/13/16 may have been his, and it sounded like something he may have written, but he was not sure it was his order. He did not recall the facility telling him the wound was a pressure ulcer. He said the resident arrived at the facility without any wound care orders when she was admitted , but wound orders would have to come from the surgeon or the wound care doctor, not him. A review of the resident medical record indicated that the resident was seen by the AP twice during Resident #258's stay, 11/30/16 and 12/02/16. The visits on 12/5, 12/7, 12/12, and 12/14/16 were completed by the physician's assistant (PA). All of the notes indicate that the resident right arm is in a shoulder sling. The physicians note on 12/14/16 stated the resident's cast was removed from the right arm with serosanguinous fluid, no warmth or odor present and the dressing was changed. This contradicts the Daily Skilled Nurse's Note on 12/13/16, that stated there was brown-red drainage and a foul odor. There were no other recommendations made by the PA about the resident's arm. The treatment to the resident's right elbow as it was documented is contradicted by the notes from the Orthopedic Surgeon (OS) for the office visit on 12/14/16. The resident was sent out of the facility to the OS's office on 12/14/16 at 3:00 PM Resident #258 was seen for a surgical follow-up appointment. The Consultation Report from the hospital dated 12/17/16 documented the events from the 12/14/16 office visit as follows: The patient has been in rehab .When her dressing from the elbow was removed it was found that this had not been changed and the patient had been still wearing splint. She had acquired a pressure wound to the R elbow. None of her staples had been removed All staples were removed and a sterile dressing placed. Orders were written for wound care and wound vac (vacuum assisted closure) placement and PT(physical therapy)/OT(occupational therapy) An Interdisciplinary Progress Notes from the OS for the 12/14/16 office visit read as follows: Post operative right elbow ORIF now has pressure wound from splint. New elbow surgical wound opening/pressure sore status/post ORIF R elbow. 1. Hyperbaric treatment R elbow 2. Wound VAC R elbow wound 3. PT with ROM (range of motion) only Rt elbow 4. No splint on R elbow 5. PT R hip - WBAT (weight bearing as tolerated) 6. Daily PT/OT A review of the Physician's Telephone Orders from 12/14 to 12/15/16 revealed that the orders from the OS for the hyperbaric treatment and wound vac to the right elbow were not implemented. A note from the WCP dated 12/15/16 indicated she was asked by UM F to evaluate an area of concern to the resident's right elbow, post cast removal. She wrote Open surgical wound with hardware visible, very little granulating tissue noted, needs surgical intervention. Staff to call surgeon to appointment for elbow, ASAP, may use Maxsorb Ag and dry drsg until seen by surgeon. We are unable to effect any healing for this type of wound. She needs surgical closure of the elbow wound. Until then Maxsorb Ag will assist in controlling drainage. There was no evidence in the medical record that the surgeon was called ASAP. During the resident's admission from 11/29/16 to 12/15/16 she regularly complained about the pain in her right arm. A review of the Pain Flow Sheet was completed and showed the resident regularly rated her pain high on the pain scale. The pain scale is 0 being no pain and 10 as the worst pain you can imagine. On 12/05/16 at 9:40 AM and 12:30 PM, 12/07/16 at 8:45 AM, and 12/08/16 at 8:30 AM, the resident rated her pain as an 8 out of 10. On 12/08/16 at 2:30 PM, 12/10/16 at 8:30 AM, 12/11/16 at 8:00 AM and 1:00 PM, 12/12/16 at 7:45 AM and 12:20 PM, 12/13/16 at 9:05 AM, 11:00 AM, and 12/15/16 at 8:30 AM and 10:30 AM., she rated her pain level as a 10 out of 10. The documentation on the flow sheet revealed the resident's pain relief was not consistently obtained, and her pain was level was checked as not acceptable on 12/05, 12, 13, and 15/16. The residents Non-Verbal Indicators of pain was listed as, A=Non-Verbal Sounds and C= Facial Expressions. The care plan for pain dated 12/07/16 noted the nursing staff was to Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain The resident's pain was not consistently controlled during her stay, and was not being adequately managed. The effectiveness of the resident's pain medication was not evaluated after it was given. The nursing staff did not communicate with the resident's attending physician that the resident was still having severe pain, without relief, even after she was medicated, and then her pain was not consistently being controlled. From 12/07/16 to 12/15/16, the resident rated her pain a 10 out of 10, and was moaning out in pain, even after medications were given. On 12/15/16, the resident was found to be lethargic, short of breath, and had an altered mental status. She was transferred to the hospital via 911 for treatment. When the resident arrived at the hospital she was diagnosed with [REDACTED]. Her prognosis was listed as poor, a hospice consult was ordered. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for pain management and end of life services. On 01/25/17 at 4:45 PM, an interview was completed with the Director of Nursing (DON). She said that after reviewing resident #258's chart on 12/13/16, she discovered the resident did not have orders for her right elbow wound. She said, I had no knowledge prior to 12/13/16 that there was any issues with this resident. I was told by our prior Case manager that we were waiting for prior authorization from the insurance company before the resident could be seen (by the orthopedic surgeon). I told UM F to call the Orthopedic Surgeons Office immediately, and they said we didn't need prior authorization for the resident to be seen. They scheduled an appointment the next day, 12/14/16. The facility then called the attending physician and told him what was going on. Per the UM the attending physician came in and saw the resident, agreed to the dressing removal and to clean the wound. The interview with the DON contradicts the medical record and interview with the attending physician. He said he did not see the resident on 12/13/16. The DON was asked about the expectations for wound care and she stated, I can't speak about what the nurse should have done. She confirmed the resident had a soft cast, and did not have orders for the wound orders for her elbow until 12/13/16. I don't know why they didn't look at it for 13 days. I can't tell you why, I can only speak about what happened from 12/13/16 forward. I am not going to answer for other staff or what they should have done. I will only comment from 12/13/16. The DON said that when the resident returned from her appointment with the Orthopedic Surgeon on 12/14/16, she received a call from the surgeon very upset because he said he sent specific orders for the dressing to be changed daily, but it was not done. The DON stated during her investigation she was never told that the resident's wound was a pressure sore. She reviewed the Pressure Ulcer Sheet dated 12/13/16, and confirmed that it was written by UM F, but she said, I don't know where that sheet came from. I didn't see it during my investigation. I was only told about this just now. The DON stated she did not speak with the RN N about the admission. but she spoke with UM F. She indicated that her investigation demonstrated that the facility did their due diligence in setting up the follow up appointment with the surgeon to meet the resident's needs. The DON did not acknowledge the failure to follow the standards of practice according to the Florida Nurse Practice Act and the American Nurses Association Standards for incomplete admission orders [REDACTED].

Based on interviews and record review, the facility failed to provide necessary treatment and care to maintain the highest practicable well-being for 1 of 12 sampled residents reviewed for wound care, pain management, and skin care management (#258). Resident #258 did not receive the necessary treatment and care to her surgical wounds to prevent the deterioration of her condition. The resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The failure to provide necessary care for wound care, pain management, and skin care management resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Based on observation, record review and interview the facility failed to coordinate, provide and monitor care and service relating to [MEDICAL TREATMENT] for 1 of 1 sampled residents reviewed for [MEDICAL TREATMENT] (#116). Findings: Resident #258 was a [AGE] year-old female who was admitted to the nursing home on 11/29/16 for surgical aftercare. She fell at home, sustained a right hip and right elbow fracture, and was hospitalized from [DATE] to 11/29/16. The hospital record revealed that the resident had an open reduction internal fixation (ORIF) surgical repairs to the right hip and right elbow resulting in 3 incisions with staples to the right hip, right thigh, and right elbow. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) Registered Nurse (RN) N, admitted resident #258, to the facility on [DATE] at 7:30 PM. She documented that the resident had 3 surgical wounds, one to the right elbow and two incisions to the right hip/thigh. She had an abrasion to the right posterior thigh. The resident arrived at the facility without any wound care orders or interventions listed on her hospital discharge paperwork. On the Admission Data Collection form, Section M/Skin, RN N, did not indicate that the resident had a right elbow surgical incision/soft cast in a sling. In her Nurse's Notes, on the same document, she writes, RUE (right upper extremity) soft cast and sling . A description of the wound, the presence of redness or drainage, the amount of staples, and the condition of the wounds/incisions were not documented. A review of the medical record did not indicate that any nurse called the physician or the surgeon to obtain wound care order orders for the surgical wounds or the abrasion on the resident's right posterior thigh. On 1/27/17 at 11:10 AM, the occupational therapist described splint to resident #258's right arm. The resident had staples to the incisions on her elbow with a dressing. She had a hard support/removable splint that ran from her mid forearm and curved around the end of her elbow that was held in place with an ace wrap. Her right arm was immobilized with a sling at all times. On 01/27/17 at 4:00 PM, RN N stated she did not remove any of the bandages to inspect the resident's arm on 11/29/16. She said that in her experience the surgeon did not want a nurse to remove any dressings or splints until the patient was seen by the surgeon. She stated she did not have any wound care orders for the resident's right hip, thigh, or elbow when the resident came to the facility, and she did not call the attending physician for orders. She did not have any orders for a follow up appointment with the surgeon. When asked what she should do if a resident does not have wound care orders and has surgical dressings, she stated, You should call the attending physician, let them know the resident has wounds, and ask how they would like to treat the wounds. She said the nurse should remove any dressings to be able to see the wound. She stated that it is the Unit Manager's responsibility to follow up on new admissions and obtain the orders from the physicians if they are missing or unclear. During the resident's admission from 11/29/16 to 12/15/16 she regularly complained about the pain in her right arm. A review of the Pain Flow Sheet was completed and showed the resident regularly rated her pain high on the pain scale. The pain scale is 0 being no pain and 10 as the worst pain you can imagine. On 12/05/16 at 9:40 AM and 12:30 PM, 12/07/16 at 8:45 AM, and 12/08/16 at 8:30 AM, the resident rated her pain as an 8 out of 10. On 12/08/16 at 2:30 PM, 12/10/16 at 8:30 AM, 12/11/16 at 8:00 AM and 1:00 PM, 12/12/16 at 7:45 AM and 12:20 PM, 12/13/16 at 9:05 AM, 11:00 AM, and 12/15/16 at 8:30 AM and 10:30 AM., she rated her pain level as a 10 out of 10. The documentation on the flow sheet revealed the resident's pain relief was not consistently obtained, and her pain was level was checked as not acceptable on 12/05, 12, 13, and 15/16. The residents Non-Verbal Indicators of pain was listed as, A=Non-Verbal Sounds and C= Facial Expressions. The Daily Skilled Nurse's Notes noted, 12/07/16, 7-3 pt. (patient) has been crying out in pain. On 12/08/16, 7-3 pt. yelling out in pain . pt cont. (continued) to moan with pain. 12/09/16, c/o (compliant of) pain. 12/10/16, Late entry - pt. crying out in pain, medicated . no relief . 12/11/16, 7-3 p.t crying out in pain . grabbing at right hip . medicated . pt. cont. to cry out . pt. again crying out in pain. 3-11 pt. seems unhappy. 12/12/16, 7-3 - late entry. Pt. has been crying out in pain, medicated .increased yelling out in pain. 12/13/16 at 2:30 AM, Pt. crying and holding elbow stating, it hurts. 4 AM pt. conts.(continues) To voice pain in right elbow. 7-3 - late entry. Pt crying out in pain . pt not showing any relief. 12/15/16, 7-3 pt. crying out in pain. Medicated .pt. cont. to cry out in pain. A review of Therapy Notes indicated resident #258 complained of pain in her right upper extremity on 11/30/16, 12/01/16, and 12/09/16. The therapy notes stated the resident's pain was a 5/10 and constant. The therapy notes indicated, Patients progress has been slower than initially anticipated due to patients pain level . On 12/06/16, Resident's pain level was discussed with RN in regards to current pain medications. A review of the Attending Physician Note dated, 12/05/16, it reads, Staff reports no new complaints. Shows slow progress at PT (physical therapy) due to pain. The physician did not write any orders for new pain medications to control the resident's pain. The physician wrote his Care Plan: Continue present medications. The resident's pain was not consistently controlled during her stay, and was not being adequately managed. The effectiveness of the resident's pain medication was not evaluated after it was given. The nursing staff did not communicate with the resident's attending physician that the resident was still having severe pain, without relief, even after she was medicated, and then her pain was not consistently being controlled. From 12/07/16 to 12/15/16, the resident rated her pain a 10 out of 10, and was moaning out in pain, even after medications were given. The Minimum Data Set (MDS) assessment dated [DATE], noted a fracture under Section I, Musculoskeletal. Her active [DIAGNOSES REDACTED]. Section M, Skin Conditions, indicated the resident had an unhealed Stage II pressure ulcer and surgical wounds. In Section J, Health Conditions/ Pain Management, the resident stated that she had pain in the last 5 days, and it was occasionally. The resident was then asked, if her pain made it hard for her to sleep or if it limited her day-today activities, the facility marked the resident was, unable to answer. When questioned about pain intensity, using the resident verbal scale, a ruler that has 0 to 10 on it, and the resident can point to where her pain level is, is marked unable to answer. The next question In Section J asks, Should the Staff Assessment for Pain be Conducted? It is marked, No. If it had been marked Yes, the assessment instructs the nurse to continue to the Indicator of Pain or Possible Pain Section. The entire section under Staff Assessment for Pain is blank. In the Indicators of Pain or Possible Pain in the last 5 days, the instructions direct the nurse to observe a resident for Non-Verbal sounds (crying, whining, gasping, moaning, or groaning), Vocal Complaints of pain (e.g. that hurts, ouch, stop), Facial expressions (e.g. grimaces winces wrinkled forehead, furrowed brow), Protective body movements or postures (e.g. bracing, guarding, rubbing or massaging). If the section had been completed, the facility would have reviewed the resident's Pain Flow Sheet. On 12/05/16 at 9:40 AM, the resident was complaining of pain at an 8 out of 10, and the resident's Non-Verbal Indicators are labeled AC (A= Non-verbal sounds and C= Facial Expressions) After being medicated the resident stated the pain intervention was not acceptable. The resident's Care Plans (CP) were initiated on 12/07/16 for Skin/Wound, Pain/Comfort, Activities of Daily Living (ADL), Nutrition/Hydration, and Safety. The Skin/Wound CP, Implemented (IMP) 12/07/16: Etiology; Fragile skin, impaired mobility, R (right) Hip Fx (fracture) ORIF (Open Reduction Internal Fixation), R Fx Elbow ORIF NWB (Non-Weight Bearing), Pressure Ulcer coccyx. As Evidenced By (AEB): Surgical Wound. The goals were: The resident will have intact skin, free of redness, blisters or discoloration through next review, The resident will not develop additional skin integrity problems or wounds through next review, The resident will be free from impaired skin integrity through next review. The Interventions were listed as: Administer medications as ordered, Inform the physician of any new area of skin breakdown, Notify nurse of any new area of skin breakdown: Redness, Blisters, and Bruises, discoloration noted during bath or daily care, Observe for pain during treatment. Treat pain as per orders prior to treatment to ensure the residents comfort, Observe skin areas around (R soft) casts, splints, adaptive devices. Remove as needed to check skin condition. Use Sling, Weekly Skin Checks, Notify physician for change in condition, Keep Skin Clean and Dry. The Pain/Comfort CP IMP 12/07/16: Etiology; The resident has the potential for alteration in pain/comfort, Postoperative discomfort r/t (related to) R Hip ORIF & R Elbow ORIF, Fracture r/t R Hip Fx /R Elbow Fx. AEB: C/O (complaint of) pain or discomfort R Elbow & R Hip. The Goals included: The resident will not have an interruption in normal activities due to pain ., The resident will not demonstrate decline in over all function r/t pain. Interventions included: Observe & report any s/sx (signs/symptoms) of non-verbal pain: Changes in breathing, Vocalizations, Mood/behavior changes, Face grimacing, Body tensing, Identify previous pain history and management of that pain and impact on function . including pain relief ., Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, Anticipate the resident's need for pain relief and respond to any c/o pain. The ADL (Activities of Daily Living) CP, Impl. 12/07/16. Etiology: The resident has an ADL Self Care Performance Deficit r/t Limited ROM (range of motion), Musculoskeletal, decreased mobility, R Hip Fx & L (should be right) Elbow fx. The Goal is: The resident will receive appropriate staff support with .Personal Hygiene. The Intervention is : Observe skin for redness, open areas, scratches, cuts, bruises, and report changes. The Nutrition/Hydration CP, Impl. 12/07/16. Etiology: The resident has potential for imbalanced nutrition, s/p fracture. The Goal is: The resident will maintain adequate nutritional status AEB maintaining weight within 105-115. with no s/sx (signs/symptoms) of skin breakdown . The Intervention is: Weight: Per Melbourne IDT Protocol; Weekly. The Safety CP, Impl. 12/07/16. Etiology: The resident has an injury, Deconditioning, Hx of Falls, [DIAGNOSES REDACTED]. The Goal is: The resident will not sustain serious injury through next review. The Intervention is: Skin Checks Weekly. The facility did not provide the care, services and treatments as stated in the interventions sections on the Care Plans. A review of the resident's medical record was completed and there was no documentation to support that the resident's skin areas around her casts/splints were checked or that the cast/splint was removed to check skin conditions underneath. The facility did not notify the physician when pain interventions were unsuccessful, to include but not limited to, pain relief. They did not complete weekly skin checks to the resident's right elbow or weekly weights. Review of the facility's policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Policy: A Clinical Nurse shall transcribe and review all physician orders [REDACTED]. -admission orders [REDACTED]. Transcribe all orders from the transfer form to the facility admission physician order [REDACTED]. -The Attending physician shall review and confirm the orders. The nurse shall document the date, time, physician's name and that the orders were confirmed on the order form: i.e. 12/01/98 11:00 AM Dr. Brown; Green, RN. -Routine Orders: The order shall be repeated back to the physician for his/her verbal confirmation. The order sheet shall be signed as follows: T.O. Dr. Brown/D. Green, RN 12/01/98 11:00 AM. The order must then be transcribed to all appropriate areas (MAR, TAR, etc.). The nurse shall sign off the orders upon completion or verification of transcription as follows: noted D. Green, RN, 12/01/98 11:45 AM. Nursing staff failed to follow their policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Nursing staff failed to transcribe all orders from the transfer form to the Facility Admission Physician order [REDACTED]. The nurse did not document the date, time, physician's name or that she had verified the orders with a physician on the facility's order form. The nurse also did not obtain orders for the residents wound care for her elbow or coccyx. The policy and procedure for Non-Pressure Skin Condition Record, Effective Date 11/30/14 included .document the presence of skin impairment/new skin impairment not related to pressure when first observed and weekly thereafter. This includes skin tears, surgical sites, etc. Procedure: -Residents will have a Non-Pressure Skin Condition Record completed for each skin impairment that is not related to Pressure. -Enter the initial identification information. -Mark the area on the body description identifying the site. -Enter the date, size, drainage information description of the wound edges and the per-wound area. -Enter the size of the non-pressure ulcer skin condition - length x width x depth in centimeters -Each week the non-pressure skin condition is to be evaluated and the information recorded until healed. The nursing staff failed to follow this policy in regards to the surgical wounds. A review of the Non-Pressure Skin Condition Records dated, 11/29/16, 12/5/16, and, 12/13/16 and Weekly Skin Integrity Review sheets dated, 11/29/16, 12/05/16, and 12/12/16 did not show that the resident had a surgical wound on her elbow. On 12/14/16, the resident was seen outpatient by her surgeon. In a hospital note, dated 12/17/16 the surgeon referred to that office visit on 12/14/16, The residents dressing had not been changed and the patient was still wearing the same splint. None of the staples had been removed, and the resident now had an open pressure wound to the right elbow with hardware exposure. At the office visit the surgeon removed the staples to the incisions around her elbow and applied a new sterile dressing. The resident returned to the facility with new wound care orders. On 1/27/16 at 6:10 PM, the unit manager (UM) said that on 12/13/16 the staff observed drainage coming from the right elbow on the day before the resident's follow appointment with the Orthopedic Surgeon. The UM stated that she called the attending physician and he ordered to 'paint' the right elbow with [MEDICATION NAME]. She stated she removed the soft cast and observed a stage III pressure sore. The UM stated that she spoke to the wound care physician (WCP) on 12/13/16 and received an order for [REDACTED]. The UM's statements directly contradicts the Orthopedic Surgeon's observation of the right elbow. The surgeon noted that the resident's right elbow dressing had not been changed. During a phone interview on 1/27/17 at 4:40 PM the resident #258's attending physician stated that he recalled that there was a treatment order for the right hip at admission. He stated that there were not any treatment orders for the right elbow. He stated that he instructed the staff to contact the orthopedic surgeon about the right elbow wound, but the staff was not able to contact the surgeon. He was aware that there were conflicting orders between the WCP and the Surgeon. He stated, They were asking me to pick between two experts, and I couldn't make that decision. The responsibility would lie with the orthopedic surgeon. He said that he was not going to change the surgeon's orders. The attending physician stated that he talks to the medical director off and on but he did not discuss resident #258 with the medical director. On 1/26/17 at 1:43 PM the WCP reviewed the treatment orders and her notes regarding resident #258. She stated she only looks at the wounds that the facility refers to her. She indicated that she was only responsible for the wound that was on the resident's leg. The WCP stated that she saw the resident's right elbow wound on the 12/15/16 when the resident did not have a soft cast, the day after she went to the surgeon's office. The WCP stated the resident needed to go back to the Orthopedic Surgeon because, We couldn't treat it (the wound). The WCP reviewed the 12/13/16 telephone order written with her name. The WCP stated that she never gave the order. She pointed out that the order did not have her signature and she stated that she always signs her orders. On 12/15/16, the resident was found to be lethargic, short of breath, and had an altered mental status. She was transferred to the hospital via 911 for treatment. When the resident arrived at the hospital she was diagnosed with [REDACTED]. Her prognosis was listed as poor, a hospice consult was ordered. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for pain management and end of life services. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. It is difficult to predict, diagnose, and treat. Patients who [MEDICAL CONDITION] have an increased risk of complications and death. www.cdc.gov. Center for Disease Control and Prevention Online. 16 Sept. 2016. [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier. MRSA is a bacteria that is resistant to many antibiotics. www.cdc.gov Center for Disease Control and Prevention Online.) Bacteremia is the presence of bacteria in blood. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. On 12/16/16 hospital staff met with the resident's family. Per the family, resident had some dementia but was pretty independent at home. The resident used a front wheeled walker for ambulation and could complete most activities of daily living without assistance. The resident was only in the nursing home for rehabilitation a for recent hip and right upper extremity injury. 2. Resident #116 was admitted to the facility on [DATE] and goes to the [MEDICAL TREATMENT] Center three times a week for [MEDICAL TREATMENT] treatments. The facility failed to interchange information with the [MEDICAL TREATMENT] Center necessary for the resident's care and failed to monitor the resident's fluid restriction. Review of resident #116's medical record noted that the attending physician had ordered Milk of Magnesia (MOM), 30 milliliters (ml), to be given as needed for constipation and [MEDICATION NAME] suppository, 10 milligrams (mg) to be given as needed. The physician also ordered Fleets Enema, as needed, if no result from the MOM and suppository. On 1/24/17 at 2:03 PM the resident's Direct Care Licensed Practical Nurse (LPN) II explained the facility's communication process with the [MEDICAL TREATMENT] Center. She explained that on the morning of the [MEDICAL TREATMENT] there is a form that the nursing home staff fill out and that form goes with the resident to the [MEDICAL TREATMENT] Center. The [MEDICAL TREATMENT] Center will fill out their section and the form comes back to the nursing home when the resident returns. The form is put in the [MEDICAL TREATMENT] Communication Book. LPN II stated that she checks the resident [MEDICAL TREATMENT] access for bruit and thrill, but she was not aware that MOM was contraindicated for [MEDICAL TREATMENT] residents. On 1/24/17 a call was placed to the resident's [MEDICAL TREATMENT] Center. The [MEDICAL TREATMENT] charge nurse stated that resident #116 should not get MOM. The resident's other medications were discussed with the [MEDICAL TREATMENT] charge nurse and she stated the resident should not be getting the Fleets Enema. The [MEDICAL TREATMENT] charge nurse stated that the [MEDICAL TREATMENT] Center did not have the MOM or the Fleets Enema on the resident's list of home medications. Further review of the medical record revealed that there was a physician's telephone order dated 1/06/17 that indicated the resident was to be on a 1,000 ml fluid restriction. On 1/24/17 at 12:36 PM, resident #116 was in the Main Dining Room eating lunch. She was eating a chicken salad sandwich and she had a 12 (353.88 ml) to 16 (473 ml) ounce bottle of black cherry flavored water. The resident stated she can't have coffee or orange juice and that she buys the flavored water her self by the twelve Pak. On 1/24/17 at 1:25 PM, Certified Nursing Assistant (CNA #E) that her and (CNA #K) worked in the Main Dining room during lunch today. CNA #E and CNA #K work on the facility's West Wing and resident #116 resides on the East Wing. CNA #E stated that after the meal the meal tray tickets are thrown away. She stated that had not documented her resident intake meal percentage yet. CNA #E could not explain how and by whom the meal percentage intake is documented for East Wing residents that eat in the main dining room. CNA #E stated that no one that ate in the Main Dining room that day was on a special diet or a fluid restriction. On 1/24/17 at 2:40 PM, resident #116's direct care CNA explained how resident food and fluid intake is documented in the Activities of Daily Living Book. The CNA explained that the following codes for food intake consumed: G = 75-100% F = 50-74% P = 25-49% R = 0-24% The CNA indicated that the actual fluids consumed are not documented. The nurses aide document how many times a resident was offered fluid. On 1/24/16 at 2:45 PM the resident's fluid restriction was discussed with the facility's Registered Dietician (RD) and Assistant Director of Nursing. The RD stated that the kitchen sends out fluid on the residents' meal trays and then nursing staff provide fluids as well. The staff were informed that in the Main Dining room fluids are not on the residents' meal trays. The CNAs in the Main Dining room pour out fluid from pitchers for each resident. The staff had no answer when they were asked how are the CNAs in the main dining room going to know how much fluid to give a resident on a fluid restriction. On 1/26/16 at 12:55 PM the RD detailed the breakdown of the residents fluid restriction. She stated that 600 ml would come from dietary and 400 ml would come from nursing. The 600 ml was divided between Breakfast, Lunch and Dinner. The resident was only to get 120 ml of fluid for lunch. The 400 ml is divided between all three nursing shifts. The RD stated the fluid provided by nursing was for medications and a 240 ml Nepro supplement. The RD did not account for the resident's personal beverages that she purchases herself or the fluids given to the resident by CNAs between meals. On 1/27/16 at 4:42 PM stated that she usually eats lunch and dinner in the Main Dining Room but eats breakfast in her room. She stated that fluids do not come on her meal tray in the Main Dining Room. She stated the staff in the Main Dining Room pour fluids from pitchers and you ask for what you want. At breakfast she will drink her own beverages or ask the staff for hot chocolate. The resident also stated that the CNAs pass out water in white Styrofoam cups. The resident stated she does not like the Styrofoam cup, so she pours the water into her personal plastic tumbler. On 1/27/17 at 5:13 PM the East Wing Unit Manager (EWUM) stated that water is passed out by the nursing staff and not by the kitchen. In the supply room the EWUM retrieved a white Styrofoam cup. This cup is 16 ounces which equates to 473 ml of fluid. The facility did not have a process to account for how much fluid resident #116 was drinking each day. The staff would not be able to determine if the resident was actually meeting the physician's orders [REDACTED]. The staff did not ensure that the kitchen, nursing and CNAs were working together to manage resident #116's fluid restriction.

Based on interview and record review the facility failed to prevent an avoidable pressure ulcer and failed to provide treatment for [REDACTED].#258). Resident #258 did not receive necessary care to prevent an avoidable stage IV pressure ulcer to her right elbow. She developed a painful stage IV pressure ulcer that became infected and exposed the bone and hardware from surgery to her right elbow requiring re-hospitalization within 16 days of admission. She was diagnosed with [REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The failure to assess and implement preventive measures for pressure ulcer development resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Based on observation, interview, and record review the facility failed to identify the accurate stage of pressure ulcer for 1 of 6 residents reviewed for pressure ulcers (#95). Findings: Resident #258 was a [AGE] year-old female that was admitted to the nursing home on 11/29/16 for surgical aftercare. She fell at home, sustained a right hip and right elbow fracture, and was hospitalized from [DATE] to 11/29/16. The hospital record revealed that the resident had an open reduction internal fixation (ORIF) surgical repairs to the right hip and right elbow. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) The admitting nurses' note dated 11/29/16 documented the resident had blister on the coccyx, the right upper extremity was in a soft cast and sling, the right hip had 8 staples and 3 staples (in the right thigh), and she had an abrasion to the right posterior thigh. The note did not contain any observation or description of the right elbow or the coccyx. On 1/27/17 at 11:10 AM, the occupational therapist described splint to resident #258's right arm. The resident had staples to the incisions on her elbow with a dressing. She had a hard support/removable splint that ran from her mid forearm and curved around the end of her elbow that was held in place with an ace wrap. Her right arm was immobilized with a sling at all times. On 1/27/17 at 4 PM, RN N stated she did not assess the resident's right arm when she was admitted on [DATE]. She confirmed that she did not have any wound care orders for any of the resident's wounds upon admission, and she did not call the attending physician to obtain orders. She said she did not remove the splint and dressing to the right elbow because she did not have any physician's orders [REDACTED]. Review of the physicians orders' and treatment record for November indicated the resident did not receive any treatment to the right elbow. Review of the physicians orders' and treatment record for December revealed inconsistent and inaccurate evidence of any treatment to the right elbow. Review of the physicians orders' and treatment record for November and December revealed the blister pressure wound on the coccyx did not receive any treatment. Review of the Minimum Data Set assessment dated [DATE]. Under Section I, Musculoskeletal that the resident has a fracture. Her active [DIAGNOSES REDACTED]. The Skin/Wound care plan was implemented on 12/07/16. The etiology was listed as fragile skin, impaired mobility, R (right) Hip Fx (fracture) ORIF (Open Reduction Internal Fixation), R Fx Elbow ORIF NWB (Non-Weight Bearing), Pressure Ulcer coccyx. As Evidenced By (AEB): Surgical Wound. The goals were: The resident will have intact skin, free of redness, blisters or discoloration through next review, The resident will not develop additional skin integrity problems or wounds through next review, The resident will be free from impaired skin integrity through next review. The Interventions were listed as: Administer medications as ordered, Inform the physician of any new area of skin breakdown, Notify nurse of any new area of skin breakdown: Redness, Blisters, and Bruises, discoloration noted during bath or daily care, Observe for pain during treatment. Treat pain as per orders prior to treatment to ensure the residents comfort, Observe skin areas around (R soft) casts, splints, adaptive devices. Remove as needed to check skin condition. Use Sling, Weekly Skin Checks, Notify physician for change in condition, Keep Skin Clean and Dry. Review of the record revealed no evidence to support any of the interventions were implemented in regards to the goal of the care plan. The facility could not provide any documentation to support that they observed the residents skin areas around casts/splints and removed them as needed to check skin conditions. The facility did not complete weekly skin checks of the resident's elbow or the coccyx. The record contained no evidence of any treatment to the resident's coccyx stage II pressure ulcer. There was no evidence of any treatment to prevent a pressure to the right elbow even though the facility was aware the resident had risk factors for developing a pressure ulcer. Resident #258 was seen by the attending physician or the physician assistant a total of 6 times during her stay in the nursing home. No orders for care or treatment to the right elbow or coccyx were written during those visits. On 1/27/16 at 4:40 PM the attending physician confirmed he saw the resident during her stay, but he did not examine her elbow wound, and did not give wound care orders upon admission. A review of the Weekly Skin Integrity Review sheets revealed the resident's wound on her elbow was not documented and it was not observed per the plan of care for skin integrity. Nursing staff failed to follow their policy and procedures (P&P) for Physician Orders/admission orders [REDACTED]. Nursing staff failed to transcribe all orders from the transfer form to the facility admission physician order [REDACTED]. The nurse did not document the date, time, physician's name or that the orders were confirmed on the facilities order form. The nurse also did not obtain orders for the residents wound care for her elbow or coccyx. The Pressure Ulcer Record Policy, Effective Date 11/30/14 read .document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is healed. Procedure: Residents will have a Pressure Ulcer Record completed for each skin impairment that is related to Pressure. - Mark the pressure area on the body description identifying the site. - Enter the date - Enter the stage of the pressure ulcer - Enter the size of the pressure ulcer - length x width x depth in centimeters - Enter the tissue type and color - Enter the wound edges and drainage - Enter the peri-wound information - Licensed nurse to sign the appropriate area On 12/14/16, the resident was seen outpatient by her surgeon. In a hospital note, dated 12/17/16 the surgeon referred to that office visit on 12/14/16, The residents dressing had not been changed and the patient was still wearing the same splint. None of the staples had been removed, and the resident now had an open pressure wound to the right elbow with hardware exposure. At the office visit the surgeon removed the staples to the incisions around her elbow and applied a new sterile dressing. The resident returned to the facility with new wound care orders. The surgeon ordered Hyperbaric treatment and a Wound VAC (vacuum assisted closure) for the resident pressure wound to the right elbow. The treatments were not initiated as ordered. On 1/25/17 at 3:25 PM the Unit Manager (UM) F stated that on 12/13/16 the resident #258 had drainage from the right elbow area. The UM said she called the attending physician and obtained orders to clean the right elbow wound with [MEDICATION NAME]. She said the doctor told her to remove the soft cast and she observed a stage III pressure wound. A stage III pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). She indicated the staples were intact and that the pressure wound was not on a staple or the surgical suture lines. Her recollection of the events on 12/13/16 contradict the evidence from the surgeon who noted on 12/14/16 the dressing and splint had not been changed. The surgeon's note on 12/14/16 indicated the resident had a right elbow open wound and exposed metal hardware from her surgery to repair the fractured bone. This type of wound is not a stage III. It is classified as a stage IV pressure ulcer, Full thickness tissue loss with exposed bone, tendon or muscle. (State Operations Manual appendix PP guidance to Surveyors for Long Term Care Facilities). During her stay in the nursing home her condition deteriorated until on 12/15/16 the resident was found to be lethargic, short of breath, and had an altered mental status. She was transferred to the hospital via 911 for treatment. When the resident arrived at the hospital she was diagnosed with [REDACTED]. Her prognosis was listed as poor. She was transferred to a hospice house for pain management and end of life care. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. It is difficult to predict, diagnose, and treat. Patients who [MEDICAL CONDITION] have an increased risk of complications and death. www.cdc.gov. Center for Disease Control and Prevention Online. 16 Sept. 2016. [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier. MRSA is a bacteria that is resistant to many antibiotics. www.cdc.gov Center for Disease Control and Prevention Online.) Bacteremia is the presence of bacteria in blood. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. 2. On 1/28/17 at 3:10 PM, a coccyx pressure ulcer treatment observation was conducted for resident #95 with the assistant director of clinical services (ADCS), Licensed Practical Nurse II, and Certified Nursing Assistant HH. The observation revealed that the coccyx pressure ulcer had yellow slough in the center of the wound bed obscuring the total depth of the wound. Review of the facility's pressure ulcer record grid for resident #95's coccyx pressure ulcer revealed that on 1/25/17, the pressure ulcer was measured at 2.5 (centimeters) cm in length times (x) 1.0 cm in width x 0 cm in depth. It was documented as an unstageable pressure ulcer. The unstageable status of the wound was validated by a wound care note dated 1/25/17 10:30 AM. The coccyx pressure ulcer grid also revealed that two days later, on 1/27/17, the pressure ulcer was measured at 4.0 cm in length x 2.0 cm in width and x 0 cm in depth. It was documented as a stage III pressure ulcer. Review of wound care rounding nurse's note written by the unit manager on 1/28/17 at 9:30 AM, revealed that the primary physician was called and told that the stage of the coccyx pressure ulcer was changed to a stage III. (Per the National Pressure Ulcer Advisory Panel, NPUAP, and unstageable pressure injury is: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed ) (Per the CMS guidelines a Stage III pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) On 1/27/17 at 4:00 PM, interview with resident #95's RN unit manager while reviewing the resident's pressure ulcer grid stated that the wound care physician had staged the pressure ulcer on 1/25/17 as unstageable because it had slough in it. The unit manager stated that she had rounded with the wound care physician when she staged it. She stated that she had written the 1/25/17 at 10:30 AM above nursing note. She then stated that the director of nursing (DON) and she had then restaged the pressure ulcer as a Stage III on 1/27/17. She did not have an explanation as to why the DON had changed the unstageable staging done by the wound care physician, to a stage III. The unit manager then stated that she had called the primary physician on 1/28/17 and described the coccyx wound over the phone to him and told him that they had restaged it to a stage III. Review of the wound rounding nursing note dated 1/28/17 at 9:30 AM validated that the unit manger had written the note and had called the physician to notify him of the change. She stated that the primary physician had told her it would be a stage III if it had slough. She stated that he never saw the pressure ulcer to determine the stage, just that she had described it over the phone. The unit manager stated that she had not really been trained with staging pressure ulcers, just had pressure ulcer prevention training. On 1/28/17 at about 4:30 PM, interview with the ADCS, who had been present during the 3:10 PM pressure ulcer treatment observation for resident #95, validated that there yellow slough in the wound bed and to the extent that it had obscured the total depth of the wound and was not a stage III. She stated that it was unstageable coccyx pressure ulcer and that she was an accredited wound care nurse.

Based on record review and interview the facility failed ensure the nursing staff demonstrated appropriate competencies and skill sets relating to surgical wound care, prevention of pressure ulcers, care and treatment for [REDACTED].#258 & 95). Resident #258 did not receive the necessary treatment and care to her surgical wounds to prevent the deterioration of her condition. The resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The failure of the nursing staff to demonstrate the competency and skill to promote residents' physical, mental and psychosocial well-being resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Based on observation, interview, and record review, the facility failed to ensure 1 of 1 residents reviewed for positioning received appropriate placement of positioning devices to prevent decrease in range of motion (#3). Findings: Cross reference to F224, F281, F309, F314, F318. Resident #258 was a [AGE] year-old female who was admitted to the nursing home on 11/29/16 for surgical aftercare. She fell at home, sustained a right hip and right elbow fracture, and was hospitalized from [DATE] to 11/29/16. The hospital record revealed that the resident had an open reduction internal fixation (ORIF) surgical repairs to the right hip and right elbow resulting in 3 incisions with staples to the right hip, right thigh, and right elbow. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) Registered Nurse (RN) N, admitted resident #258, to the facility on [DATE] at 7:30 PM. She documented that the resident had 3 surgical wounds, one to the right elbow and two incisions to the right hip/thigh. She had an abrasion to the right posterior thigh and a blister on her coccyx. RN N, did not provide a description of the wounds, presence of redness or drainage, the amount of staples, or the condition of the wounds/incision. The resident arrived at the facility without any wound care orders or interventions listed on her hospital discharge paperwork. On 1/25/17 at 3:25 PM the Unit Manager, RN M, stated that the resident did not have any wound treatment orders for the right elbow at admission. She indicated that the RN N, did not assess the wound. RN M stated that every day new admissions from the day before are reviewed at the morning meeting. She stated that both the Director of Nursing (DON) and Assistant Director of Nursing are at the morning meeting as part of the review team. She said that the admission paper work from the hospital is reviewed to determine what is missing and what needs to be done. There was no evidence the nurse review team found that resident #258 did not have wound care orders for the right elbow and that the resident needed a follow up appointment with the Orthopedic Surgeon within 1 week of discharge from the hospital. The facility failed to keep residents free from neglect by failing to provide care and services for treatment of [REDACTED]. Resident #258 did not receive the necessary treatment and care to prevent a painful and infected pressure ulcer wound to her right elbow for 15 days. As a result of this neglect, the resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. www.cdc.gov/sepsis. The facility failed to provide nursing care to meet professional standards of quality. Resident #258 did not receive quality nursing treatment and care for surgical wounds and prevention of a painful, infected pressure ulcer. As a result of the lack of professional nursing judgement and failure to follow nursing policies and procedures and care plans, the resident required hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her elbow. The resident was diagnosed with [REDACTED]. The facility failed to provide necessary treatment and care for wound care, pain management, and skin care management to maintain the highest practicable well-being. The resident endured severe pain as the worst pain you can imagine and it was not adequately relieved. Resident #258 did not receive necessary care to prevent an avoidable stage IV pressure ulcer to her right elbow. She developed a painful stage IV pressure ulcer that became infected and exposed the bone and hardware from surgery to her right elbow requiring re-hospitalization within 16 days of admission. She was diagnosed with [REDACTED]. Resident #95 did not receive accurate staging of a pressure ulcer to the coccyx. On 1/27/17 at 4:00 PM, interview with resident #95's RN unit manager while reviewing the resident's pressure ulcer grid, she stated that the wound care physician had staged the pressure ulcer on 1/25/17 as unstageable. She then stated that the DON restaged the pressure ulcer as a Stage III on 1/27/17. She did not have an explanation as to why the DON had changed the staging done by the wound care physician. The unit manager stated that she had not really been trained with staging pressure ulcers. On 1/28/17 at 1:55 PM, RN I said the nurses complete wound care demonstration upon hire and they do not demonstrate any other competencies unless a problem is identified. The nursing staff did not provide the care, services and treatments as listed in the interventions sections on the Care Plans for skin/wounds and pain. The nursing staff did not follow the policies and procedures for Admissions Assessment, Physician Orders/admission orders [REDACTED]. The medical record revealed conflicting and contradicting documentation of treatment to wounds to include treatment to the wrong site and treatment performed without physician order. The resident experienced excruciating pain with inadequate pain management. The nursing staff did not communicate with the attending, medical director, and orthopedic surgeon for orders for care and treatment for [REDACTED]. On 1/25/17 at 4:45 PM, the Director of Nursing (DON) stated she did not speak with the RN N about the admission, but she spoke with the Unit Manager F. She indicated that her investigation demonstrated that the facility did their due diligence in setting up the follow up appointment with the surgeon to meet the resident's needs. The DON did not acknowledge the failure to follow the standards of practice according to the Florida Nurse Practice Act and the American Nurses Association Standards for incomplete admission orders [REDACTED]. She said that the facility was not to be blamed for the resident's lack of wound care to the right elbow and that the fault should be placed upon the orthopedic surgeon's office for delay in the follow up appointment. On 12/15/16, the resident's condition deteriorated so that she was found to be lethargic, short of breath, and had an altered mental status. She was transferred to the hospital via 911 for treatment. When the resident arrived at the hospital she was diagnosed with [REDACTED]. Her prognosis was listed as poor, a hospice consult was ordered. A hospital assessment dated [DATE] at 21:55 noted that the resident appears to uncomfortable, unkempt and uncooperative. The resident smelled of urine and foul odor. Hospital records indicated on 12/16/16, the hospital staff met with the resident's family. Prior to her admission to the nursing home they said the resident had some dementia but was pretty independent at home. The resident used a front wheeled walker for ambulation and completed most of her activities of daily living without assistance. The resident went to the nursing home for rehabilitation for her recent hip and right upper extremity injury. Hospital clinical notes dated 12/21/16 indicated that the resident was discharged to a hospice house for pain management and end of life services. On 1/23/17 at 2 PM, resident #3 was observed in the hallway in his wheelchair near his room. The resident was motioning and pointing down at his feet. The Foot Drop Pad was incorrectly attached to the wheelchair and the front end of the pad was on the ground. The resident's feet were dangling and his heels were barely touching the front end of the Foot Drop Pad A nearby certified nursing assistant (CNA) was instructed to get a therapist. About 8 minutes later, two other CNAs arrived and the therapist arrived after them. The two CNAs attempted to adjusted the Foot Drop Pad, and the therapist confirmed that the Foot Drop Pad was not attached to the wheelchair correctly. On 1/25/17 at 1:47 PM, the Rehabilitation director stated that resident #3's Drop Foot Pad was implemented last Friday, 1/20/17. Staff had not received training for proper application of the positioning device-foot drop pad.

Based on record review and interview, the facility failed to ensure that a physician was participating and supervising the medical care for 1 of 12 sampled residents reviewed for wound care (#258). Resident #258 did not have orders for wound care and treatment upon admission to the facility. The attending physician did not provide treatment for [REDACTED]. Resident #258 did not receive treatment to a right elbow surgical wound and developed a painful, infected pressure ulcer that exposed the bone and hardware from surgery to her elbow. The resident became septic, was hospitalized and then transferred to a hospice house for end of life care. The failure to ensure that a physician was participating and supervising medical care for resident #258 resulted in Immediate Jeopardy starting on 11/29/16. Immediate Jeopardy was ongoing as of 1/28/17. Finding: On 11/29/16, resident #258 was transferred from the hospital to the nursing home. Prior to her hospital admission, the resident fell at home fracturing her right hip and right elbow. The resident was status [REDACTED]. ORIF is a type of surgery in which the fractured bones are stabilized and are fixed in place by screws, plates, wires, or nails. (www.hopkinsmedicine.org) The physician's orders [REDACTED]. Orders were present for daily wound care to the left hip, but the resident's surgical wounds were not on the left hip, they were on the right. Orders were also present for a posterior left thigh abrasion, but the abrasion was on the right thigh. Hospital discharge instructions that came with the resident to the nursing home indicated that the resident was to follow with the orthopedic surgeon in one week. Other instructions in the hospital records dated 11/24/16 indicated the resident's pain was under control at that time and the staples to the ORIF to the right hip and right elbow were to be taken out by rehab (facility) in 10-12 days. On 1/27/17 at 4:00 PM, registered nurse (RN) N stated that upon admission, the resident's right elbow was in a soft cast and sling. She confirmed that there were no orders for care and treatment for [REDACTED]. RN N indicated that she did not observe the resident's right elbow area because she did not have a physician's orders [REDACTED]. She said that the Unit Manager (UM) F should have followed up with the physician to get treatment orders for the right elbow and follow up appointment with the orthopedic surgeon. The Attending Physician's (AP) progress note dated 11/30/16 documented that the resident's right elbow was in an immobilizer. The AP noted the right hip and right elbow were status [REDACTED]. There was no documentation of any follow up appointment with the orthopedic surgeon. The AP's progress note dated 12/02/16 documented that the visit was unremarkable and to continue current medications and therapy. There was no documentation of any communication regarding any treatment for [REDACTED].#258. On the 12/05/16, the Physician Assistant (PA) saw the resident. The PA noted, Ongoing follow up for the patient on the current regimen. Continue Physical therapy. Monitor labs. Continue present medications. On the 12/07/16, the PA noted no new complaints from the resident and that she is showing slow progress in physical therapy. The PA noted to continue present medications and therapy. The PA did not note any new wounds the resident acquired or if the Wound Care Physician (WCP) was treating any of the resident #258's wounds. The note did not indicate there was any communication regarding the lack of orders for the resident's wounds or the resident crying out in pain. A WCP progress note dated 12/07/16, indicated the resident had a new open blister to the right posterior thigh. The WCD noted that the UM F asked her to evaluate and treat an area of concern to the posterior right thigh. The WCP ordered to clean wound with normal saline, pat dry and apply Xeroform gauze and a dry dressing, every day and as needed. The WCP noted that the resident had an ORIF to the right hip and right elbow, but did not examine or treat those areas. The PA's progress note dated 12/12/16 indicated that the resident's husband stated that his wife was not eating food. The PA ordered nutritional shakes between meals and a Dietitian consult. The PA wrote to continue present medications, labs and therapy. There were no new wound care orders or attempts to discuss wound care orders with the orthopedic surgeon even though neither the attending physician, nor the wound care doctor were treating and monitoring the resident's wounds and pain management. On 12/14/16, the PA noted the resident was to have a follow up appointment with the orthopedic physician that day. The PA noted the resident was uncooperative with transfers, but it did not include any documentation of pain despite the nurses notes indicated the resident was crying out in pain and received no relief from medication. The note documented that the resident denied any new complaints. The note did not indicate any communication regarding the resident's lack of wound care. In the afternoon on 12/14/16, the resident had her follow up appointment with the orthopedic surgeon at his office. The resident returned to the nursing home with the surgeon's progress note and new wound treatment orders. The surgeon noted, post op R (right) elbow ORIF now has pressure wound from splint. The wound treatment orders for the right elbow were: 1) hyperbaric treatment to right elbow, 2) wound vac to right elbow wound, 3) physical therapy and range of motion only to right elbow, 4) no splint on right elbow. Later that evening on 12/15/16 at 5 PM, the nurse's note indicated that the resident was restless and grimacing in pain. The dressing to the right elbow was saturated and the dressing was changed. The area was noted to be red and warm to touch and the nurse called the AP. The AP did not answer the phone at that time. Two and half hours later at 7:30 PM, the AP called back and informed the nurse that the resident's sodium was very high. The physician gave new orders to send the resident to hospital 911. The nurse noted that the resident appeared to be lethargic, had labored breathing and altered mental status. At 8 PM, the nurses' note indicated the resident was transferred to hospital via stretcher by the emergency medical services (EMS). The hospital assessment dated [DATE] at 9:55 PM noted that the resident appeared to be uncomfortable, unkempt and uncooperative. The resident smelled of urine and foul odor. The resident presented with a right elbow open wound and exposed metal hardware. The site was red and hot to touch. The resident's admitting [DIAGNOSES REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis) [MEDICAL CONDITION] is a diffuse, acute bacterial infection of the skin and subcutaneous tissue characterized most commonly by local heat, redness, pain, and swelling and occasionally by fever, malaise, chills, and headache. Abscess and tissue destruction usually follow if antibiotics are not taken. The infection is more likely to develop in the presence of damaged skin, poor circulation, or diabetes mellitus . (Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.) MRSA is a bacteria that is resistant to many antibiotics. (www.cdc.gov/mrsa) Bacteremia is the presence of bacteria in blood. (McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.) On 12/20/16 the hospital consult note read, Orthopedic consultation report noted from (orthopedic surgeon): History of Present Illness: The patient is known to (orthopedic surgeon) from previous admission with s/p (status [REDACTED]. She was seen in our office on Wednesday with X-rays. The patient had been in rehab at (nursing home). She was accompanied in the office by her family. The patient has severe dementia. When her dressing from the elbow was removed it was found that this had not been changed and the patient had been still wearing splint. She acquired a pressure wound to the R elbow. None of her staples had been removed. (orthopedic surgeon) saw the patient in the office. All staples were removed (to right elbow) and sterile dressing placed. Orders were written for (nursing home) for wound care and wound vac placement and PT/OT (physical therapy/occupational therapy). The patient presented yesterday to the ER (emergency room ) and was subsequently admitted and (orthopedic surgeon) was reconsulted. On 1/26/17 at 1:43 PM, the WCP indicated that she observed the resident #258's right elbow pressure wound on 12/15/17. The WCP stated that she was treating the resident's wound to the right leg and that the right elbow wound was not been referred to her until 12/15/17. The WCP indicated that the staff should have contacted the AP for any orders for the right elbow wound prior to 12/15/16. The WCP stated, I can only look at the wounds that they recommend me to look at. The lack of wound treatment orders for the right elbow was discussed with the WCP. The WCP stated that she can't come between (resident) and her surgeon. The WCP reviewed the telephone order dated 12/13/16. This order was for Xeroform to the staples/surgical incision and [MEDICATION NAME] for the pressure wound on the right elbow. The WCP stated that she did not give the order. She stressed, It is not my hand writing. The WCP added, I didn't sign it. I always sign my orders, and I didn't sign that, because I didn't give it. On 1/27/17 at 4:40 PM, the AP was contacted by phone. He stated that he did not look at the resident #258's right elbow, but remembered looking at the right hip. He stated there were wound treatment orders for the right hip, but not the right elbow. This contradicts the evidence in the record showing there were no orders for treatment to the right hip. The AP stated that initially there were no reports that the resident was having drainage from the right elbow. The AP stated that later there were reports about right elbow drainage and that the resident had a follow up with the Orthopedic Surgeon. He stated that he was not sure that he ordered the [MEDICATION NAME] treatment to the right elbow, but said that he may have ordered it if there was drainage. The AP stated he did not recall if the nursing home staff informed him that the resident had a pressure sore on the right elbow. The AP acknowledged that there was a conflict of orders between the orthopedic surgeon and the WCP. The AP stated, ' .they were asking me to pick between two experts, and I couldn't make that decision. The AP stated the responsibility for the treatment to the wounds is with the Orthopedic surgeon in reference to the resident's right elbow. The AP stated that he talks with the nursing home's Medical Director off and on but he did not discuss resident #258 with the Medical Director. Resident #258 was seen by the attending physician or the physician assistant a total of 6 times during her stay in the nursing home. The physician did not supervise the care and treatment of [REDACTED]. The resident's condition the deteriorated until she became septic, was hospitalized , and then transferred to a hospice house for pain management and end of life care.

Based on record review and interview, the administration failed to use resources effectively to ensure residents were free from neglect and failed to provide timely and effective wound care to maintain the resident's highest practicable physical, mental and psychosocial well-being in accordance with professional standards of practice for 1 of 12 sampled residents (#258). Resident #258 did not receive the necessary treatment and care to prevent a painful pressure ulcer and infected wound for 15 days. Resident #258 did not have admission orders [REDACTED]. The Quality Assessment and Assurance Committee (QAAC) failed to identify quality deficiencies and develop and implement appropriate plans of action regarding resident care and services. As a result of this neglect, the resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis). The failure of the administration to use its resources effectively resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Findings: Cross Reference to F224, F271, F281, F309, F314, F353, F385, and F520. Resident #258 fell at home and fractured her right hip and right elbow. The resident had surgery to the right hip and right elbow and was admitted to the nursing home on 11/29/16. The admitting registered nurse (RN) N noted the surgical areas to the right hip and right elbow. RN N documented that the resident's right upper extremity was in a soft cast and that arm was in a sling. The Physician order [REDACTED]. However, the attending physician did not give any orders to treat the right elbow and the nursing staff did not contact any physician to obtain orders for care and treatment. The hospital discharge paper work in the resident's nursing home medical record revealed an orthopedic surgeon's progress note, dated 11/24/16 and written before the resident was admitted to the facility. The surgeon wrote, Follow up with (orthopedic surgeon) after DC (discharge) for RUE (right upper extremity) and R (right) hip. Staples out by rehab in 10-12 days. The resident remained in the nursing for 15 days, without treatment orders for the right elbow. The resident went to a follow-up appointment with the orthopedic surgeon on 12/14/16. The surgeon wrote, Post-op R elbow ORIF (open reduction internal fixation) now has pressure wound from splint. The orthopedic surgeon's assessment and plan included hyperbaric treatment to right elbow, wound vac to right elbow wound, and no splint on right elbow. The resident returned to the facility with the orthopedic surgeon's treatment plan. However, there was no evidence the facility staff arranged and scheduled hyperbaric treatments or obtained a wound vac for the right elbow wound. On 12/15/16, the resident transferred to the hospital. The Nursing Home to Hospital Transfer Form dated 12/15/16, timed at 8 PM, noted the resident as lethargic, had altered mental status, and labored breathing. The hospital assessment, dated 12/15/16 at 9:55 PM noted the resident appeared to be uncomfortable, uncooperative, and smelled of a foul odor. The resident presented with a right elbow open wound and exposed metal hardware at that site. The site was red and hot to touch. The hospital's consultation note, dated 12/20/16, read, S/p (status [REDACTED]. When her dressing from the elbow was removed, it was found that this had not been changed and the patient had been still wearing splint. She acquired a pressure wound to the R elbow. None of her staples had been removed all staples were removed and sterile dressing placed. Orders were written for (nursing home) for wound care and wound vac placement and PT/OT (physical therapy/occupational therapy). The patient presented yesterday to the ER (emergency room ) and subsequently admitted and (orthopedic surgeon) was re-consulted. Photos on chart to support findings, report called into DCF (Department of Children and Families) Hospital clinical notes, dated 12/21/16, indicated the resident was discharged from the hospital to a hospice house. On 1/25/17 at 3:25 PM, the resident's unit manager (UM), Registered Nurse (RN) F confirmed the resident did not have any treatment orders for the right elbow at the time of admission. UM F indicated admitting RN N did not assess the resident's right elbow at the time of admission. UM F stated at the morning meeting, the reviews admissions from the previous day. UM F stated she has to check every resident's skin from head to toe. She stated a physician must order the removal of the soft cast. UM F could not explain how a complete head to toe skin assessment would be conducted if the resident did not have a physician's orders [REDACTED]. UM F stated, I don't know how you monitor it (right elbow) if you don't look at it. I guess you should call the doctor and see if he wants us to look at it. UM F stated that anytime there is a resident without treatment orders, the doctor should be called to find out how to take care of the wound. UM F stated that on 12/13/16, the resident had drainage from the right elbow, so she called the attending doctor and obtained an order to remove the soft cast. She said the staples were in place but the resident had a stage III pressure wound on the right elbow. The resident went to the orthopedic surgeon's office for follow-up on 12/14/16. UM F's interview and recollection of the facility's wound care treatments to the right elbow were not what the orthopedic surgeon's hospital notes reflected when the resident was seen at his office. The orthopedic surgeon noted that the dressing to the right elbow had not been changed when he examined the resident on 12/14/16. On 1/25/17 at 4:45 PM, the director of nursing (DON) said she was aware resident #258 needed a follow-up appointment with the orthopedic surgeon. She stated that there was required pre-authorization from the insurance company before the resident could have the follow-up appointment. She said she contacted the orthopedic surgeon's office and found out a pre-authorization was not needed. The resident had a follow-up appointment with the orthopedic surgeon on 12/14/16. The DON stated she was informed of resident #258's condition on 12/13/16. The DON said she was not aware that UM F had documented that the resident had a pressure sore on 12/13/16. She stated the facility conducted their own investigation. She was aware Department of Children and Families was investigating allegations of neglect concerning resident #258. She stated the facility had attempted to get a follow-up appointment for the resident with the orthopedic surgeon. She said the facility's investigation regarding the lack of care to the post-op area of the right arm and right hip was caused by the delay with the orthopedic surgeon's follow-up appointment. The DON stated the facility did it's due diligence in setting up the appointment and meeting the resident's needs. On 1/26/17 at 1:43 PM, the wound care physician indicated she observed resident #258's right elbow pressure wound on 12/15/16. She stated the wound was very shallow and a wound vac would not have worked, and that the resident needed to go back to the orthopedic surgeon because, We couldn't treat it. The wound care physician stated she treated the resident's wound to the right leg, but the right elbow wound was not referred to her until 12/15/16. She indicated that the staff should have contacted the attending physician for any orders for the right elbow wound prior to 12/15/16 because, I can only look at the wounds that they recommend me to look at. The lack of wound treatment orders for the right elbow was discussed with the wound care physician. She stated she can't come between (the resident) and her surgeon. She reviewed the telephone order dated 12/13/16 for Xeroform to the staples/surgical incision and [MEDICATION NAME] for the pressure wound on the right elbow. The wound care physician stated she did not give that order, It is not my hand writing. Look, I didn't sign it. I always sign my orders, and I didn't sign that, because I didn't give it. On 1/27/17 at 4 PM, admitting RN N stated the resident had a soft cast on the right elbow upon admission. RN N stated the resident did not have wound treatment orders for the right elbow, from the hospital. RN N explained that if a resident doesn't have treatment orders, you are supposed to remove the dressing and look at the wounds. She added, that if there was any confusion with the wound, she would have the wound care physician look at it. She could not recall if she received wound care treatments from the doctor at the time of admission. She remembered that she did not remove resident #258's soft cast, Because it was a fresh post-op wound and you aren't supposed to remove (soft cast) until it was seen by the physician. RN N stated the unit manager should have followed-up to get the wound treatment orders for the right arm, and the follow-up appointment with the orthopedic surgeon for resident #258. On 1/27/17 at 4:40 PM, resident #258's attending physician was contacted by phone. He recalled observing resident #258's right hip but not the right elbow. He stated there were treatment orders for the right hip but not the right elbow. He said orthopedic surgeons give specific orders for treatment to post-operative areas. He stated that the wound care physician was seeing the resident and that the orthopedic surgeon had written wound treatment orders after the resident's follow-up appointment. He was aware of the conflict of orders between the wound care physician and the orthopedic surgeon. The wound care physician did not want the wound vac. He stated the responsibility would lie with the orthopedic surgeon. The attending physician stated, I did not talk to (the medical director) about this resident. The facility did not effectively use the services of the medical director. The medical director is ultimately responsible for the care and treatment of [REDACTED]. Assessment, care and treatment was non-existent for the right elbow wound for 15 days since the resident's admission. On 1/28/17 at 4:07 PM, a meeting was held with the administrator, UM F and the clinical consultant RN. The administrator did not offer any additional information regarding his involvement to ensure that the highest degree of quality care can be provided to residents at all times. An interview was conducted to determine if the facility had an effective QA process. The staff identified several tools such as the Grievance log, Guardian Angel Rounds, Mock Survey Audits, Wound Audits, and Admission Order Audits to help identify quality of care and resident rights issues. The staff stated that anything identified as an issue during morning meeting, 24-Hour report, and any verbal concerns are put on the Homework Sheets, and given to the unit managers. The Executive Director's job description, acknowledged on 8/30/16, read, The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. You are entrusted to provide .responsible healthcare Among the Duties and Responsibilities are, Schedule regular meetings with direct report staff to provide supervision, ensure communication and to monitor facility operations. The Medical Director's responsibilities read, The Medical Director shall generally be responsible for the oversight and delivery of medical services at the Care Center The Director of Clinical Services' (DON) job description, acknowledged on 11/29/16 read, The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide .responsible healthcare The Unit Manager's job description read, The primary purpose of tour position is for managing the staffing needs and providing supervision for nursing staff providing direct resident care to ensure quality resident care on the assigned unit. You are entrusted to provide .responsible healthcare Among the Duties and Responsibilities are, to Maintain ongoing communication with physicians concerning resident care The facility administration failed to efficiently and effectively utilize the resources for physicians services and nursing services to ensure quality of care and use the input and recommendation of the QAAC to provide responsible healthcare.

Based on record review and interview, the facility failed to maintain an effective Quality Assessment and Assurance Committee (QAAC) to identify quality deficiencies, and failed to develop and implement appropriate plans of action for surgical wound care and services and neglect to provide wound care and service to 1 of 12 sampled residents (#258). Resident #258 did not receive the necessary treatment and care to prevent a painful pressure ulcer and infected wound for 15 days. As a result of this neglect, the resident endured severe pain and required re-hospitalization within 16 days of admission for an infected wound that exposed the bone and hardware from surgery to her right elbow. The resident was diagnosed with [REDACTED]. Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. (www.cdc.gov/sepsis). The failure to prevent neglect resulted in Immediate Jeopardy, starting on 11/29/16 with Substandard Quality of Care. The Immediate Jeopardy was ongoing as of 1/28/17. Findings: Cross Reference to F224, F271, F281, F309, F314, F353, F385, F490. Resident #258 was admitted to the nursing home on 11/29/16. On 11/29/16, the admitting registered nurse (RN) N's documentation included that the resident had an open reduction and internal fixation (ORIF) of the right arm and right hip. The right hip had staples on the surgical incision, and the right elbow had a soft cast and was in a sling. RN N also noted a blister to the resident's coccyx and an abrasion to the right posterior thigh. A blister on a bony prominence is a stage II pressure sore by definition. The Physician order [REDACTED]. RN N's admitting note revealed the stage II coccyx pressure sore was cleansed and covered with barrier cream. Review of the medical record failed to produce any evidence of treatment orders for both the stage II coccyx pressure sore, the right elbow and the right hip. On 12/15/16, the resident was transferred to the hospital. The nursing home's Transfer form, dated 12/15/16, noted that the resident was lethargic, had altered Mental Status, and labored breathing. The hospital assessment, dated 12/15/16 at 9:55 PM, noted the resident presented with a right elbow open wound and exposed metal hardware. The site was red and hot to touch. On 1/25/17 at 3:25 PM, resident #258's unit manager RN F stated the resident did not have wound treatment orders from the hospital at the time of admission. RN F said the facility did not have orders to remove the soft cast. She said the facility conducts weekly skin checks for all residents residing in the facility. RN F could not explain how a thorough, comprehensive weekly skin check is done without removing the soft cast. She stated that on 12/13/16, the resident had drainage from the right elbow, and she called the attending physician who ordered treatment to the right elbow area. The Treatment Administration Record (TAR), dated 12/13/16, reflected the treatment to the right elbow was done. However, RN F's recollection of the series of events for 12/13/16, and the right elbow treatments that the resident received contradicts the orthopedic surgeon's findings from 12/14/16, who documented that the dressing to the right elbow wound was not changed. On 1/25/17 at 4:45 PM, the director of nursing (DON) stated that she was made aware of resident #258's right elbow wound on 12/13/16. The DON stated facility staff started an investigation, and provided a summary of the investigation. The facility's investigation focused on the difficulty of getting resident #258 a follow-up appointment with the orthopedic surgeon. The DON could not verify that the resident had treatment orders to the right elbow at the time of admission. She was not aware that RN F had noted a stage III pressure sore on the resident's right elbow on 12/13/15. The DON indicated that it was her understanding that the surgical wound had opened. She stated facility staff attempted several times get a follow-up appointment with the orthopedic surgeon. She said there was difficulty obtaining authorization before the follow-up appointment could be scheduled. The facility's investigation on the Agency for Health Care Administration's (AHCA) Five Day Report, dated 12/20/16, noted, Facility did its due diligence in setting up an appointment and meeting the residents need. No new measures were implemented, as findings were unsubstantiated. On 1/27/17 at 4 PM, RN N recalled that resident #258 had a soft cast to the right elbow but did not look at the surgical incision on the right arm. RN N stated she did not have a physician's orders [REDACTED]. She stated she could not remember if she called the physician to get treatment orders for the stage II coccyx pressure sore. She said on 12/14/16, the resident saw the orthopedic surgeon, and he wrote, Elbow Surgical wound open/pressure sore, s/p (status [REDACTED]. The surgeon ordered a wound vac to the right elbow wound and no splint to the right elbow. The resident returned to the facility but the facility staff did not implement the wound vac. On 1/28/17 at 4:07 PM, a meeting was held with the administrator, Unit Manager Registered Nurse F and the clinical consultant RN to discuss the facility's Quality Assessment and Assurance (QAAC) program. They indicated the QAAC consisted of the medical director, administrator, DON, unit managers, social services, rehabilitation, activities and dietary representatives. The staff did not provide any QA Meeting notes and data collection documents. An interview was conducted to determine if the facility had an effective QA process. The staff identified several tools such as the Grievance log, Guardian Angel Rounds, Mock Survey Audits, Wound Audits, and Admission Order Audits to help identify quality of care and resident rights issues. The staff stated that anything identified as an issue during morning meeting, 24-Hour report, and any verbal concerns are put on the Homework Sheets, and given to the unit managers. Review of the facility's survey history revealed that on 6/30/15, the facility was cited at the Immediate Jeopardy level for non-compliance with F224, F225, F281, F309, and F490. The facility's Quality Assessment and Assurance program, F520, was also cited at the Immediate Jeopardy Level for the QAAC's failure to identify quality deficiencies in resident care, safety and wellness. At that time, the facility's corrective action included the Prevention of Deviation in Care Processes and Correct Inappropriate Care Processes. The QAAC failed to recognize and identify the issues that led to resident #258 acquiring an avoidable right elbow pressure sore, exposing the surgical hardware inserted during the ORIF. Based on the medical record and interview with staff, there was a delay obtaining an orthopedic follow-up appointment. The facility is responsible for care and treatment to the resident's right elbow. The QAAC failed to identify that lack of treatment orders at the time of admission and for 15 days, resident #258 did not receive any wound care to the right arm and right hip. The resident had excruciating pain without relief. Based on the facility's investigation, the administrative staff concluded that the facility acted accordingly and met resident #258's care needs. However, the QAAC failed to identify and prevent substandard quality of care exhibited by the professional medical and nursing staff.

Based on observation, interview, record review and policy review, the facility neglected to provide services necessary to avoid harm. They failed to follow facility policy for head injury, failed to provide accurate assessments, and failed to provide nursing care to prevent neglect. The result of the facility's neglect resulted in Immediate Jeopardy for 1 of 16 sampled residents who had a fall and change in condition, resulting in a transfer to a higher level of care (#1). The facility failed to ensure timely completion of an X-ray ordered after a fall, which resulted in the resident sustaining a fractured right hip (#2). The total sample was 16 residents. Findings: Cross Reference F225. 1. Resident #1 was admitted to the facility on [DATE] with [MEDICAL CONDITIONS], dysphagia due to [MEDICAL CONDITION] disease, muscle weakness, [MEDICAL CONDITION], hypertension, and diabetes mellitus type II. Review of the Situation, Background, Assessment, Appearance and Request (SBAR) form, dated [DATE] at 3:30 PM, revealed documentation from licensed practical nurse (LPN) H who noted that the resident stood up from her wheelchair and fell to the floor, striking the back of her head on the floor. Review of facility policy and procedures for Head Injury, effective date [DATE], read, Licensed nursing personnel will stabilize the resident with a head injury. Procedure: Call physician. Monitor vital signs. Contact emergency transport and transfer to local hospital emergency room . Note: Any resident with acute injury could develop changes at a later date due to trauma resulting in swelling of the brain. Report any changes such as restlessness, increased confusion, decrease in awareness, change in communication or decline in activities of daily living (ADLs), which would indicate subdural hematoma or stroke. An interview with LPN H on [DATE] at 3 PM confirmed the resident sustained [REDACTED]. He said he was the nurse who completed the SBAR form and the pain evaluation sheet, and notified the advanced registered nurse practitioner (ARNP). He said the fall was not witnessed. He stated She (resident #1) was in her room, stood up from her wheelchair and fell to the floor, striking the back of head on the floor. I don't know if the alarm was going off. I told the ARNP that she hit her head and that is why she ordered ice. A review of the Pain Evaluation Sheet, not dated, noted an onset of sharp head pain when the resident fell and hit her head on the floor. An anatomical picture was marked to show the right side, back of head as the area of pain. The level of pain was documented as 4 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. In an interview on [DATE] at 1:40 PM, the ARNP stated, I was told on the phone the nurse found her on the floor. He said he went in and she had slipped out of the chair and hit her head on the wheelchair. It was unwitnessed. I was not told the resident hit her head on the floor. I ordered neuro (neurological) checks and told the nurse to call if there was any obvious trauma or change to contact me. I did not come in and see her. Review of the medical record found neurological (neuro) checks initiated on [DATE] at 3:30 PM. Review of the physician's orders [REDACTED]. apply ice to injury, head every 20 minutes PRN (as needed). 2. Neuro check list. 3. Call if any change in mental status. During an interview on [DATE] at 4:30 PM, the director of nursing (DON) said, The fall protocol is our fall policy. After a fall, the nurse is to assess the resident, complete an SBAR, and notify the family and physician. Neuro checks should be done for 72 hours after a fall. They should document in the nurses' notes any changes in condition and call the physician and family. When an injury occurs, loss of brain function can occur even without visible damage to the head. The trauma can potentially cause bleeding in the spaces surrounding the brain It is important to remember that a head injury can have different symptoms and signs, ranging from a patient experiencing no initial symptoms to coma In some situations, concussion type symptoms can be missed. Patients may experience difficulty concentrating, increased mood swing, lethargy, or aggression, and altered sleep habits A medical evaluation is always wise even after an injury has occurred . (emedicinehealth.com). Review of the Neurological Assessment Flow Sheet, dated [DATE], did not show neuro checks documented at 8:30 PM. This flow sheet revealed the following data: level of consciousness, pupil response, motor function, pain response, vital signs, and observations. An injury to the head requires a full neurological assessment to help determine the extent of the injury. Neuro checks are used to monitor the condition of the patient and evaluate a patient's status. (www.ehow.com). Review of nurses' notes following the fall did not have documentation from [DATE] until [DATE] at 7:45 PM. In an interview on [DATE] at 3 PM, LPN O said she was the nurse assigned to resident #1 on [DATE] on the 11 PM to 7 AM shift. She said, She (resident #1) was awake all night. She did finally go to sleep, but I really don't know when. It was not usual for her to be awake all night. She would usually be sleeping when I came on shift and would sleep through the night. I was able to give 6 AM medications. She had no problem taking them. I reported to the day nurse the resident was awake all night. LPN O did not say she contacted the physician about the resident's restlessness, which was not the resident's normal behavior. Resident #1 had a recent history of a fall, complaint of head pain after the fall, and a history of a previous [MEDICAL CONDITION]. In an interview on [DATE] at 5 PM, LPN A said she was assigned to assist resident #1 on [DATE] on the 7 AM to 3 PM shift. She said she received report from LPN O who told her the resident had not slept all night and was still awake at 6 AM. She said, Between 7 AM and 8 AM, I tried to wake her up. She looked at me but she wasn't awake. I thought she just needed to sleep, so I left her sleeping. I went back to wake her after 8 AM to give her medications. She opened her eyes but was not able to take her medication. I did not call the doctor and tell him I had held the medication. I don't know if I called or told the ARNP that she was sleepy but I didn't write it down. I can't remember if I did or did not talk to her. I think I did but I don't know for sure. I didn't document in my nursing notes she could not take her medications. Her brother was here around 11 AM, he did say to me that she wasn't as she normally was. I told him it was because she hadn't slept the night before. The CNAs (certified nursing assistants) came to me and told me she wasn't eating. Normally she would eat really good, but not that day. She was sleepy because she was tired, she didn't sleep the night before, so it was ok that she slept through my shift. If someone was awake all night it would be normal for them to sleep all through my shift. It wasn't a big deal. She said she gave report to the 3 to 11 PM nurse (LPN J). She told her the resident had been sleeping all day and if she didn't eat dinner, she should call the doctor, because that would be too long. LPN A did not say that the physician was contacted when the resident, who had a recent history of a fall and complaint of head pain after the fall and a history of previous [MEDICAL CONDITION], exhibited this declined change in condition. An interview with CNA E on [DATE] at 2:50 PM revealed she worked the 7 AM to 3 PM shift on [DATE] and was not assigned to the resident on [DATE], but remembered resident #1 was sleeping and didn't open her eyes. She said she helped another CNA to pull her up in bed for breakfast to feed her, but she would not eat. She stated Normally we set her food up. She always ate all her food. She would usually eat sitting up in her chair or in bed. She did not open her eyes that day. I told LPN A and she came in and looked at her, but I don't know what she did about it. When something is different, I tell the nurse and she is supposed to do something. She is the nurse. In the afternoon, her son came in. We did all her care that day. During her bath, she never opened her eyes. She just slept. In an interview on [DATE] at 1:30 PM, CNA R said she usually works with resident #1 and was assigned to her on [DATE] for the 7 AM to 3 PM shift. She stated, She (resident #1) could tell you what she wants, what to eat, and could use the bathroom. She needed help getting up to the chair and to the bathroom. She would hold on and stand up when she used the bathroom so we could clean her. She would talk to you and she knew who I was. She had her mind, but sometimes she is forgetful. I was with her that day. The night CNA (Q)told me she was sleepy and didn't want to wake up. Normally when I came in, she was awake. She would eat and then go back to sleep. When I tried to wake her, she would answer me with Ya Ya but she would just go back to sleep. She said she told LPN A she had tried to get her to eat and could only get her to take one sip of milk and she went right back to sleep. She said LPN A told her to keep an eye on her. CNA R stated, Her (resident #1's) brother came in to see her and I asked her (resident #1) if she wanted to get up for lunch. I told her it was time to get up. I put a wash cloth on her face to wake her up and she woke up and then went right back to sleep, and she just slept. She did not eat lunch. I washed and cleaned her. She could not hold on to the bed rail. She was very sleepy at the end of my shift. It is not normal for her to sleep like that. Her family said Get her up. Get her up. He asked if something has to be done and I told him the nurses will do what they have to do. CNA R said she was not aware the resident had a fall on [DATE]. An interview was conducted with the ,[DATE] hall unit manager (UM) on [DATE] at 3:20 PM. She said she was the UM on the unit for resident #1 on [DATE]. She said the resident was sleeping more during the day. She said, The nurse (LPN A) told me that she was sleepy, but that it was because the roommate kept her up. I did not know that she wouldn't eat or open her eyes. They never told me she wouldn't wake up. I had assumed they could wake her up, but when I came in the next day, night shift told me she wouldn't wake up. She said LPN A took care of her that day. The UM did not say that she contacted the physician when the resident, who had a recent history of a fall and complaint of head pain after the fall and a history of previous [MEDICAL CONDITION], exhibited this declined change in condition. During an interview on [DATE] at 3:30 PM, LPN J said she was assigned to assist resident #1 on [DATE] on the 3 to 11 PM shift. She stated, I had her on the 21st ([DATE]) and sent her out to the hospital. The son and daughter-in-law were in the room that day. I came on shift and the nurse told me she had been up all night. This isn't normal for her. I was told she went to sleep right at shift change in the morning of the 21st and slept during the day. At beginning of my shift, I went in to check on her and I checked her blood sugar and pupils. At the beginning of the shift, she opened her eyes, looked at me, and grimaced. She was able to grasp my hands but she wasn't awake like her normal. This was not her normal behavior. This was at about 3 PM. The day shift nurse (LPN A) said they had called the physician before I came in. I called the ARNP and left messages with the physician's answering service but I can't remember when and I did not document this in my nurse's note. I did a sternal rub and she (the resident) only looked at me. She normally would have slapped you if you had done that. This just wasn't normal for her to be up all night. She usually goes to bed and sleeps all night. I knew something was going on, but I didn't know what. I thought maybe a stroke or maybe it was her time. I wrote everything on scrap paper not in my nurses' notes. I only wrote down when they called back and I only wrote down one set of vitals (vital signs). In an interview on [DATE] at 4:30 PM, the DON revealed she was aware of resident #1 being less awake on [DATE]. When asked if this was the resident's baseline, she replied, No, normally this resident will talk to you and is awake. She was just sleepy because she didn't sleep the night before. I wasn't worried. The DON did not say that she contacted the physician when the resident, who had a recent history of a fall and complaint of head pain after the fall and a history of previous [MEDICAL CONDITION], exhibited this declined change in condition. When asked if she was aware of where the resident was now, she replied, Yes, she died . She had a stroke and died in hospice. When asked if she had initiated any investigation to prevent this from happening again, she replied, Why would we? We didn't do anything wrong. She was sleepy. We didn't think it was anything. She said she had not done an investigation or any training for the staff related to this incident. In an interview on [DATE] at 1:40 PM, the ARNP stated, I received a call in the afternoon on [DATE], sometime between 3 and 5 PM. I am not sure of the exact time. The nurse told me she had been sleeping a lot today. She skipped breakfast and participated in therapy. She did not tell me about a low blood sugar at this time. I wasn't concerned because they told me her roommate kept her awake all night. There was some [MEDICAL CONDITION] going around, so I thought maybe it was that. I ordered a chest X-ray and labs, because they heard something in her lungs. They called me back around 7 PM because her blood sugar was low and she had not eaten. They wanted to know if they should hold the insulin. I asked more questions and based on their answers, they told me she was really sleepy and difficult to arouse, and based on that, I didn't like it, so I sent her to the hospital. In a telephone interview on [DATE] at 4:15 PM, CNA P said she did remember taking care of resident #1 on [DATE] during the 3 to 11 PM shift. She said, She was not awake when I came on shift. She kept her eyes closed and she did not talk to me. I tried to feed her but she never opened her eyes. I told the nurse. The family was there, I think the daughter and the son. This was the first time I ever took care of her. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on [DATE] at 11:10 AM, LPN V said that she heard resident #2 call for help around 9 PM on [DATE]. She said, The doctor ordered an X-ray in the AM. I did not call Mobilex (portable X-ray company). I gave the ,[DATE]-,[DATE] 11 PM-7 AM nurse the information to call for the X-ray. Sunday Morning ([DATE]) I went to give (resident #2) her medications. She wanted to get up. I gave her medications and checked her blood pressure. When I realized the X-ray was not done, I called it in STAT (immediately). Mobilex told me the report would be back in hour. They called and told me it was a fracture. I called the doctor and she went out with .ambulance. Review of facility SBAR form and progress note dated [DATE] regarding the fall revealed the following: Functional status changes - decreased foot mobility, fall sustained skin tear; Assessment (RN) or appearance (LPN). LPN documented complaint of pain to right hip. The Request section did not have anything checked. Nurses' notes with additional information on the resident's change in condition read, At 2100 (9 PM) heard a patient (resident #2) calling for help upon entering the room noted patient on the floor in her bedroom. (Resident) stated that PT & OT (physical therapy & occupational therapy) told her she could walk so she decided to try walking and fell . (Resident) is complaining of pain to right hip during range of motion. (Resident) also sustained skin tear to right foot and right elbow. Dr. (doctor) was notified, new orders for x-ray of right hip. Patient will only attempt to walk with PT. Will continue to monitor. A resident family member was notified on [DATE] at 9:30 PM time of incident was identified. On [DATE] at 9:15 PM, the physician was notified and orders were received: Clean right leg with normal saline apply [MEDICATION NAME] and cover with dry dressing until healed. X-ray to right hip, result in AM to MD. The following interdisciplinary note shift reports and 24 Hours Reports beginning on the 11 PM-7 AM shift on [DATE] through 7 AM on [DATE] were completed by 5 nurses involving 5 shifts, none of which identified that the X-ray ordered in the early evening of [DATE] was completed or reviewed. Review of the Mobilex tracking form, dated [DATE], was changed to [DATE] for resident #2, and the claim number was noted. During the survey, a Mobilex customer service representative was contacted [DATE] at 4:06 PM. He stated that there was an X-ray order for resident #2 on [DATE] at 8:38 AM and completed at 12:55 PM. He confirmed that there was no X-ray ordered or completed on [DATE] or [DATE]. Review of the radiology report dated [DATE] and reviewed by the radiologist at 1:57 PM of the Hip unilateral complete minimum 2 views Right. Results: There is a fracture involving the right femoral trochanteric region with mild displacement. Conclusion: Acute right [MEDICAL CONDITION] as described above. There was no documentation on the 24 Hour Reports that noted that the X-ray was completed on [DATE] or [DATE], as ordered by the physician. This resulted in 2 days passing after a fall before an ordered X-ray was completed. When the X-ray and report was finally completed on [DATE], the resident was sent to the hospital for [MEDICAL CONDITION] repair. The facility neglected to provide services necessary to avoid physical harm by not completing a physician's orders [REDACTED]. Review of the facility's policy Resident Abuse included a section for neglect. It read in part that neglect includes Failure to provide services that result in harm to the resident Neglect -failure to take precautionary measures to protect the health and safety of the resident Lack of attention to physical needs The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM. These practices resulted in Immediate Jeopardy starting on [DATE]. It was determined to be ongoing as of the exit date of [DATE].

Based on interview and record review, the facility failed to thoroughly investigate an incident after a fall for 1 of 16 sampled residents (#1). Failure to do a thorough investigation after resident #1 fell caused a delay in providing proper care and treatment to the resident. Resident #1 fell and hit the back of her head on the floor on [DATE]. The resident was not transferred to acute care after the fall per the facility policy. On [DATE], the resident had a serious change in condition, was transferred to the hospital with a [DIAGNOSES REDACTED]. After 5 days of treatment in the hospital, the resident never regained consciousness. She was placed on hospice care and died on [DATE]. The facility could not demonstrate that such neglect was caused by factors beyond the control of the individuals providing care to resident #1. The facility's failure to thoroughly investigate the fall and fully assess the resident's condition resulted in an Immediate Jeopardy for resident #1. Findings: Cross Reference F224. Resident #1 was an [AGE] year old female resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment done on [DATE] showed the resident's BIMS (Brief Interview of Mental Status) score of ,[DATE] (score ,[DATE] is moderately impaired). She was able to feed herself in her room after the tray was set up by staff. She required one person assistance with toileting, transfers, and bed mobility. She was at risk for falls. The care plan listed an alarm on the wheelchair, which was added on [DATE] during the last quarterly review. A review of the facility Fall Root Cause Investigation Report revealed on [DATE], resident #1 fell to the floor while standing up from the wheelchair, and struck head on the floor. The resident was watching TV prior to the fall. Resolution/intervention for minimizing future occurrences was the use of a chair alarm. The report did not address the cause of the fall. The facility's Policy and Procedure for Falls Committee (Quality Assurance), effective date [DATE], read to Investigate to determine cause. A review of the Quality Assurance Accident/Incident and Follow-Up log of [DATE] noted the date and time of incident as [DATE] at 3:30 p.m. The type of injury was not listed. On [DATE] starting at 8 a.m., licensed practical nurse (LPN) A from the 7 AM-3 PM shift, and LPN J from the ,[DATE] PM shift did not identify that the resident had a serious change in condition, as exhibited by not being able to stay awake, speak, or eat. The resident could not take any of her medications by mouth or eat breakfast and lunch, but LPN A gave 2 units of regular [MEDICATION NAME] at 6:30 a.m. and [MEDICATION NAME] ,[DATE] insulin 21 units at 8 a.m. The resident's blood sugar was 168 at 6:30 AM. The physician was not notified of these changes until a call was placed to the advanced registered nurse practitioner (ARNP) sometime about 5 p.m. on [DATE]. On [DATE] at about 4:30 p.m., the director of nursing (DON) was asked what the facility did to prevent the reoccurrence of the delay in assessment, reporting to the physician, and providing care, and when staff was re-educated about these issues, after the facility found out the resident had a stroke and died . She replied, No, why would we? We didn't do anything wrong. She was sleepy. We didn't think it was anything. In an interview with the ARNP on [DATE] at 1:40 PM, she said the nurse called her in the late afternoon on [DATE] and told her the resident had been sleeping a lot, and did not eat breakfast. The ARNP said not eating breakfast was not a change because the resident often would get up at noon. Another call was placed to the ARNP at about 7:45 p.m. on [DATE] to inform her of the resident's low blood sugar of 87 from 4 PM that day, that was not reported earlier to her. At that time, the resident was more lethargic, not arousable, and did not open her eyes. The resident was then transferred to the hospital and diagnosed with [REDACTED]. After 5 days of treatment in the hospital from [DATE] to [DATE], the resident never regained consciousness. She was placed on hospice care and died on [DATE]. On [DATE] at 12:50 p.m., the medical director stated he was unaware of the incident involving the resident's fall, and was not aware the facility failed to follow procedure for fall and head injury and delay of treatment for [REDACTED]. He said the last QA (Quality Assurance) meeting was in [DATE] and this issue was not discussed at that meeting. The facility did not ensure that the alleged violation of neglect was reported immediately to the administrator of the facility and to other officials in accordance with State law. The facility could not provide evidence that the alleged neglect violation was thoroughly investigated, and did not prevent further potential neglect while the investigation was in progress. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM. These practices resulted in Immediate Jeopardy starting on [DATE]. It was determined to be ongoing as of the exit date of [DATE].

Based on observation, interview and medical record review, the facility failed to provide nursing care for a resident with a fall and change of condition based on professional Standards of Quality Nursing Care per the American Nurses Association Standards of Practice and Nurse Practice Act for 1 of 16 sampled residents by failing to appropriately assess and provide care (#1). The facility failed to ensure 1 sampled resident received an ordered X-ray promptly after a fall with complaint of pain (#2). The sample was 16 residents. Findings: American Nurses Association Standards of Practice include: Standard 1. Assessment - The registered nurse collects comprehensive data pertinent to the healthcare consumer ' s health or the situation. Standard 2. Diagnosis - The registered nurse analyzes the assessment data to determine the [DIAGNOSES REDACTED]. Outcome Identification - The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. Standard 4. Planning - The registered nurse develops a plan of care that prescribes strategies and interventions to attain expected outcomes. Standard 5. Implementation - The nurse implements the interventions identified in the plan. Standard 5A. Coordination of Care Standard 6. Evaluation - The registered nurse evaluates progress toward attainment of outcomes. (ferris.edu). The Florida Statutes Chapter 464 The Nurse Practice Act. (SS464.001.461.027) defines the Practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, inured, or infirm, and the promotion of wellness, maintenance of health and prevention of illness of others 2. The administration of medications and treatments as prescribed or authorized by a dully licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. 1. Resident #1's medical record indicted she was [AGE] years old, had a history of [REDACTED]. She sustained a fall on [DATE] at 3:30 PM as per review of Situation, Background, Assessment, Appearance and Request (SBAR) form completed by licensed practical nurse (LPN) H on [DATE]. It noted that the resident stood up from her wheelchair and fell to the floor, striking the back of her head on the floor. Review of the facility policy and procedures for Head Injury, effective date [DATE], noted the following: Call physician, monitor vital signs. Contact emergency transport and transfer to local hospital emergency room . Note: Any resident with acute injury could develop changes at a later date due to trauma resulting in swelling of the brain. Report any changes such as restlessness, increased confusion decrease in awareness change in communication or decline in activities of daily living, which would indicate subdural hematoma or stroke. According to an interview with LPN H on [DATE] at 3 PM, he confirmed he was the nurse who completed the SBAR report. He said the resident stood up from her wheelchair, fell and struck her head on the floor. This was an unwitnessed fall. He said the resident provided him with the information about the fall. Review of the pain evaluation form, not dated, read, Onset of pain was after fall - hit head on floor. The anatomical picture was marked showing the right side, back of head as the site of complaint of pain by resident #1. A physician's telephone order, obtained from the advanced registered nurse practitioner (ARNP) and dated [DATE] read, Apply ice to injury to head every 20 minutes PRN (as needed), neuro (neurological) checks, and call if any change in mental status. In an interview on [DATE] at 2:50 PM with CNA E and CNA R on [DATE] at 1:30 PM, they both said the resident was usually awake for breakfast, needed her tray to be set up, and would feed herself either in bed or in the chair. They said the resident was able to make her needs known and needed assistance to the bathroom. They said the resident knew who she spoke with when they spoke with her. They said on [DATE] on the 7 AM 3 PM shift, she was not normal, she kept her eyes closed most of the time, she would not eat her breakfast and she did not talk to them like she usually did. They gave her a bed bath and she did not wake up. They said they reported to LPN A that the resident was not the same but they were not sure what LPN A had done. CNA R said she put a wash cloth on the resident's face to wake her up and she woke up and then went back to sleep. When the resident's lunch tray arrived, CNA R said she tried to wake the resident up to eat but she did not wake up. CNA R said it was not normal for the resident to sleep like that. In an interview on [DATE] at 3:30 PM, LPN J said she was the nurse assigned to resident #1 on the ,[DATE] PM shift on [DATE]. She said she had taken care of the resident before. She stated, I was told in report the resident had been up all night, went to sleep at shift change and had slept all day. This was not normal for her. I went in to check on her at the beginning of my shift. She opened her eyes, looked at me, and grimaced. She wasn't awake like normal. About 3 PM, I did a sternal rub and she only looked at me. She normally would have slapped you if you had done that. This just wasn't normal for her. I knew something was going on, but I didn't know what. I thought maybe a stroke or maybe it was her time. She confirmed she had not written any nurses' notes to document the resident's drowsy sluggish condition on [DATE]. During an interview on [DATE] at 4 PM, the ADON stated, I started the nurse's note when the family came to me and said she (the resident) was acting different. It was in the afternoon around 3:30 PM. Her son was the one who came and told me. I shook her a little bit and she opened her eyes and went back to sleep. She was sleepier than she was the day before. Normally she will open her eyes and say a few words. She interacts with you. This compared to her baseline was very different. I spoke with the day shift staff and they told me that she had been up all night and was tired. I don't know if the nurses did neuro checks that day. I didn't do a neuro check. I don't know why I didn't put the times on the nurses' notes. She confirmed her nurses' notes were not timed and did not indicate that the resident slept all day, was drowsy, sluggish, and did not take any food or medication. When asked if this was normal for this resident, she said, No, it isn't. She always eats and responds to you when you enter the room. She confirmed she had not known about the resident's condition or assessed the resident until approximately 3:30 PM on [DATE], when the son reported it to her. She said she did not assess the resident before 3:30 PM on [DATE]. The ADON did not say she contacted the physician about the resident's change of condition at that time. During interview on [DATE] at 4:30 PM, the director of nursing (DON) stated, Our fall protocol is our fall policy. She could not provide a specific fall protocol. She said the nurses were to assess the resident, complete an SBAR and notify the family and physician. Neuro checks should be done for 72 hours after a fall and they should document in the nurses' notes any changes in condition and call the physician and family. The facility's Neurological Assessment Flow Sheet did not indicate assessments to be completed for 72 hours. The DON said she was aware of resident #1 being less awake on [DATE]. She said this was not the resident's baseline. She stated, Normally, she (the resident) will talk to you and is awake. She was just sleepy because she did not sleep the night before. We didn't think anything was wrong. She confirmed she had not done an investigation or educated nursing staff about failure to accurately assess and report to the physician the resident's change in condition. She stated, Why would we? We didn't do anything wrong. She was sleepy. We didn't think it was anything. The DON did not say she contacted the physician about the resident's change in condition. The Neurological Assessment Flow Sheet for resident #1, dated [DATE], was reviewed. At 8:30 PM and 11 PM on [DATE], and on [DATE] at 3 AM, information was not documented on the sheet for those dates and times. Review of nurses' notes did not show any documentation indicating resident #1's condition after the fall from [DATE] until [DATE] at 7:45 PM. In an interview on [DATE] at 5 PM, LPN A said she was assigned to the resident on [DATE] on the 7 AM to 3 PM shift. She stated, I received report from the night nurse (LPN O) and she told me the resident had not slept all night and was still awake at 6 AM. I tried to wake her between 7 AM and 8 AM. She looked at me but wasn't awake. At 8 AM, I tried to give her medications and she was not able to take them. I did not call the doctor to report the resident had not taken her medications or that she was very sleepy. She confirmed she had not written a nurse's note on [DATE] describing the resident's condition or that she was unable to give the resident her medications. When asked if she called the physician on her shift on [DATE], she stated, I can't remember if I did or did not talk to her. I think I did, but I don't know for sure. LPN A said the resident's brother was visiting around 11 AM and told her the resident wasn't as she normally was. She stated, I told him it was because she had not slept the night before. She stated, The CNAs told me the resident was not eating and the resident usually ate well. She was sleepy because she was tired. She didn't sleep the night before, so it was ok that she slept though my shift. If someone was awake all night, it would be normal for them to sleep all through my shift. It wasn't a big deal. I told the night nurse she had been sleeping all day and if she didn't eat dinner, she should call the doctor, because it would be too long. LPN A never mentioned that the resident had a history of [REDACTED]. LPN A did not say that the physician was called because of the resident's change in condition. On [DATE] at 1:40 PM during a telephone interview, the ARNP said she was not aware the resident had hit her head on the floor on [DATE] at 3:30 PM. She stated, It was reported to me the resident had hit her head on the back of the wheelchair. I told the nurse to call me if there was any obvious trauma or change. I did not come in to see her. During a telephone interview on [DATE] at 2:39 PM, CNA Q, who worked on [DATE] on the 11 PM to 7 AM shift, said the resident was awake most of the night on [DATE] into [DATE]. She stated, She (the resident) was still awake at 11 PM and complaining of pain in her foot. She was awake until 3 or 4 AM and then she went to sleep. About 5 or 6 AM, I changed her and she was very groggy but I felt that was normal because she had pain medication. In an interview on [DATE] at 2:50 PM, LPN O said that on her 11 PM to 7 AM shift, the resident was restless and awake most of the night on [DATE] into [DATE]. She said this was not normal for the resident, as she usually slept through the night. Nursing documentation was not found to indicate the resident's neurological status on [DATE] on the 11 PM to 7 AM shift. Review of the Medication Administration Record [REDACTED].) 2 tablets at 10 PM. There were no other pain medications documented as given. There was no documentation showing the resident had complained of pain. Review of facility policy and procedures for Head Injury, effective date [DATE], read, Licensed nursing personnel will stabilize the resident with a head injury. Procedure: Call physician. Monitor vital signs. Contact emergency transport and transfer to local hospital emergency room . Note: Any resident with acute injury could develop changes at a later date due to trauma resulting in swelling of the brain. Report any changes such as restlessness, increased confusion, decrease in awareness, change in communication or decline in activities of daily living (ADLs), which would indicate subdural hematoma or stroke. Assessment when a resident falls includes: Check the vital signs and the apical and radial pulses .check the skin for pallor, trauma, circulation check the nervous system for sensation and movement in the lower extremities. Assess the current level of consciousness and determine whether the patient has had a loss of consciousness. Look for subtle cognitive changes. (nursing center.com). Every neuro check involves an assessment of the patient's ability to move. Movement also includes an evaluation of strength the neuro check is comparing the patient's ability at the initial assessment to the current condition. Watch for any decrease in strength or lack of mobility Any abnormal behavior requires notifying the treating physician . An eye examination that focuses upon the pupils is part of the neuro check (ehow.com). The initial assessment should be a comprehensive exam covering several critical areas: level of consciousness and mentation, cranial nerves, movement, sensation, cerebellar function, and reflexes Evaluation of level of consciousness (LOC) and mentation are the most important part of the neuro exam. A change in either is usually the first clue to a deteriorating condition (modernmedicine.com). Nursing staff did not assess accurately resident #1's status and ultimate change in condition. On [DATE], the resident had a serious change in condition, was transferred to a hospital with a [DIAGNOSES REDACTED]. After 5 days of treatment in the hospital, the resident never regained consciousness. She was placed on hospice care and died on [DATE]. 2. Resident #2's medical record revelaed [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS assessment, dated [DATE], noted that the resident She had 1 fall prior to the assessment. She was receiving occupational and physical therapy since [DATE]. On [DATE] at 9 PM, the SBAR Communication form revealed the resident complained of pain to the right hip during range of motion and indicated that The patient (resident) stated that PT & OT told her that she can walk, so she decide(d) to try walking and fell . Pt. is complaining of pain to right hip. On [DATE], the resident's phyiscian ordered an X-ray of the right hip. There was no documentation on the 24 Hour Report that noted the X-ray was completed on [DATE] or [DATE], as ordered by the physician. The 24 Hour Report for [DATE] read, 11 PM to 7 AM S/P fall S/T to right leg/left arm intact. PRN pain increased depression Transport to hospital. ,[DATE] PM left facility at 4:15 PM via stretcher On [DATE] at 4:06 PM, a representative from the portable X-ray company said there was no X-ray ordered or completed on [DATE] or [DATE]. On [DATE] at 11:10 AM, LPN V said, On Sunday morning ([DATE]), I went to give resident #2 her medications. She wanted to get up. I gave her medications and checked her blood pressure. When I realized the X-ray was not done, I called it in STAT. Mobilex told me the report would be back in hour. They called and told me it was a fracture. I called the M.D. and she went out with .ambulance. On [DATE], an X-ray of resident #2's hip was ordered by the physician at 9:30 PM but was not completed until [DATE] at 12:55 PM. The X-ray report read, Acute right [MEDICAL CONDITION] Approximately thirty nine (39) hours passed from the time the hip X-ray was ordered to the time it was completed. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM. These practices resulted in Immediate Jeopardy starting on [DATE]. It was determined to be ongoing as of the exit date of [DATE].

Based on observations, interviews and record review, the facility failed to implement necessary care and services for 2 of 16 sampled residents. The facility failed to monitor 1 sampled resident to ensure her condition did not deteriorate after a head injury and when she began to experience a change in mental status and condition (#1). The facility failed to ensure 1 sampled resident received an ordered X-ray promptly after a fall with complaint of pain (#2). Resident #1 fell on [DATE] and hit her head on the floor. She complained of head pain at the time of the fall. Nursing staff failed to follow the policy and procedures (P&Ps) for Falls and Head Injury. Nursing staff failed to identify signs of complications due to head injury, as listed in their P&P and implement appropriate measures to address the resident's change in condition. As a result of the failure to provide necessary care and services following a fall on [DATE] with a head injury, the resident did not receive prompt treatment when the change in condition occurred. When resident #1 experienced restlessness on [DATE], three (3) days following a fall with complaint of head pain, and then had progressive decreased awareness and a change in communication, the physician was not notified for approximately eighteen (18) hours. As a result of this failure, the resident was not transferred to a higher level of care for approximately eighteen (18) hours after she exhibited a change in condition. The resident was transferred to the emergency room where she was diagnosed with [REDACTED]. The delay in treatment resulted in Immediate Jeopardy for resident #1, starting on [DATE], and determined to be ongoing as of the exit date on [DATE]. Resident #2 fell on [DATE] at 9 PM and orders for an X-ray were obtained on [DATE] at 9:15 PM. The X-ray was completed on [DATE] at for 12:55 PM. The X-ray revealed a [MEDICAL CONDITION] femoral trochanteric region with mild displacement. The resident was transferred to the emergency room at 4:15 PM on [DATE], forty-three (43) hours after the fall. Findings: 1. Resident #1's medical record revealed on [DATE] at approximately 3:30 PM, she sustained an unwitnessed fall in her room. She was admitted to the facility on [DATE]. Her clinical [DIAGNOSES REDACTED]. A review of the individual resident daily participation records from January, February, March, and [DATE] indicated resident #1 actively participated in various activities including bingo, religious services, outings with family, music, group discussions, movies, and sing-alongs. Her Minimum Data Set (MDS) assessment, completed on [DATE], showed she had clear speech, was able to make needs known, and had clear comprehension for understanding others. The brief interview for mental status (BIMS) Score was 12. A resident with a score of ,[DATE] has a moderately impaired mental status. The resident was able to recall the year, month, and two of three recall items. The MDS assessment, completed on [DATE], did not identify any acute changes from her last yearly assessment. Resident #1 required extensive assistance with activities of daily living (ADLs). This included one person assistance with transfers, and the ability to eat independently after setup. A quarterly data collection, completed on [DATE], noted she had an alteration in safety awareness due to cognitive decline at night. Nursing staff recommendation at that time was to add side rails for safety. She was independently mobile once assisted to her wheelchair. The resident's current fall risk score was 11. A total score of 10 or above deems the resident is at risk for falls. Review of the Physician order [REDACTED]. Order: 1. Apply ice to injury, head, Q-20 mins, PRN. 2. Neuro check list. 3. Call if any change in Mental Status. Indication: patient fall. A Pain Evaluation Form, completed on [DATE], indicated that the resident complained of pain on the back of her head After fall - Hit head on floor. Review of the Neurological Assessment Flow Sheet revealed checks were initiated on [DATE] at 3:30 PM. The last check was documented on [DATE] at 7 PM. No other neurological checks were documented for resident #1. The checks included level of consciousness, pupil response, motor function, pain response, and vital signs. On [DATE] at 4:30 PM, the director of nursing ( DON) and administrator both said the facility did not have a policy for neuro checks, only the Neurological Assessment Flow Sheet. In an interview on [DATE] at approximately 3:35 PM, the resident's son said, My mother was always awake and alert. She would talk to me all the time. He said his mother told him about this fall the next day on [DATE] during their daily visit. He said he spoke with a male nurse, name unknown, in which this male nurse confirmed the fall. Interviews with staff members noted the resident's usual interactions with others: In an interview on [DATE] at 2:50 PM, certified nursing assistant (CNA) E stated, I was working the 7 AM to 3 PM shift on [DATE]. (Resident #1) was not on my assignment that day. Usually (Resident #1) eats and opens her eyes, look and speak with us. She knew who we were, could tell us what she wanted, and let us know what she needed. She was sleeping that day. She wouldn't open her eyes. We pulled her up in bed so we could feed her but she wouldn't eat. Normally, we set her food up. She always ate all her food. She would eat in her chair or bed. I told LPN A, and she came in and looked at her but I don't know what she did about it. When something is different, I tell the nurse and she is supposed to do something. She is the nurse. We did all of her care that day, a bath, food, and she never opened her eyes, she just slept. On [DATE] at 3 PM, licensed practical nurse (LPN) H said he was the nurse assigned to resident #1 on the ,[DATE] PM shift on [DATE]. He said he entered resident #1's room for unknown reasons at approximately 3:30 PM and found her lying on the floor. He said after assessing the resident, he assisted her back to bed and called the ARNP to inform her of the fall. On [DATE] at 3:30 PM, the unit manager (UM) for resident #1 stated, she had some intermittent confusion, but she was cooperative and pleasant. In an interview on [DATE] at 3:30 PM, LPN J stated, I have taken care of (resident #1) before. I sent her out to the hospital. The family was in the room that day ([DATE]). In report when I can on shift, LPN A told me she (resident #1) had been up all night. This isn't normal for her. I was told she went to sleep right at shift change in the morning of the 21st and she slept during the day. After report, I went in to check on her. I checked her sugar (blood sugar) and pupils. I was worried because she is a diabetic and hadn't eaten all day. I did a sternal rub and she only looked at me. Normally she would have slapped you if you had done that. It isn't normal for her to be up all night. She usually goes to bed and sleeps all night. I knew something was going on but I didn't know what. During the assessment she opened her eyes and looked at me and grimaced. She was able to weakly grasp my hands. Her pupils were equal and reactive but she wasn't awake like her normal. This was not her normal. This was around 3 PM. (LPN A) said she had called the physician and the ADON before I came in. I then called after I came on shift. At 7:45 PM, the ARNP called me back, and gave orders to send (resident #1) to the hospital. (Resident #1) opened her eyes when EMS (emergency medical services) was here. I was telling them, EMS, that this wasn't normal for (the resident). In an interview on [DATE] at 4 PM, the ADON (assistant director of nursing), a registered nurse (RN) stated, I started the nursing note when the family came to me and said she was acting different. It was in the afternoon around 3:30 PM. (Resident #1's) son was the one who came and told me. I assessed (resident #1) in bed. I went in and shook her a little bit. She opened her eyes and went back to sleep. She was sleepy. She opened her eyes and went back to sleep. (Resident #1) was sleepier than the day before. Normally she will open her eyes, talk and interact with you. This compared to her baseline was very different. I spoke with the day shift staff and they told me that she had been up all night and was just tired. I spoke with the ARNP and she gave STAT (immediate) orders for a chest X-ray and lab (laboratory blood work) in the morning. When I talked to LPN J, she said the vital signs were fine thought she heard some rattle in her lungs. I thought maybe it was a UTI (urinary tract infection) or pneumonia. I know the nurses did neuro checks the day (resident #1) fell ([DATE]) but I don't know if they did it that day ([DATE]). LPN J checked her pupils and vital signs only, she was just sleepy. I didn't do a neuro check. We did not call the resident's family that day. He (the resident's son) was there when I went into the room. (LPN J & LPN A) told me she hadn't been eating that day but it was because she didn't sleep the night before. The ADON confirmed this was not normal for resident #1. She said, She (the resident) always eats and responds to you when you enter the room. ADON confirmed her handwritten note on the Interdisciplinary Progress Notes. She stated, I don't know why I didn't put the times on the notes. I just didn't. The ADON said, She (resident #1) would interact with you. In an interview on [DATE] at 4:30 PM, the DON stated, I was in the room with (LPN A). I went in and assessed this resident. She opened her eyes, and then went back to sleep. I did not take vital signs. (LPN A) had already done them. I did not complete a neuro check. (LPN A) had done that. I just shook her to see if she would wake up. She looked at me and went back to sleep. Normally this resident will talk to you and is awake. She was just sleepy because she didn't sleep the night before. I wasn't worried. She said, After a fall, nursing staff is to evaluate the resident and call the physician and family. They will then get orders from the physician and begin our Fall Protocol. We do not actually have a fall protocol other than our Fall Policy. A Situation Background Assessment Appearance and Request (SBAR) is completed, the physician and family are called, orders are obtained, neuro checks are started and completed for the next 72 hours. The nursing staff are to assess and document any changes to the resident and notify the physician and family immediately. In an interview on [DATE] at 5 PM, LPN A confirmed she was the 7 AM-3 PM shift nurse assigned to resident #1 on [DATE]. LPN A stated she received morning shift report from LPN O on the morning of [DATE]. In report, she was told that resident #1 did not sleep the night before, and was awake until 6 AM. LPN A stated she went in to wake up resident #1 around 7 or 8 AM, she said, I tried to wake her up, and she (resident #1) looked at me but she wasn't awake. I thought she just needed to sleep, so I left her sleeping. I went back to wake her after 8 AM to give her morning medications. She opened her eyes but she wasn't awake, so I held the medications. I didn't let the doctor know that I held her medications or that she hadn't eaten, because I wanted her to sleep. I don't know if I called or told the ARNP that she was sleepy but I didn't write it down. I cannot remember if I did or did not talk to her. I think I did but I don't know for sure. I didn't document anywhere that she couldn't take her medications and I didn't want to bother the doctor. (Resident #1's) brother was here around 11 AM. He did say to me that she wasn't as she normally was but he didn't seem worried, and I told him it was because she hadn't slept the night before. The CNAs came to me and told me she wasn't eating. Normally she would eat really good, but not that day. She was sleepy because she was tired. She didn't sleep the night before, so it's ok that she slept though my shift. If someone is awake all night, it would be normal for them to sleep though my shift. It wasn't a big deal. (Resident #1) did not take any medications or eat at all during my shift. During report with the ,[DATE] PM nurse (LPN J) I told the nurse that (resident #1) had been sleeping all day. The resident would wake and look at me but not stay awake. I told her that if (resident #1) didn't eat dinner, she (LPN J) should call the doctor, because after dinner would be too long for her to go without food or medications. In an interview on [DATE] 1:40 PM, the ARNP said, I was told on the phone that the nurse found her (resident #1) on the floor (on [DATE]). He told me that he went in, she had slipped out of the chair and hit her head on the wheelchair. It was unwitnessed. There did not appear to be an injury, and per the patient (resident #1), she said she hit her head, but there was no evidence of trauma. The resident was complaining of pain. I was not told that she hit her head on the floor. I ordered neuro checks and to call if there was any obvious trauma. I ordered ice for pain, and to contact me if there was any change. She said, I received a call in the afternoon, ([DATE]). It was between 3 and 5 PM. That was the first time they contacted me. The nurse told me (resident #1) had been sleeping a lot today, skipped breakfast, and participated in therapy. I wasn't concerned because they told me her roommate kept her awake all night. During that time, there was [MEDICAL CONDITION] going around, so I thought maybe it was that. I ordered a chest X-ray and labs because I was told they heard something in her lungs. They called me back around 7 PM because her sugar was low and they wanted to know if they should hold the resident's insulin. I was told her blood sugar was low and she was not eating. I then began to ask more questions. They told me she was really sleepy and difficult to arouse, and based on what they were telling me, I didn't like the answers. So I sent her to the hospital for evaluation. (Resident #1) did not remember names, she knew the roles they played in her care. Like she knew I was her doctor. She could always tell you what was wrong. In an interview on [DATE] at 1 PM, CNA G, a restorative CNA, she said she completed passive ROM (range of motion) exercises with resident #1 on [DATE]. She said, I worked with her for approximately 30 minutes on that day. Normally she (resident #1) would participate with the therapy and talk with you the entire time but that day she just slept. Because she was so sleepy,I only did passive range of motion with her. When I was done with her treatment, I went out and told LPN A that the resident was very sleepy and not talking. She told me that the resident had been up all night and was very tired. The Restorative Tracking Form from [DATE] had documentation that resident #1 was seen by CNA G on [DATE] for 30 minutes. CNA G confirmed she completed the form and initialed it. In an interview on [DATE] at 1:30 PM, CNA R stated, I worked with (resident #1) on [DATE] on the 7 AM-3 PM shift. (Resident #1) can tell you what she wants, what to eat, and she can use the bathroom. She needs help getting up to the chair and to the bathroom. She will stand up and hold on when you are cleaning her in the bathroom. She will talk to you, and she knows who I am. She has her mind, but sometimes she is forgetful. When I come in, I would set her up for breakfast, she would eat, and then go back to sleep. She can feed herself but if she didn't eat enough, I would help her eat. (CNA Q) told me during our shift report that (resident #1) was sleepy and didn't want to wake up. I told (LPN A) hat I tried to get her to eat, and I only got her to take a sip of milk. She went right back to sleep. I told (LPN A) to check on her. (LPN A) told me that her blood sugar and blood pressure (BP) were fine, and to keep an eye on her. (Resident #1's) brother came in to see her and I asked her if she wanted to get up. I washed her face with a wet washcloth to wake her up and she went back to sleep. When her lunch tray came, we tried to give her some MedPass and ice cream, but she only took a sip and went back to sleep. I washed and changed her but she couldn't help, so the nurse helped me change and wash her. She was very sleepy at the end of my shift. (Resident #1's) family came to me and said 'Get her up. Get her up, something has to be done.' (Resident #1's) son asked how her sugar was, and I told him her sugar and BP were fine. I kept going back in there to check on her all day because she was so sleepy. Normally I would take her to activities but she didn't go to Bingo that day. She didn't go to any activities. CNA R confirmed that she did not know that resident #1 had fallen on [DATE]. In an interview on [DATE] at 2:08 PM, CNA Q said she cared for resident #1 on [DATE]. She said the resident was awake until about 3 or 4 AM, and then went to sleep. She said, When I went in to change her around 5 or 6 AM, she was very groggy but I thought it was from the pain medication. For (resident #1) to be awake all night would not have been normal for her. She would go to bed late sometimes, 11 or 12 PM, but usually she would be in bed asleep when I would come on shift. In an interview on [DATE] at 2:50 PM, LPN O said, (Resident #1) was up till about 3 or 4 AM in the morning during the shift of [DATE]. It was not usual for her to be up till then. Normally it's till 11 PM. That was the report I gave in the morning. (Resident #1) was always able to talk with me I wasn't aware that she fell and hit her head. LPN O confirmed that she gave the resident her morning medications at 6 AM on [DATE], including [MEDICATION NAME] (for [MEDICAL CONDITION]), [MEDICATION NAME] (for pain), and took an Accu-Check/Fingerstick to test her blood sugar. The resident's blood sugar was 165 and she was given 2 units of [MEDICATION NAME] per sliding scale. A Sliding Scale is a tool that is used for insulin administration. Based on the blood sugar score, the scale indicates the amount of insulin a resident is to receive per physician's orders [REDACTED]. That's when she told me she was going to sleep. I told (LPN A) that I was able to give her medicine and that (resident #1) told me she was going to sleep. Review of the Situation, Background, Assessment, Appearance and Request form (SBAR), Communication Form and Progress Note, completed by LPN H dated [DATE], read, I'm calling about a Fall The resident appears fine. Only complaint is pain at injury site head [DATE] 1530 hr (3:30 PM), Resident stood up from w/c (wheelchair) and fell to the floor, striking the back of her head on the floor. No loss of consciousness (LOC) - Neuro (neurological) check initiated. NP (nurse practitioner) notified Ice to injury/pain site Q (every) 20 min PRN (as needed). Continue Neuro check, and call if any change in mental status. The Medication Administration Record [REDACTED]. Resident #1 did receive [MEDICATION NAME] ,[DATE] injection 21 units subcutaneously before breakfast. [MEDICATION NAME] ,[DATE] is a short and long acting insulin for diabetics. Interdisciplinary Progress Notes from [DATE] to [DATE] were reviewed. The ADON confirmed her entries on the form. One note on [DATE] read, Resident slightly lethargic today. Not eating. Family in to visit. Doctor notified and N/O (new order) for STAT CXR (chest X-ray). Another note on [DATE], Resident in bed all day. Turned and repositioned. Abnormal lung sounds. There was another entry on this form after the ADON's entries. It read, [DATE], resident slept all day, lethargic, no food intake or medications. Brother at bedside to visit. Reported haven't been sleeping all night. Will continue to monitor. Interdisciplinary Progress Notes from [DATE] revealed the following: LPN J confirmed all of the entries were written by her. On [DATE] at 7:45 PM, it read, Recall to ARNP about change in mental status for (resident #1). Patient (resident) has become more lethargic, harder to arouse. The note on [DATE] at 8:10 PM read, Return call ARNP advised us to send (resident #1) via 911 to hospital for AMS (altered mental status), possible pneumonia. Nurses's Medication Notes on [DATE] read, Unable to take medication all day/asleep. This form was signed by LPN A. Physician order [REDACTED]. A second entry written by LPN J on [DATE] at (8:10 PM) read, Discharge (D/C) to hospital via 911 for Altered Mental Status (AMS), possible pneumonia, per ARNP. A SBAR was completed on [DATE] at 9:45 PM, after the resident was sent to the hospital. It read that the onset was [DATE], symptoms were 'lethargic'. Received report 7a-3p nurse. Patient (resident) has been sleeping all day. Not eating, drinking, or taking her medication. Patient became hard to arouse. Recall to physician - talk with ARNP advised to send to hospital 911 for AMS, pneumonia. The CNA ADL Tracking Form from [DATE] showed that on [DATE], resident #1 required total assistance with bathing which was not her normal need as previously noted before that date. Review of the facility's policy for Change in Resident Condition read, The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The primary Clinical Nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs. In the event of an emergency situation, 911 will be called and the Physician/Family/Responsible Party will be notified as soon as possible. With change of resident status, the Clinical Nurse will gather all subjective and objective assessment information. The Nurse is responsible to complete an assessment of the resident's condition to include Vital Signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken. Review of the facility's policy for Head Injury, effective date [DATE], read, Licensed nursing personnel will stabilize the resident with a head injury Any resident with acute injury could develop changes at a later date due to trauma resulting in swelling of the brain. Report any changes such as restlessness, increased confusion, decrease in awareness, change in communication or decline in ADL, which would indicate subdural hematoma or stroke. On [DATE] on the 11 PM - 7 AM shift, resident #1 began having a significant change in condition, which was not identified by nursing staff and not reported to the physician until 7:45 PM that evening. There was a delay of twenty (20) hours and forty-five (45) minutes before the resident's change in condition was assessed, and reported to the physician. The change in condition resulted in resident #1 being transported to the hospital. Resident #1's [DATE] CT scan revealed a large acute-to-subacute right middle cerebral artery [MEDICAL CONDITION] infarction. The resident never regained consciousness and died under hospice care on [DATE]. 2. Resident #2 was admitted to the nursing home on [DATE]. Present [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS assessment, dated [DATE], noted that the resident was able to understand others and make herself understood. The BIMS identified resident #2 as a 13 (,[DATE] indicates cognitively intact). Her functional status was noted as extensive assistance of one person for bed mobility and transfer, and she did not walk in the room or corridor. She was not steady but was only able to be stabilized with staff assistance. Mobility devices included a walker and wheelchair. She had 1 fall prior to the assessment. She was receiving occupational and physical therapy since [DATE]. On [DATE] at 9 PM, the SBAR Communication form revealed the resident complained of pain to the right hip during range of motion and had a skin tear to the right foot and right elbow. It indicated that The patient (resident) stated that PT & OT told her that she can walk, so she decide(d) to try walking and fell . Pt. is complaining of pain to right hip. Nurses' notes for additional information on the change in condition indicated that, At 2100 (9 PM) heard a patient (resident) calling for help. Upon entering the room, noted patient on the floor in her bedroom. Pt. state that PT/& OT told her she could walk so she decided to try walking and fell . Pt. is complaining of pain to right hip during range of motion. Pt also sustained skin tear to right foot and right elbow. Dr. was notified, new orders for X-ray of right hip. Also notified pt.'s daughter. Patient will only attempt to walk with PT. Will continue to monitor. A resident family member was notified on [DATE] at 9:30 PM. The physician was notified at 9:15 PM, and orders were received. The order read, Clean right leg with normal saline, apply [MEDICATION NAME], and cover with dry dressing until healed. X-ray to right hip, result in AM to MD. Resident was sitting in wheelchair watching TV in bed room. No environmental concerns. LPN V noted on [DATE], no date, that the resident felt she could walk because of therapy. Patient was educated to use call light for assistance. On [DATE], an interdisciplinary progress (IDT) note at 3 PM, read, Post fall complaint to right leg relieved by [MEDICATION NAME] right leg dressing change. On [DATE], an IDT note at 3 AM read, status [REDACTED]. Relieved by as needed Tylenol; O2 maintenance. On [DATE] (time not legible), an IDT note read, Noted status [REDACTED]. Upon further evaluation and question, patient admits she has a pain level on scale of ,[DATE] is 5. Patient stated 'I am OK. Get me up please.' X-Ray order received report. Call Dr., left message. On [DATE], an IDT note (time not legible) read, Call Dr. (medical director) gave report, received new orders to send patient to the hospital. On [DATE], an IDT note at 9:10 PM read, Resident left facility at 4:15 PM via stretcher The 24 Hour Report for [DATE] read, 11 PM to 7 AM S/P fall S/T to right leg/left arm intact. PRN pain increased depression Transport to hospital. ,[DATE] PM left facility at 4:15 PM via stretcher There was no documentation on the 24 Hour Report that noted the X-ray was completed on [DATE] or [DATE], as ordered by the physician. On [DATE] at 4:06 PM, a representative from the portable X-ray company said there was no X-ray ordered or completed on [DATE] or [DATE]. On [DATE] at 3:30 PM, the resident was observed in her bed lying with the head of bed slightly elevated and her heels floated on a pillow. An interview was conducted with resident #2 at that time. She stated that she fell on [DATE] when she dropped her lower dentures into her wheel chair They wiggled my legs, I said no pain. They manually set me back in my wheelchair with 2 people and checked my vitals. They helped me back to bed. Then on [DATE], at breakfast after getting up, everything started hurting. They (staff) told me to take it easy. I got up and went to Bingo. I was walking to the bathroom and it started hurting. The night of [DATE], I did not sleep well and took two Tylenol. On [DATE], I was still hurting. X-rays were done. There was something wrong there. Then they thought it was a good break, a bigger break. I still hurt, they gave me Tylenol. I was sent to the hospital on [DATE]. I was operated on [DATE] and returned here on [DATE]. On [DATE] at 11:10 AM, LPN V said that she heard resident #2 called for help around 9 PM on [DATE]. She went to the resident's bedroom and found her lying on her back by the door. She said she observed skin tears and had a little pain when she moved. She said, I told her not to move, would call Dr. and family, assisted her to the chair and had 2 CNAs to help. The resident thought she could walk because she was in PT/OT and walking. The doctor ordered an X-ray in AM. I did not call Mobilex (portable X-ray company). I gave the ,[DATE]-,[DATE] ,[DATE] AM nurse the information to call in the X-ray. On Sunday morning ([DATE]), I went to give resident #2 her medications. She wanted to get up. I gave her medications and checked her blood pressure. When I realized the X-ray was not done, I called it in STAT. Mobilex told me the report would be back in hour. They called and told me it was a fracture. I called the M.D. and she went out with .ambulance. On [DATE], an X-ray of resident #2's hip was ordered by the physician at 9:30 PM but was not completed until [DATE] at 12:55 PM. The X-ray report read, Acute right [MEDICAL CONDITION] Approximately thirty nine (39) hours passed from the time the hip X-ray was ordered to the time it was completed. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM. These practices resulted in Immediate Jeopardy starting on [DATE]. It was determined to be ongoing as of the exit date of [DATE].

Based on observation, interview and record review, the facility failed to efficiently and effectively coordinate the implementation of policies and procedures to prevent resident neglect in order to maintain the highest practicable measure of care to 1 of 16 sampled residents. This failure put the other 154 residents at risk for potential neglect. Administration failed to ensure accurate and appropriate assessment of a resident with a history of [MEDICAL CONDITIONS]/stroke, and failed to ensure the provision of prompt care when there was a change in resident condition. This resulted in Immediate Jeopardy for resident #1 (#1). Findings: Cross Reference F224, F225, F281 and F309. Review of Executive Director's I Job Description, date unknown, read, As Executive Director I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility and ensures compliance with all state and federal regulations. Supervises Director of Clinical Services Maintain and guide the implementation of facility policies and procedures in compliance with state, federal, and other regulatory guidelines Support and guide the facility's quality improvement process Maintain a file for and monitor incident reports Review of the Director of Clinical Services' I Job Description, date unkown, read, As Director of Clinical Services I, you are delegated the administrative authority, responsibility and accountability necessary for carrying out planning, organizing and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality, efficient nursing care Supervises Assistant Director of Clinical Services, Clinical Nurses and Nurse Techs Maintain and guide the implementation of current policies and procedures Assure compliance with resident rights Establish and monitor compliance with an effective medical record documentation Actively participate in the quality improvement process for the facility Resident #1 sustained a fall on [DATE] which resulted in the resident complaining of head pain. The resident had a history of [REDACTED]. The nurse did not report the correct information to the Advanced Registered Nurse Practitioner (ARNP) after the fall, which consisted of increased lethargy. The resident had a change in condition which included a change in mental status starting on [DATE] on the 11 PM to 7 AM shift, three days after the fall. The night nurse did not notify the physician or the family at the time the change began. The resident continued to have a declined change in condition and mental status on the 7 AM to 3 PM shift on [DATE]. The resident was unable to verbalize to staff, eat her meals or take her medications for the entire 7 AM to 3 PM shift on [DATE]. The nurse did not notify the physician that the resident was unable to eat, speak, and take her medications during the day shift. On [DATE], the 3 to 11 PM nurse, LPN J, notified the advanced registered nurse practitioner (ARNP) between 3 PM and 5 PM but did not give an accurate report of the resident's condition. The resident's family was present on [DATE] and reported to the nurse that the resident was not her normal self. The family was told by nursing staff that the resident was just sleepy because she was restless and awake the night before. In an interview on [DATE] at 4:40 PM with the executive director (ED) and the director of nursing (DON), the DON said she was aware of the incident and stated, The resident would normally talk to her and is awake. She was just sleepy because she didn't sleep the night before. I wasn't worried. When asked if she knew what had happened to the resident after she left the facility, she answered, Yes, she had a stroke and died . When asked if administration investigated the incident, she replied, No. Why would we? We didn't do anything wrong. She was sleepy. We didn't think it was anything. She confirmed they had not done a complete investigation of the [DATE] fall and the change in condition on [DATE]-[DATE], and had not educated the staff on following their policy for Head Injury which included assessing for change in condition, and documenting after falls and change in condition. The ED did not comment on any of the questions. On [DATE] at 10:08 AM, the ED indicated that adminsitration communicates with nursing staff daily at Stand Up and Stand Down meetings. The unit managers attend the morning Stand Up meetings and communicates back to unit nurses and certified nursing assistants (CNAs) daily. The ED was not specific about how the unit managers communicate with staff from the other shifts, evening and night shifts, and how administration monitors the care to ensure qaulity. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM. These practices resulted in Immediate Jeopardy starting on [DATE]. It was determined to be ongoing as of the exit date of [DATE].

Based on observation, record review and interview of the facility's Quality Assurance (QA) program committee did not evaluate and identify nursing non-compliance with the facility's fall/accident/assessment program, head injury, and change in condition, in order to identify and correct quality deficiencies to ensure the safety and wellness of residents in the facility for 1 of 16 residents reviewed for falls, head injury and change in condition. These actions caused a delay in care for resident #1 and resulted in Immediate Jeopardy starting on [DATE] (#1). Findings: Cross Reference F224, F225, F281, F309, and F490. Resident #1 sustained a fall with a head injury on [DATE] at 3:30 PM which was verified by review of Situation, Background, Appearance and Request form (SBAR) dated [DATE] and interview with licensed practical nurse (LPN) H on [DATE] at 3 PM. LPN H confirmed the resident had fallen and sustained a head injury on [DATE]. He said the fall was unwitnessed, but the resident had told him she hit her head on the floor and she complained of pain. In an interview on [DATE] at 3:20 PM, the Advanced Registered Nurse Practitioner (ARNP) stated, I was not told the resident had hit her head on the floor when the nurse called me. I was told the resident had slipped out of her chair and hit her head on the back of the wheelchair. Review of the medical record did not show any documentation the resident was transferred to local hospital emergency room after sustaining a head injury after a fall on [DATE], as indicated by the facility's Head Injury policy. On [DATE], resident #1 had a change in condition starting on the 11 PM to 3 PM shift. The resident was reported as being awake most of the night, which was unusual for her. On [DATE] on the 7 AM to 3 PM shift, LPN A said the resident was asleep most of the day, did not talk with the staff, did not take medication, and did not eat. It was reported to the 3 to 11 PM LPN J that the resident was kept up all night by her roommate and was sleepy. LPN A, the 7 AM to 3 PM shift nurse, did not call the ARNP to report the resident's change in condition. LPN J did not notify the ARNP with any information about the resident until sometime between 3 PM and 5 PM. At that time, the ARNP was not informed that the resident had not eaten all day, had slept all day, was not verbal with staff, and her blood sugar results from 4 PM was low at 87. It was not until 7:45 PM on [DATE], the ARNP was informed about the resident's total change in condition, and then the resdient was sent to the hospital in an unresponsive state. In an interview on [DATE] at 4:30 PM, the Executive Director (ED) and Director of Nursing (DON) were interviewed. The ED said she was the lead for the QA&A (Quality Assessment & Assurance) meetings and was also the Risk Manager (RM). The ED and DON were asked if they had investigated or brought before the QA&A committee the incident of a fall with head injury and for nursing not communicating a change in condition accurately to nursing staff and the physician. They were also asked if they knew what happened to resident #1 after she left the facility. The DON answered, Yes, she died . The ED did not reply. When asked if they had identified, investigated any risk factors from the fall with head injury on [DATE] or the lack of assessment and communication on [DATE] for resident #1, and whether it had been discussed in QA&A, the DON said, No. Why would we? We didn't do anything wrong. We didn't think it was anything. The ED did not reply to the question. On [DATE] at 12:50 PM, the medical director said the facility has monthly QA (quality assurance) meetings and the committee reviews any issues and ongoing management concerns. He said they talk about falls, incidents, and change in condition. He said. I don't remember response time being brought up for delay in care and services at these meetings. When asked if he was required to review medical records for specific concerns, he replied, Yes, but I haven't had to review a chart for that (change in condition). On [DATE] at 10:08 AM, the ED indicated that administration reviews daily at the Stand Up Meeting the following: environment concerns, new admissions, resident concerns from previous shifts, and falls. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:50 PM. These actions caused a delay in care for resident #1 and resulted in Immediate Jeopardy starting on [DATE]. It was determined to be ongoing as of the exit date of [DATE].