Every finding on record at Park Manor of the Woodlands

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review on a daily basis at the beginning of each shift for 1 of 1 facility reviewed for required postings. The facility failed to update the daily nursing postings on 02/05/26. This failure could affect residents, by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 02/05/26 at 09:08 AM revealed, the facility Daily Nursing Staff Direct Responsible for Resident Care on the top of the center nursing station facing the front door that read 02/04/26. The posting indicated that the facility had 3 shifts (6AM- 2 PM, 2 PM - 10 PM, 10 PM- 6 AM) for Nurses, 3 shifts (6AM- 2 PM, 2 PM - 10 PM, 10 PM- 6 AM) for CNA, 2 shifts (6AM- 2 PM, 2 PM - 10 PM) for CMAs, and 2 shifts (6AM- 2 PM, 2 PM - 10 PM) for RNAs. The posting indicated the facility census, number of staff types (RN, LVN, CNA, CMA and RNAs) and total hours worked for all shifts. In an observation and interview on 02/05/26 that started on 12:28 PM, the Administrator said the staffing coordinator was responsible for updating the facility daily staffing posting. He said the posting included the facility name, date and the staffing ratio, and the staffing coordinator updated the posting when she came to work around 06:30 Am. The Administrator said the staffing coordinator was on leave today, so the DON was responsible for updating the posting. He said the daily nursing posting served to notify all in the building the type and number and staff available for resident care on a particular day and failure to update the posting would place visitors at risk of not knowing the staff to resident ratio. The Administrator walked out to the nursing station and confirmed the daily staff posting was not updated, it read 02/04/26. In an interview on 02/05/26 at 12:46 PM, the DON said the staffing coordinator was responsible for updating the staffing posting. She said she was responsible for updating the posting when the staffing coordinator was absent. She said the posting served to provide anyone in the building with the staffing to resident ratio. The DON said the posting is typically updated before the first shift. She said failure to update the posting could place visitors at risk of not knowing what the current census or staffing was. Record review of the facility policy titled Posting Direct Care Daily Staffing Numbers revised 07/2016 revealed, Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 5. Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety reviewed for food procurement in 1 of 1 kitchen to demonstrate the prevalence of the noncompliance in that: -The facility failed to ensure 10 pounds of raw fish was stored at proper temperature. -The facility failed to ensure scoops were not stored in food bins. -The facility failed to ensure gallons of milk were not stored on a rack 4 1/2 inches off the floor. These failures could place residents at risk of food borne illnesses and diseases. Observation and interview on 9/09/25 between 8:30 am and 8:40 am with the Dietary Manager revealed the following: -10 pounds of raw fish was inappropriately being held on a pan being thawed at room temperature, evidenced by taking the temperature revealed the internal temperatures of 64 degrees Fahrenheit. -Scoops with handles submerged in the sugar bin and flour bin. -4 gallons of milk were on a rack 4 1/2 inches off the floor in the walk-in refrigerator. Interview with the Dietary Manager on 09/09/25 at 8:40 AM, she stated food held with danger zone temperature could place the residents who ate the food at risk of food borne illness and disease. She also stated frozen food should not be thawed at room temperature. Scoops in the food bins could cause cross- contamination and the staff should be storing the scoops container not touching food. Food had to be stored 6 inches off the floor. She stated that she was responsible for training staff on proper storage/temperature. Record review of facility's Food and Nutrition Services Policy and Procedure Manual dated revision date January 2012 read in part Cold foods shall be maintained at temperatures of 40 degrees Fahrenheit or below. Hot foods or potentially hazardous food shall have a temperature of 140 degrees Fahrenheit or above. Food service scoops are not permitted to be stored inside dry storage bins, ingredient containers or product bags. This practice poses a risk of contamination from handles or hands coming into contact with food product. All foods must be kept on shelves at least 6 inches off the floor to prevent contamination and facilitate cleaning. Record review of FDA Food Code 2022 read in part .3-501.11 Frozen foods shall be maintained frozen. 3-501.12 Time/Temperature Control for safety food shall be held under refrigeration that maintain the food temperature at 41 degrees Fahrenheit or less or at any temperature if the food remains frozen.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #75, Resident #78 and Resident #79) and 1 of 1 Kitchen (Kitchen A) reviewed for infection control. 1.The facility failed to ensure MA E used the required PPE for Resident #75, who was on enhanced barrier precautions, while checking BP on 9/23 /25. 2. The facility failed to ensure LVN K used the required PPE for Resident #78 on 9/23/25. 3. The facility failed to ensure CNA B maintained hand hygiene during incontinent/FC on 9/24/25 for Resident #79. 4. The facility failed to ensure CNA B cleansed around the buttocks for Resident #79 on 9/24/2025. These failures could place residents at risk of cross-contamination, development of infections, and food-borne illnesses and diseases.1.Record review of Resident# 75's reflected the resident was admitted to the facility on [DATE]. Resident #75 had diagnoses which included essential (primary) hypertension (high blood pressure), other hyperlipidemia ( high fat in the blood), chronic kidney disease, stage 3a, other sleep apnea, gastro-esophageal reflux disease without esophagitis (gastric reflux), lymphedema, not elsewhere classified, gout, unspecified, other hyperparathyroidism(Parathyroid glands produce too much parathyroid hormone), inflammatory disorders of other specified male genital organs, bandemia(immature white blood cells called band cells, in their blood), other hydrocele, other specified disorders of the male genital organs, acute cholecystitis, other elevated white blood cell count, epididymitis, left testicular pain, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus without complications ( acute on chronic diastolic (congestive) heart failure, other insomnia.Record review of Resident's #75's admission MDS assessment, dated 08/19/2025, reflected Resident #75's BIMS score was 13, which indicated the cognition was moderately impaired. Resident #75's was incontinent of bowel and continent bladder. Record review of Resident's #75's care plan, dated 8/17/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs. I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff over the next 90 days.Observation on 09/23/25 at 9:52 AM revealed Resident #75 lying in bed. Resident #75 had EBP signage posted outside his door. MA E entered Resident #75's room without donning PPE to check his blood pressure and administer medications. MA E touched Resident #75 and checked his blood pressure using a wrist blood pressure cuff twice. Resident #75 disputed the blood pressure (BP 150/74 P76), MA E went out the resident's room to get a manual blood pressure cuff and rechecked the blood pressure ( BP 114/64 P81) without donning PPE. Interview with the MA E on 9/24/25 at 12:30 PM revealed she forgot to don PPE. MA E said she realized she should have donned PPE to protect the resident and herself for infection. 2. Record review of Resident #78's admission Assessment reflected an [AGE] year-old male who was admitted to the facility on [DATE] and was readmitted on [DATE]. His diagnoses included gastrostomy tube (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), dysphagia (difficulty swallowing), diagnoses included essential (primary) hypertension ( high blood pressure) other hyperlipidemia (high lipid/fat in the blood) other specified depressive episodes (persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities that were enjoyed) other specified anemias( healthy red blood cells), obesity (unhealthy amount of extra body fat that can lead to serious health problems like heart disease diabetes), class 2, other disorders of plasma protein metabolism (the process where proteins in the blood plasma are continuously broken down into smaller parts ( amino acids) and then rebuilt to form new proteins), not elsewhere classified, narcolepsy without cataplexy(, is a sleep disorder characterized by excessive daytime sleepiness and overwhelming urge to sleep )her pulmonary embolism without acute cor pulmonale (deep vein thrombosis (DVT),tumor emboli, fat emboli from broken bones, air emboli or amniotic fluid emboli) from multiple sclerosis ( a chronic autoimmune disease where the body's immune system mistakenly attacks the protective covering (myelin) of nerve fibers in the brain and spinal cord), other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere, acute respiratory failure with hypoxia (low oxygen), dyskinesia of esophagus, abscess of lung without pneumonia (an infection in your lungs that causes them to fill with fluid or pus, making it difficult to breathe.) of the lungs that causes inflammation of the, acute respiratory failure with hypercapnia( have too much carbon dioxide (CO2) in your blood, pulmonary fibrosis ( a lung disease that causes deep lung tissue to became thick and scarred, making it hard to breathe and get oxygen into the blood).Record review of Resident # 78's admission MDS, dated [DATE], reflected a BIMS score 08, which indicated moderate cognitive impairment. Resident # 78 was totally dependent on two or more staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. He required 1 to 2 people for assistance with activities of daily living. Resident #78 was also marked in section K0510 Nutritional. Approach as B. Feeding Tube while a resident. Record review of Resident #78's Physician's Orders, dated 09/11/25, reflected the following orders: Had NPO (Nothing per oral) only GT: Bolus give 1 can Isosource 1.5 five times a day. Check for residual every shift if > 150cc's, stop feeding and notify MD every shift. Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift.Record review of Resident #78's physician's summary orders and MAR, start date of 09/11/25, reflected the following medications:1. Sucralfate Oral Suspension 1GM/10ml. Give 10 ml via Peg-Tube before meals at bedtime for gastric ulcer (use to treat and prevent duodenal ulcers and other conditions as determined by your doctor).During an observation of peg-tube medication administration on 09/23/2023 at 11:09 AM, revealed Resident #78 had EBP signage posted on his door. LVN K did not don (put on) PPE during medication administration. LVN K did not verify placement of Resident #78's peg tube. LVN K did not palpate Resident #78's stomach. LVN K crushed Sucralfate 1 gm in pill crusher and poured it in a medicine cup then tried to dissolve Sucralfate with 5 cc of water and used the syringe tip to mixed it, it would not dissolved. She removed the syringe plunger, did not check the residual, and the resident said he was too full of breakfast. LVN K said she was holding Resident #78's bolus feeding, LVN K then poured 20cc of water in the syringe, there was a milky substance flowing back form the stomach in to tubing and was not going down despite LVN K milking peg-tube. LVN K then poured the residual with water in a cup, and she removed the syringe and went to restroom to rinse the syringe, she then place the plunger in the syringe, then checked the residual, it was about 10cc she did not return it to the stomach she poured it in a cup. LVN K then tried to administer Sucralfate 1gm, it was not going down the peg tube, she then picked up the cups and threw cups in the trash. Surveyor picked up Sucralfate medicine cup from the trash and LVN K confirmed the medication (Sucralfate) was not given in totality because she was not able to dissolve it and the wife does not want the medication changed. DON was shown crushed medication (Sucralfate)in the medicine cup.During an interview with LVN K on 09/23/25 at 12:45 PM revealed LVN K forgot to don PPE before providing GT medication administration for Resident #78 and she knew not donning PPE could cause infection. LVN K said she would be more careful. In an interview with the DON on 9/24/25 at 12:15 PM, she stated any resident who had wounds, contact isolation, Gastrostomy tube feeding, or Foley catheter was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside to the door, which explained what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with a catheter required the use of a gown and gloves. She stated the staff received training on the use of Enhanced Barrier Precautions and hand washing. 3/4.Record review of Resident #79's face sheet reflected, the date of admission was 8/27/25 and was readmitted on [DATE]. Resident #79 had diagnoses which included history of generalized anxiety disorder, other specified depressive episodes, obesity, class 1(excess body fat0, other specified hypothyroidism (e03.8), other hyperlipidemia (high lipid/fat in the blood), gastro-esophageal reflux disease without esophagitis, pneumonia due to other specified bacteria, other acute kidney failure, essential (primary) hypertension(high blood pressure), paroxysmal atrial fibrillation (irregular heart beat) obstructive sleep apnea (adult) (pediatric), other specified chronic obstructive pulmonary disease, other insomnia(sleeplessness), other acute osteomyelitis, right ankle and foot, acquired absence of left leg above knee, type 2 diabetes mellitus without complications, chronic systolic (congestive) heart failure, ulcer of anus and rectum, other specified peripheral vascular diseases, acute posthemorrhagic anemia, other hypotension, acute and chronic respiratory failure with hypoxia. Record review of Resident #79's admission MDS assessment, dated 09/16/2025, Section C (Cognitive Patterns) reflected a BIMS score was 14, which indicated no impairment in thinking. Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #79's functional status reflected she was independent with supervision of staff with bed mobility, transfer and toilet use. Resident#79 had an indwelling Foley catheter. Record review of Resident's #79's care plan, dated 9/14/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Observation on 09/24/25 at 4:14 PM of incontinent and Foley Catheter care completed by CNA B for Resident #79 revealed Resident #79 had a small pasty BM and CNA B did not open the labia to clean it but did not clean around the buttocks before placing a clean brief and fastened it. CNA B changed gloves 3 three times without washing hands or using hand sanitizer.Interview with CNA B on 9/24/25 at 4:47 PM, she said she was very nervous, she forgot to wash or sanitize her hands or. She said she used wet wipes to clean the groin twice, used the same wipes to clean labia and she did not clean around her buttock. CNA B stated she knew if she didn't clean a resident well it could cause itchiness, skin break down, urinary tract and odors. CNA B further said she usually did not use the same wipes from the groin to clean the labia and she forgot to clean around the buttocks because she was nervous. CNA B said she was in-serviced for incontinent care and skilled check. Interview with the Dietary Manager on 09/09/25 at 8:40 AM, she stated food held with danger zone temperature could place the residents who ate the food at risk of food borne illness and disease. She also stated frozen food should not be thawed at room temperature. Scoops in the food bins could cause cross- contamination and the staff should be storing the scoops container not touching food. Food had to be stored 6 inches off the floor. She stated that she was responsible for training staff on proper storage/temperature. Record review of the facility's policy revised, October 2018, on Enhanced Barrier Precautions, reflected the following: Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO)Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs)refer to infection prevention and control interventions designed to reduce the transmission of multi-drug -resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when:a. A resident with an infected or colonized with a CDC -targeted, MDRO but does have a wound or indwelling medical device and does not have secretions or excretions that cannot be covered or contained. Record review of CDC guidelines reflected: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Record review of facility's Food and Nutrition Services Policy and Procedure Manual dated revision date January 2012 read in part Cold foods shall be maintained at temperatures of 40 degrees Fahrenheit or below. Hot foods or potentially hazardous food shall have a temperature of 140 degrees Fahrenheit or above. Food service scoops are not permitted to be stored inside dry storage bins, ingredient containers or product bags. This practice poses a risk of contamination from handles or hands coming into contact with food product. All foods must be kept on shelves at least 6 inches off the floor to prevent contamination and facilitate cleaning. Record review of FDA Food Code 2022 read in part .3-501.11 Frozen foods shall be maintained frozen. 3-501.12 Time/Temperature Control for safety food shall be held under refrigeration that maintain the food temperature at 41 degrees Fahrenheit or less or at any temperature if the food remains frozen.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #79) reviewed for ADL care. The facility failed to ensure CNA B cleaned Resident #79 properly during incontinent care on 9/24/25.This failure could place residents at risk for pain, infection and hospitalization.Record review of Resident #79's face sheet reflected the date of admission was 8/27/25 and readmitted on [DATE]. Resident #79 had diagnoses which included history of generalized anxiety disorder, other specified depressive episodes, obesity, class 1( excess body fat0, other specified hypothyroidism, other hyperlipidemia(high lipid/fat in the blood), gastro-esophageal reflux disease without esophagitis, pneumonia due to other specified bacteria, other acute kidney failure, essential (primary) hypertension (high blood pressure), paroxysmal atrial fibrillation (irregular heart beat) obstructive sleep apnea (adult) (pediatric), other specified chronic obstructive pulmonary disease, other insomnia(sleeplessness), other acute osteomyelitis, right ankle and foot, acquired absence of left leg above knee, type 2 diabetes mellitus without complications, chronic systolic (congestive) heart failure, ulcer of anus and rectum, other specified peripheral vascular diseases, acute posthemorrhagic anemia, other hypotension, acute and chronic respiratory failure with hypoxia.Record review of Resident #79's admission MDS assessment, dated 09/16/2025, Section C (Cognitive Patterns) reflected a BIMS score was 14, which indicated no impairment in thinking. Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #79's functional status revealed she was independent with supervision of staff with bed mobility, transfer and toilet use. Further review reflected Resident #79 had an indwelling Foley catheter. Record review of Resident's #79's care plan, dated 9/14/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities. I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Observation on 09/24/25 at 4:14 PM of incontinent and Foley Catheter care done by CNA B revealed Resident #79 had a small pasty BM and CNA B did open the labia to clean it but did not clean around the buttocks before placing a clean brief and fastening it. Interview with CNA B on 9/24/25 at 4:47 PM, she said she was very nervous, she used wet wipes to clean the groin twice, used the same wipes to clean the labia she did not clean around her buttock, CNA B knew if she didn't clean a resident well it could cause itchiness, skin break down, urinary tract and odors. CNA B further said she usually did not use the same wipes from the groin to clean the labia and she forgot to clean around the buttocks, she was nervous. CNA B said she was in-serviced for incontinent care and skilled check. Interview with the DON on 9/25/25 at 11:22AM, the DON said she did skill checks, and the ADON monitored the CNAs randomly monthly and not performing good incontinent care could result in infection, skin break down and UTI. The DON said she did rounds with the nurse aides before the CNA got on the floor to work, also watching them hands on and checked them off on hand washing, incontinent/Foley catheter care. DON said her expectation was for incontinent care was to done well to prevent urinary tract infections and ski break down.Record review of the facility's policy on Perineal Care, revised 6/24/25, reflected: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #79) reviewed for incontinent care. 1.The facility failed to ensure CNA B properly cleaned Resident #79's indwelling Foley catheter.2. The facility failed to ensure CNA B followed proper hand hygiene during incontinent care on 9/24/25.3. The facility failed to ensure CNA A secured Resident #79's Foley catheter. These failures could place residents at risk for pain, infection, injury, and hospitalization.Record review of Resident #79's face sheet reflected the date of admission was 8/27/25 and readmitted on [DATE]. Resident #79 had diagnoses which included history of generalized anxiety disorder, other specified depressive episodes, obesity, class 1(excess body fat, other specified hypothyroidism(e03.8), other hyperlipidemia(high lipid/fat in the blood), gastro-esophageal reflux disease without esophagitis, pneumonia due to other specified bacteria, other acute kidney failure, essential (primary) hypertension(high blood pressure), paroxysmal atrial fibrillation (irregular heart beat) obstructive sleep apnea (adult) (pediatric), other specified chronic obstructive pulmonary disease, other insomnia(sleeplessness), other acute osteomyelitis, right ankle and foot, acquired absence of left leg above knee, type 2 diabetes mellitus without complications, chronic systolic (congestive) heart failure, ulcer of anus and rectum, other specified peripheral vascular diseases, acute posthemorrhagic anemia, other hypotension (low blood pressure, acute and chronic respiratory failure with hypoxia.Record review of Resident #79's admission MDS assessment, dated 08/29/2025, Section C (Cognitive Patterns) reflected a BIMS score was 14, which indicated no impairment in thinking. Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #79's functional status reflected he was independent with supervision of staff with bed mobility, transfer, and toilet use. Resident#79 had an indwelling Foley catheter.Record review of Resident's #79's care plan, dated 9/14/2025, reflected, I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities. I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Record review of Resident #79's physician order, dated 8/27/2025, read in part .change Foley catheter with 18-inch catheter and 10cc bulb on the 1st of each month, dated 8/25 . keep catheter from kinks and drainage bag lower than bladder at all times, dated 8/29/25. Observation of incontinent/indwelling Foley catheter on 9/24/25 at 4:14 PM, revealed CNA B performed F/C and incontinent care. CNA B did not wash their hands and did not use hand sanitizer. CNA B donned clean gloves, undid Resident #79's soiled brief, using the wet wipes, cleaned the resident's groin and the F/C was not secured. CNA B did not clean the indwelling catheter; she did not open Resident #79's labia to clean it from the insertion site. Resident #79 had a small BM, CNA A cleaned in -between the buttocks and did not clean around the buttocks, she picked up a clean brief and fastened it on the resident. Interview with C.NA B on 9/24/25 at 4:41 PM, she said she was nervous and did not open the labia to clean the indwelling catheter insertion site. CNA B said not cleaning the indwelling catheter from the insertion site for Resident #79, her hands could cause a UTI, she had an in-service on Foley catheter/incontinent care. Interview with the DON on 9/25/25 at 11:22 PM, she said she did the initial training and would monitor while on the unit. The DON said they monitored the CNAs randomly monthly and not performing good incontinent could result in infection and UTI. Record review of the facility's policy for Catheter Care Urinary, date 3/31/2016, reflected: For the female: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #78) reviewed for feeding tubes. The facility staff failed to ensure LVN K verified placement of Resident #78's feeding tube prior to medication administration on 9/23/25. This failure could place residents at risk for complications such as aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space), and/or hospitalization.Record review of Resident #78's admission Assessment reflected an [AGE] year-old male who was admitted to the facility on [DATE] and was readmitted on [DATE]. His diagnoses included gastrostomy tube (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), dysphagia (difficulty swallowing), diagnoses included essential (primary) hypertension ( high blood pressure) other hyperlipidemia (high lipid/fat in the blood) other specified depressive episodes (persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities that were enjoyed) other specified anemias (healthy red blood cells), obesity (unhealthy amount of extra body fat that can lead to serious health problems like heart disease diabetes), class 2, other disorders of plasma protein metabolism (the process where proteins in the blood plasma are continuously broken down into smaller parts [ amino acids] and then rebuilt to form new proteins), not elsewhere classified, narcolepsy without cataplexy (is a sleep disorder characterized by excessive daytime sleepiness and overwhelming urge to sleep) her pulmonary embolism without acute cor pulmonale (deep vein thrombosis [DVT],tumor emboli, fat emboli from broken bones, air emboli or amniotic fluid emboli) from multiple sclerosis (a chronic autoimmune disease where the body's immune system mistakenly attacks the protective covering [myelin] of nerve fibers in the brain and spinal cord), other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere, acute respiratory failure with hypoxia (low oxygen), dyskinesia of esophagus, abscess of lung without pneumonia ( an infection in your lungs that causes them to fill with fluid or pus, making it difficult to breathe.) of the lungs that causes inflammation of the, acute respiratory failure with hypercapnia (have too much carbon dioxide [CO2] in your blood, pulmonary fibrosis (a lung disease that causes deep lung tissue to became thick and scarred, making it hard to breathe and get oxygen into the blood).Record review of Resident #78's admission MDS, dated [DATE], indicated a BIMS score 08, which indicated moderate cognitive impairment. Resident # 78 was totally dependent on two or more staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. He required 1 to 2 people for assistance with activities of daily living. Resident #78 was also marked in section K0510 Nutritional. Approach as B. Feeding Tube while a resident. Record review of Resident #78's Physician's Orders, dated 09/11/25, reflected the following orders: Had NPO (Nothing per oral) only GT: Bolus give 1 can Isosource 1.5 five times a day. Check for residual every shift if > 150cc's, stop feeding and notify MD every shift. Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift.Record review of Resident #78's physician's summary orders and MAR with start date of 09/11/25 for the following medications:1. Sucralfate Oral Suspension 1GM/10ml. Give 10 ml via Peg-Tube before meals at bedtime for gastric ulcer (use to treat and prevent duodenal ulcers and other conditions as determined by your doctor).During an observation of peg-tube medication administration on 09/23/2023 at 11:09 AM, LVN K did not verify placement of Resident #78's peg tube. LVN K did not palpate Resident #78's stomach. LVN K crushed Sucralfate 1 gm in pill crusher and poured it in a medicine cup then tried to dissolve Sucralfate with 5 cc of water, then used the syringe tip to mix it, it would not dissolved she then removed the syringe plunger, did not check the residual, the resident said he was too full of breakfast. LVN K said she was holding Resident #78's bolus feeding, LVN K then poured 20cc of water in the syringe, there was a milky substance flowing back from the stomach into the tubing and was not going down despite LVN K milking the peg-tube. LVN K poured the residual with water in a cup, and she removed the syringe and went to the restroom to rinse the syringe, she placed the plunger in the syringe, then checked the residual, it was about 10cc, she did not return it to the stomach she poured it in a cup. LVN K then tried to administer Sucralfate 1gm, it was not going down the peg tube, she picked up the cups and threw the cups in the trash. The State Surveyor picked up the Sucralfate medicine cup from the trash and LVN K stated the medication (Sucralfate) was not given in totality because she was not able to dissolve it and the family member did not want the medication changed. The DON was shown the crushed medication (Sucralfate)in the medicine cup. During an interview with LVN K on 09/23/25 at 12:45 PM, regarding not checking the peg tube placement for Resident #78 GT before medication administration and LVN K not checking for placement could cause aspiration pneumonia, bloating and being too full. Further interview with LVN K on 09/23/25 at 12:45 PM, LVN K said she would be more careful and would double-check after pouring medications, LVN K said he had medication training upon hire by DON. Record review of enteral feed order schedule for [DATE], reflected every shift check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding, or at least every shift for continuous feeding. Enteral feed order schedule for [DATE], had every shift flush with 30-60 ml water before and after medication, before initiating feeding or when there was an interruption of feeding to maintain tube patency.During an interview on 09/25/25 at 12:50 PM, the DON reported a feeding tube should be verified with a stethoscope and a staff member should listen to gurgling. The DON reported if you do not verify if a feeding tube was in the right place, then a resident could receive a feeding or medication that could result in infection, bloating, or discomfort. The DON stated the two policies provided were what the facility had for feeding tube administration and they had a policy specific on verifying feeding tube placement. Record review of the facility provided policy titled Flushing a Feeding Tube, revised 2021, reflected the following . Policy Explanation and compliance Guidelines .9. Prior to flushing the feeding tube, the administration of medication or providing tube feedings, the nurse verifies the proper placement by noting the length of the tubing or performing a measure of the PH of gastric secretions, if performed in the facility. 10. After tube placement has been verified, flush the tube utilizing the 60 ml, catheter tip syringe with the prescribed amount of water every four (4) hours, before and after feedings and medications or as directed by the physician. Allow medications to flow down the medication syringe.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records on each resident were maintained that were complete and accurately documented for 1 of 6 residents (Resident #144) reviewed for accurate records.-The facility failed to ensure urine output was documented on 9/14/2025 and 9/19/2025 per physician orders for Resident #144.This failure could place residents at risk of changes in condition not being detected and treated in a timely manner. Record review of Resident #144's face sheet, dated 09/25/2025, reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included type 2 diabetes mellitus (high blood sugar), neuromuscular dysfunction of bladder (damage or dysfunction in the nerves or muscles that control bladder function), rheumatoid arthritis (chronic inflammatory disorder affecting small joints in the hands and feet), and extended spectrum beta lactamase resistance (resistance to a bacterium that produces an enzyme making them resistant to certain antibiotics).Record review of Resident #144's physician order summary reflected an order with a start date of 09/12/2025, to record suprapubic catheter output every shift for 6-2, 2-10 and 10-6 shifts. Resident #144 also had orders for cleansing the suprapubic catheter site with NS, pat dry and apply dressing for every shift with a start date of 09/12/2025, nystatin external cream 100000 unit/gm for suprapubic catheter with a start date of 09/24/2025.Record review of Resident #144's Comprehensive MDS, dated [DATE], reflected a BIMS of 15, which indicated she was cognitively intact. Resident #144 required substantial assistance with toileting, showering or bathing, lower body dressing and putting on/taking off footwear. She was coded for having an indwelling catheterRecord review of Resident #144's care plan, captured 09/25/2025, reflected she had an indwelling catheter (a tube inserted into the bladder through the urethra for bladder drainage) suprapubic (below the navel) catheter due to diagnosis of neurogenic bladder with interventions including checking for patency and urinary output every shift. Resident #144 also had a focus area for being on antibiotic therapy due to a urinary tract infection with interventions which included administering medication as ordered and monitoring/communicating sudden changes in condition and or worsening to the MD/NP.Record review of Resident #144's September MAR reflected she did not have recorded output on 09/14/2025 during night shift (10p-6a) and 09/19/2025 during morning shift (6a-2p).Interview with Resident #144 on 09/24/2025 at 11:16 AM, she had no concerns with care at the facility. In a later interview on 09/25/2025 at 3:30pm with Resident #144, she said someone would come two or three times a day and empty her catheter and measured the output. Resident #144 said she had no infection but had a rash near her suprapubic catheter which the wound care nurse was treating and she had orders for zinc oxide and other cream for the skin irritation. Interview with the DON on 09/25/2025 at 11:47 PM, she said aides could empty residents' catheter and report the urine output to the nurse. If the output was not documented, the facility would not know if residents had any output and if interventions were needed. Interview with RN A on 09/25/2025 at 12:21 PM, RN A said they worked 6:00 AM to 6:00 PM. RN A stated they had taken care of Resident #144 on 9/19/2025. RN A said they usually documented output on the electronic medical record, and they wrote the output first but overlooked entering it into the medical record. RN A said they measured the output but did not document. If output was not documented, it could have resulted in a delay in care and things being missed from lack of output. RN A said Resident #144 was doing okay and had no issues with output. Interview with LVN [NAME] 09/25/2025 at 12:27 PM, she said she provided catheter care to Resident #144 who had no complaints about her catheter. LVN G worked 6:00 PM to 6:00 AM and would document Resident #144's twice since her shift overlapped with Resident #144's orders for output measurement for the two nursing shifts from 2:00 PM-10:00 PM and 10:00 PM-6:00 AM. LVN G said she wrote down the output but did not document the output in Resident #144's medical records and she overlooked it and would go back and do a late entry or progress note. If Resident #144 did not have output, she would have called the doctor to check and continue to monitor. The LVN stated possible negative outcomes of not documenting would be something could go wrong and they would not have it documented such as vitals or UTI . Skills checkoff was requested for LVN A and RN A on 09/25/2025 at 11:50am and was not received as of exit. Record review of the facility's policy on charting and documentation, last revised July 2017, read in part, all services provided to the resident .shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: c. Treatments or services performed

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 16% based on 4 errors out of 25 opportunities, which involved 1 of 8 residents (Resident #99) reviewed for medication errors. -The facility failed to ensure LVN N administered the correct dose of Potassium Chloride or Ferrous sulfate liquid to Resident #99 according to Physician orders. -The facility failed to ensure LVN N did not crush and administer; Acetaminophen ER (an extended-release formulation which should not be crushed) to Resident #99 via g-tube (a way to deliver liquid nutrition through a flexible tube to your digestive system) instead of Acetaminophen as ordered by the Physician. These failures could place residents at risk of inadequate therapeutic outcomes. Findings include: Record review of Resident #99's face sheet dated 8/8/24 revealed an [AGE] year-old female readmitted on [DATE]. Her diagnoses included gastrostomy status (a surgical procedure used to insert a tube through the abdomen and into the stomach.), type 2 diabetes, hypertension (high blood pressure), and cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). Record review of Resident #99's admission MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired-never/rarely made decisions. She was dependent on staff for ADL care. Record review of Resident #99's care plan dated 7/11/24 revealed she had pain related to wounds and impaired mobility. Interventions were to administer pain medication as per MD orders. Record review of Resident #99's Physician Orders for August 2024 revealed the following orders: Acetaminophen 325 mg give 2 tablets via g-tube two times a day for pain, order date 7/12/24, Ferrous Sulfate oral solution 220 (44 Fe) mg/5 mL give 5 mL via peg tube one time a day for anemia, order date 7/19/24, Potassium Chloride oral solution 20 mEQ/15 mL give 15 mL via g-tube one time a day for supplement, order date 7/29/24. In an observation on 8/8/24 at 8:34 a.m. with LVN N revealed she prepared Resident #99's morning medications for administration. She prepared Acetaminophen ER 650 mg - 1 tablet, 10 mL of Ferrous Sulfate 220 mg/5 mL liquid, 11 mL of Potassium Chloride 10% 20 mEQ/15 mL liquid, and six additional medications. She crushed the tablets including the Acetaminophen ER and administered all medications individually to Resident #99 via g-tube. In an observation and interview on 8/8/24 at 9:14 a.m. LVN N said she did not realize Resident #99's Ferrous sulfate and Potassium chloride liquid were not at the correct dosage and said she may have been nervous. She said when preparing liquid medications, she ensured she located the measurement, poured the appropriate amount, and verified the amount to ensure accuracy. She said it was important to administer the correct amount of medication to the resident because that was the amount ordered by the physician. She said she was not sure if the Acetaminophen ER could be crushed because the bottle did not specify that it could not be crushed. She said she did not originally see the acetaminophen 325 mg tablets on the nurse cart and instead administered one acetaminophen ER 650 mg tablet. In an interview on 8/8/24 at 10:11 a.m., the DON said acetaminophen ER and acetaminophen were not the same medication. She said the extended-release formulation could not be crushed because it was a slow-release medication. In an interview on 8/8/24 at 3:44 p.m. the Administrator said he expected a 0% medication error rate and for nursing staff to follow physician orders. Record review of the facility's Administering Medications policy dated December 2012 read in part, .Medications shall be administered in a safe and timely manner, and as prescribed . 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication . Record review of the facility's undated Do not crush list of medications form read in part, . Below is a list of the most common medications that shouldn't be crushed, cut, or chewed. Medications that have modified-release dosage forms or a special coating: Acetaminophen ER .

Based on interview and observation the facility failed to ensure residents received drinks consistent with preference and sufficient to maintain hydration for 10 of 10 (confidential group) and 3 of 21 (Resident #1, Resident #2, and Resident # 78) of residents reviewed for hydration. The facility did not provide hot coffee to residents during mealtimes. This failure could place residents who depend on the facility for their hydration needs at risk for thirst, dehydration, and decreased quality of life. Findings included: Record review Resident #1's face sheet revealed resident admitted to the facility on [DATE]. Resident #1's was diagnosed with essential (primary) hypertension, type 2 diabetes mellitus without complications, cerebral infarction, unspecified, spinal stenosis (space inside the backbone is too small placing pressure on the spinal cord and nerves), site unspecified, muscle weakness (generalized), unspecified atrial fibrillation (irregular heart beat), benign prostatic hyperplasia with lower urinary tract symptom (weak urine stream causing frequent urination), narcissistic personality disorder (inflated sense of self-importance), other recurrent depressive disorders, insomnia, unspecified nicotine dependence, unspecified, uncomplicated, adult failure to thrive (decline and health and ability), and pain, unspecified. Record review of Resident #1's care plan dated 06/05/23 revealed resident had ADL self-care performance deficit with limited mobility. Record review of Resident #1's admission MDS dated [DATE], revealed Resident #1's BIMS was scored as 13 which indicated his cognition was intact. Resident #1's active diagnoses included medically complex condition. Record review of Resident #2's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE]. The resident was diagnosed with unspecified fall, subsequent encounter, encounter for other specified surgical aftercare, essential (primary) hypertension, type 2 diabetes mellitus without complications, elevated white blood cell count, benign prostatic hyperplasia with lower urinary tract symptoms (weak urine stream causing frequent urination), hyperlipidemia (hardening of the arteries), unspecified), pain, unspecified, presence of left artificial knee joint, encounter for other orthopedic aftercare, aftercare following joint replacement surgery. Record review Resident #2 care plan dated revealed Resident #2's was at risk for weight fluctuations due to his changes in appetite, and difficulty adjusting to new environment from recent hospitalization . Record review of Resident #2's admission MDS dated [DATE], revealed Resident #2's BIMS was scored as 14 which indicated his cognition was intact. Resident #2's active diagnoses included hip and knee replacement. Record review of Resident #78's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE]. The resident was diagnosed with dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, overactive bladder, constipation, unspecified anemia, unspecified, pain, unspecified, gastro-esophageal reflux disease without esophagitis (inflammation of the esophagus/throat), other muscle spasm, insomnia, unspecified, dehydration, Alzheimer's disease with late onset. Record review of Resident #78's care plans dated 05/04/2023 revealed Resident #78 had the potential for fluid volume deficit with medication side effects. Record review of Resident #78's admission MDS dated [DATE], revealed Resident #78's BIMS scored of 12 indicates moderate cognitive impairment. Resident #78's active diagnoses included traumatic brain disfunction. Observation on 07/12/23 at 08:43 AM Resident #2 observed in the activities room sitting in his wheelchair in front of the television drinking coffee from a white styrofoam cup. Interview on 07/11/23 at 08:55 AM Resident #78 stated that his coffee is always cold at every mealtime every day. He told staff (could not provide exact dates, names, or titles) his coffee is always cold, but they do not do anything about it. Interview on 07/11/23 at 10:00 AM Resident #1 stated that coffee is always cold at every mealtime every day. He told staff (could not provide exact dates, names, or titles) his coffee is always cold and asked for a fresh hot cup. Interview on 07/11/23 at 10:02 AM Resident #2 stated that the facility does not serve hot coffee. He stated he has to go all the way down to the activities room to get a fresh hot cup of coffee. He stated some days he is too tired and does not have the energy to wheelchair himself down to the activities room on at the end of hall-3 from his room on hall-4, especially after physical therapy. Interview on 07/12/23 at 08:43 AM Resident #2 stated he received coffee on his breakfast tray this morning, but it was not hot and did not taste good. He stated he comes to the activities room to get hot cups of coffee. He stated it is not always easy for him to get to the activities room when he is feeling weak and/or tired especially on days when he has had therapy. Interview on 07/12/23 at 09:33 AM AD stated that at the monthly resident council's meetings the resident's regularly complain of cold food and coffee and the Administrator and DM address every time. Interview on 07/12/23 at 10:15 AM during the confidential resident council meeting, 10 of 10 residents stated that they did not receive hot coffee during mealtimes on a consistent basis. Coffee is poured by the CNAs on each hall. The coffee must sit for a while before being poured. If they are lucky, it's hot, but it is often cold or lukewarm at best. Interview on 07/12/23 at 12:27 PM the Administrator stated that he will ensure that hot coffee is available more by speaking with the DM and having her check temperatures and change warm or cold coffee with hot coffee. He stated that the coffee machine was broken recently, and residents were complaining of cold coffee. The coffee machine had since been repaired and he was not aware of any cold coffee complaints until this one. The staff are required to take coffee temperatures before the coffee goes out on the floor. He stated that there is always hot coffee in the dining room at all times. Interview on 07/13/23 at 10:10 AM DM stated she has been the DM for the last five years. She stated she works Monday thru Saturday and most Sundays. She stated she is scheduled to work 7 AM to 4 PM but often comes in early and stays late for her shifts. She stated that the residents have complained of cold coffee in the past. She stated and for that reason, kitchen staff no longer serve coffee on the trays to avoid serving cold coffee. She stated that two coffee urns are filled with coffee for each of the 4 halls. Coffee temperatures are taken prior to the coffee leaving the kitchen and logged on the coffee temperature log before the breakfast, lunch, and dinner meals. She stated the two urns are placed on top of each of the food carts. She stated once the carts are on the hall, the CNAs are responsible for pouring coffee for the residents who desire coffee and who have no coffee dietary restrictions. She stated that she had coffee temp logs for May 2023, June 2023 and July 2023 and would provide copies along with the coffee temp policy. Record review of the facility's Grievance QA Log dated May 2023: Date of Grievance 05/17/2023. Grievance: Coffee Temperature. Resident's Name: Resident Council. Following Investigation: Date 05/17/2023. Person Assigned: AIT. Resolution: Monitoring Temp with thermometer. Date Complainant Notified 05/17/0223. Record review of Grievance/Complaint Report dated 05/17/2023. Received by AD. Resident Representative: Resident Council. Following investigation Date: 05/15/2023 Person Assigned: AIT. Manager Meeting. tested coffee on hall with thermometer. Resident Council informed of temperature results at next council meeting. Form completed by AIT. Record review of Grievance QA Log dated June 2023: Date of Grievance 06/08/2023. Grievance: Dietary Concern. Resident's Name: Resident Council. Following investigation Date: 06/09/2023 Person Assigned: DM. Resolution: 1:1 with staff. Discussed with Residents. Date Complainant Notified: 06/09/2023. Record review of Grievance/Complaint Report dated 06/08/2023. Received by AD. Resident representative: Resident Council. Documentation of Grievance/Complaint: Dietary Concerns. Documentation of Facility Follow-up: Manager meeting discussed concerns. DM addressed concerns with residents. Coffee maker was broken and fixed. Resolution of Grievance Dated 06/09/2023: Coffee maker fixed. Discussed with residents. Form completed by SW. Record review In-Service Training Report. Dated 5/2023, From DON Designee to Employee Group: CNAs/Nursing. Topic: ADL documentation/Serve Meals/Cold Coffee. Summary of Training: Ensure Coffee warm enough. Replace warm coffee if it's cold. Conducted by DON. Record review Hot Beverage Temperature Log dated May 2023, June 2023 and July 2023. All temperature range between 130 degrees and 150 degrees. Record review of Policy Code of Federal Regulations SS 483.60 Food and nutrition services. 20. Prior to the point of serve, the temperature of coffee or hot beverage will be checked to ensure temperature is 155F or below. If above 155 F, ice will be added to the coffee until the at or below 155 F.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in 1.The facility failed to ensure that ice scoops will be cleaned and stored in a separate container that limits cross-contamination. 2.The facility failed to ensure that all cold and dry goods items will be stored 6 inches above the floor. These failures could place residents at risk of foodborne illness and disease. Findings included: 1. Observation on 7/13/23 at 8:30 AM with Dietary A revealed that the ice scoop was left in the ice bin on top of the ice. 2. Observation on 7/13/23 at 9:00 AM with the Dining Services Director revealed that dry goods and cold foods were stored 4 inches above the floor. Interview with the Dining Services Director on 7/13/23 at 9:20 AM revealed the ice scoop should not be left in the ice bin. Interview with the Dining Services Director on 7/13/23 at 9:25 AM revealed that dry goods and cold foods will be appropriately stored 6 inches above the floor to ensure that food is not subject to contamination, leakage, rodents or vermin. Record review of Facility 's Policy and Procedure for Ice dated 9/2017 read in part. Ice will be prepared and distributed in a safe and sanitary manner 5. Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention. And or stored in ice machine on holder provided for storage. Record review of Facility's Policy and Procedure Dry Goods and Cold Foods Storage dated 9/2017 read in part. All dry goods and all cold foods will be appropriately stored in accordance with the FDA Food Code rule 228.224 1. All items will be stored on shelves at least 6 inches above the floor 4. The Dining Services Director or designee regularly inspects the dry and cold storage area to ensure it is well lit, well ventilated, and not subject to sewage or wastewater back flow or contamination by condensation, leakage, rodents, or vermin. https://www.dshs.texas.gov/sites/default/files/foodestablishments/pdf/GuidanceDocs/TFER-2021_TAC-228_August-2021.pdf

Based on observation, interview, and record review, the facility failed to develop and implement person-centered care plans for each resident's services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 21 residents (Resident #86) reviewed for the develop and implement comprehensive care plans. - The facility failed to ensure Resident #86's comprehensive care plan included the care for her schizoaffective and delusional diagnoses. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Record review of Resident #86's face sheet undated revealed an [AGE] year-old female who admitted into the facility on [DATE]. The resident was diagnosed with schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder such as depression or bipolar disorder), delusional disorder (is a fixed false belief based on an inaccurate interpretation despite evidence to the contrary), encephalopathy ( a term for any brain disease that alters brain function or structure), acute kidney failure and bacteremia (the presence of bacteria in the blood). Record review of Resident #86's PASRR Level 1 Screening dated 06/02/2023 revealed C0100 Mental Illness revealed yes to indicated evidence or an indicator of a mental illness. Record review of Resident #86's care plans dated 06/05/2023 revealed no care plan for the diagnoses of schizoaffective disorder and delusional disorder. Record review of Resident #86's admission MDS dated [DATE], revealed Resident #86's BIMS (Brief Interview for Mental Status) was scored as 14 which indicated her cognition was intact. Resident #86's active diagnoses included psychiatric/mood disorder. Record review of Resident #86's Behavioral Health Evaluation/ Initial Psychiatry assessment dated [DATE] reflected in part past psychiatric history schizoaffective disorder and delusional disorder. Diagnoses of adjustment disorder with mixed anxiety and depressed mood. Recommendation was the resident would benefit from an antidepressant. Resident declined medication at this time. Therapy referral for Resident #86 was recommended. Observation and interview on 07/12/2023 at 12:44 PM revealed Resident #86 was sitting on the side of her bed eating lunch. Resident #86 stated she was good. The resident stated she had everything she needed. Resident #86 stated she did not want to talk to any one any longer. In an interview on 07/14/2023 at 8:35AM LVN A stated she has worked in the facility for a month. LVN A stated she has worked with Resident #86 two times. LVN A stated she was aware of Resident #86's diagnoses from review of the resident's clinical record. LVN A stated she read the resident's notes, care plans and talked with the resident to assess the resident's mental status. In an interview on 07/14/2023 at 9:18 AM LVN B stated she did participate in the development of the resident care plan as the MDS nurse. LVN B stated multiple departments participated in the development of the care plan. LVN B stated the purpose of the care plan was a [NAME] for the plan of care for the resident. The LVN B continued and stated the care plan should include anything that could create a problem for the resident. LVN B stated yes Resident #86's diagnoses should be included in the care plan. The LVN B stated the DON was responsible for monitoring the accuracy of the care plan. LVN B stated the risk of an inaccurate care plan was it could provide an inaccurate picture of the resident which could result in a delay in care. LVN B stated Resident #86's diagnoses were missed because she was here for short term care. LVN B stated there was a standard of care for the short-term residents. The standard of care address the same issues that are care planned. Resident # 86 did not have any symptoms for the diagnoses. LVN B stated to prevent this again the standard of care should be included in the comprehensive care plan. In an interview on 07/14/2023 at 9:42AM the DON stated the purpose of the care plan was to highlight the care needed for the resident. The DON stated it was important to care plan the diagnoses for resident care. The DON stated the development of the care plan was interdisciplinary to include all department heads. The DON stated the MDS department was responsible for monitoring care plan accuracy. The DON stated the risk of an inaccurate care plan was the effect on the resident care. In an interview on 07/14/2023 at 10:41 AM the Administrator stated the purpose of the resident care plan was to make sure the resident received the required care. The Administrator stated for a long-term resident the diagnoses of schizoaffective disorder and delusional disorder needed to be care planned. The Administrator stated there was a standard of practice for the short-term resident. The Administrator stated he and the DON were responsible for monitoring care plan accuracy in the morning meetings for resident changes. The Administrator stated an inaccurate care-plan could have a negative effect on the resident care. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered Revised dated December 2016, reflected in part Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems .

Based on observation, interview and record review, the facility failed to ensure garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 07-13-23 at 8:55 am, with the Dining Services Director revealed the facility's dumpster area,was not in use when it was observed to be open which was in the lot behind the dietary department had a commercial -size dumpster and the lid and door were opened. Interview on 07-13-23 at 9:00 am, with the Dining Services Director she stated the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of the facility policy and procedure of Dispose of Garbage and Refuse dated 8/2017 read in part. All garbage and refuse will be collected and disposed of in a safe and efficient manner. 2. The Dining Services Director will ensure that: appropriate lid and door should be closed when not in use.

Based on observation, interview, and record review, the facility failed to have assessments that accurately reflected the status of one (CR#104, Resident #92) 2 of 22 residents reviewed for assessments. CR#104's MDS discharge status was documented incorrectly. Resident #92's Care Area Assessment was not triggered for pain. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of CR#104's face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and discharged on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#104's MDS dated [DATE] revealed CR#104 had a BIMS of 15 that meant resident's cognition was intact. CR#104's discharge assessment indicated-return not anticipated. CR#104's discharge status was documented as discharging to acute hospital. Record review CR#104's Physician Discharge Summary dated 04/20/22 revealed CR#104 was admitted to the facility on [DATE] and discharged on [DATE]. Disposition: Discharge home with family and personal belongings. Medications called in to pharmacy of choice. Record review of CR#104's Progress Notes revealed 4/15/2022 1:57 PM Discharge Summary Note Text: The patient discharged today. He denies any pain, no distress. He received a new wound vac to his affected stump. The wound care gave instructions to the [family member]. The patient refused his shower and was reeducated on good hygiene and the prevention of skin infections. He denied any constipation, no shortness of breath. His vitals BP 147/68, P 61, R 18, T 97.8, O2 96% RA. His medications were called in to the voice mail of [pharmacy name] at [phone number]. He left by private vehicle with his [family member]. In an interview on 06/15/22 at 1:00 PM Social Worker stated Resident CR#104 was discharged home, with home health. CR#104 was admitted to the facility more than once for reoccurring infections. They were able to get him well and he discharged home. In an interview on 06/15/22 at 1:12 PM the MDS Coordinator stated she made a mistake with CR#104's MDS. She thought it was documented as discharging home. Record review of Resident #92's face sheet revealed he was an [AGE] year-old male that was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #92's MDS dated [DATE] revealed he had a BIMS of 15 which meant resident's cognition was intact . Resident #92 was diagnosed with cancer , wound infection, arthritis, spinal stenosis, and strain of muscle. Under pain management Resident #92 received PRN pain medications. Resident #92 had presence of pain during interview, he occasionally had pain, his pain level was moderate. Resident #92 had 2 venous and arterial ulcers present. The Care Area Assessment (CAA) was not trigger for pain. Record review of Resident #92's Progress Notes dated 05/27/22 revealed Resident arrived with EMS via stretcher. Resident from from LSTW . Resident will be under [Physician Name] as medical management. DX: Back Pain. Hx. AFib, [CONDITION(S)], Sleep Apnea-has his own personal machine. BLE resting on pillow. Appears to be edematous and BLE have ABD pads and ace wrapped. AAOX3-4. Very pleasant and answers all questions. Wears only reading glasses. No hearing aides. Noted a brown growth on left ear. No drainage. Good grips. Resident does not wear dentures and does not have any teeth. Diet CC no salt added. NKA. Full code, mixed incontinences 1-2 staff assist. Observation and interview on 06/14/22 at 10:20 AM revealed Resident #92 was lying in bed, wedge under feet. Resident #92 said he had a rotator cuff injury and had pain, he was given prn Tylenol. In an interview on 06/15/22 at 12:40 PM MDS Coordinator stated Resident #92 may have not complained of pain during assessment, he did have cognition issues at times. With the list of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Coordinator tried to review the MDS and adjust during a resident's stay if issues are discovered . In an interview on 06/15/22 at 1:30 PM the DON stated the MDS Coordinator was responsible for the accuracy of the MDS, and she was responsible for the completion of the MDS but all nursing task fall under her. The facility tried to keep multiple eyes on the MDS to review them. The facility had a lot of residents and it was hard to document accurately on all the MDS's. The facility tried to review when they looked at the CMS 802 and when inaccuracies are noticed she would email the MDS Coordinator to fix the issues. Documentation was important for the resident's care. Record review of the facility policy MDS Assessment Coordinator dated 04/2008 revealed Policy Interpretation and Implementation 2. The Assessment Coordinator must date and sign each assessment (MDS) to certify that the assessment has been completed. 3. Each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by: a. Dating and signing the assessment (MDS); and b. Identifying each section completed. 4. Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment is subject to disciplinary action and such incident must be promptly reported to the Administrator.

Based on observation, interview, and record review the facility failed to provide an ongoing activity program designed to meet the interest of and support the physical, mental, and psychosocial well-being for 1 of 19 residents reviewed for activities. (Resident #154) The facility failed to consistently provide in room activities for Resident #154. This failure could place residents at risk for a decline in social, mental, psychosocial well-being and decreased quality of life. Findings included: Review of Resident # 154's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #154's Admission MDS dated [DATE] reflected he had a BIMS of 14 out of 15 indicating no cognitive impairment. It was very important for him to have books, newspapers, and magazines to read, to listen to music he likes, and keep up with the news. The primary responder to the questions was a family or significant other. He required extensive assistance of two plus person for bed mobility, transfer, dressing, and toilet use. He required extensive assistance of one person for eating, personal hygiene, and bathing. His active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #154's Comprehensive Care Plan reflected a focus on precaution due to [CONDITION(S)] in the sacral wound with the start date of 05/08/2022 and revised on 05/12/2022: Resident's goal was initiated on 05/08/2022 Provide for in room visits and activities. Record review of resident #154's Activity note dated 5/31/2022 reflected This Activity Director visited with Resident to inquire if he had any recreation needs this department could provide for him. He said No. At bedside this Activity Director observed an I-pad, cell phone, and remote control. He is in isolation. Activity Director will continue to visit on a regular basis and inquire about his recreational needs. Record review of the facilities in room activity binder revealed activities for residents residing only on 300 and 400 halls. Resident # 154 was on the 200 hall. Observation of Resident #154 on 6/14/2022 at 10:26 am reveled resident in room sleeping on his back with water and snacks on his tv tray. The TV was off. Isolation sign on resident's door with PPE outside of resident's room. In an interview with the Activities Director on 6/16/2022 at 12:45 PM revealed Resident #154 is on isolation and she did offer him puzzles or games he was ok with listing to music on his phone and watching TV. His family representative takes him outside. She depends on family to take care of isolation residents' activities. Interview with the DON on 6/16/2022 at 12:58 PM revealed Resident #154 has not been outside. Resident is on isolation and isn't supposed to leave the room. She thinks the Activities Director misspoke as Resident #154 is bedfast. It is difficult to provide 1 on 1 to all the residents who do need in room activities as she is by herself and we do depend on family to come help with in room activities. Not sure what she does for residents on isolation. Interview with the Activity Director on 6/16/2022 at 1:50 PM revealed she misspoke she got Resident #154 mixed up with a different gentleman and Resident #154 is bedfast. His family representative visits every now and then. On 6/16/2022 at 2:33 PM in an Interview with the DON stated there where 10 residents on in room activities.

Based on interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to ensure residents who were assessed as requiring specialized services received the specialized services for one (Residents #1) of one resident reviewed for PASRR assessments. The facility failed to provide and arrange for specialized durable medical equipment (DME) for Resident #1 within the time frame set by PASRR. This failure could affect residents with intellectual and developmental disabilities (IDD) and place them at risk of not receiving services that would enhance their quality of life. Findings included: Review of Resident #1's Face Sheet dated 01/14/2022 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent quarterly MDS dated [DATE] revealed she had a BIMS of 15 which indicates she was cognitively intact. Resident #1 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the PASRR evaluation dated 06/06/2018 was provided by the MDS Coordinator revealed the recommended services provided/coordinated by the nursing facility was durable medical equipment for an air mattress. Interview with the MDS Coordinator on 01/20/2022 at 2:13 p.m. she said no NFSS was entered in the PASRR portal when the mattress was initially requested 11/20/2021. She said she did not know why the NFSS was not entered in the THMP portal but when it was brought to her attention, she tied to enter the NFSS but she could not. She said Resident #1 had not gone without an air mattress all this time, the facility provided the resident with an air mattress they had on hand. She said they had another meeting on 12/22/2021 at that meeting the resident refused a new air mattress and was fine with the facility provided air mattress. Interview with the Administrator on 01/20/2022 at 2:50 p.m. he said the facility provided the DME, air mattress for Resident #1 but the NFSS was not entered in the portal. He said the resident was fine with the facility provided air mattress. Record review of the facility PASRR Clinical Policy dated May 2014 it says in part .the MDS/PPS nurse will coordinate and deliver specialized services the HMG facility is responsible for providing .

Based on interview and record review the facility failed to have physician orders for the resident's immediate care for one (CR #1) of three residents reviewed for admission admission orders [REDACTED] The facility failed to have a written physician order for [REDACTED]. This failure could affect newly admitted residents by placing them at risk of not receiving essential care and treatment services, consistent with the resident's mental and physical status upon admission. Findings include: Review of CR#1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. uterus. On [DATE] she was sent back to the hospital. Review of CR #1's Admission MDS assessment dated [DATE] revealed a BIMS score 15, indicating she had intact cognitive skills. She required extensive assistance from 2 people for bed mobility; extensive assistance from one person for dressing and toileting; and limited assistance from 2 people for personal grooming. The skin ulceration and treatment section of the MDS, indicated she required surgical wound care. Review of CR #1's consolidated physician orders dated [DATE] revealed no order for surgical wound site care. Record review of CR #1's treatment administration record (TAR) for [DATE] revealed no treatments for surgical wound site care. Review of CR #1's care plan dated [DATE] revealed in part Focus, CR #1 [MEDICAL CONDITION]. Interventions included document/report to the doctor (MD) as needed (PRN) any signs or symptoms of infection, encourage fluid intake and adequate rest, give antibiotic as ordered, monitor/document/report to MD PRN abnormal laboratory values, use universal precautions to prevent infection. There were no interventions to cleanse CR #1's wound or to use wet to dry dressing. Review of CR #1's pre-admission assessment, with referral date [DATE] revealed in part .Skin: the box for wound was checked surgical procedures: exploratory laparotomy, total abdominal hysterectomy, bilateral, salpingo oophorectomy, omentectomy, staging biopsy. Review of CR #1's hospital discharge papers included a Discharge Summary Final Report dated [DATE], revealed in part, Physical Examination .Gastrointestinal: Soft, Incision with wound vac Discharge Summary Plan .Orders: Wet to dry for transfer and wound VAC to be placed at SNF (skilled nursing facility) upon arrival . (A Wound VAC is negative-pressure wound therapy, also known as a vacuum assisted closure (VAC). It is a suction pump, tubing and dressing to remove excess exudate and promote healing in acute or chronic wounds). Record review of CR#1's progress notes revealed the following entries revealed: - [DATE] 4:15 p.m.: Assessments: LVN 1 recorded: .incision to midline, 5 staples present, wound is approximately 7 inches deep at 6 o'clock , 4 inches deep at 4 o'clock pending wound VAC arrival, wet to dry dressing in place. - [DATE] 6:33 p.m.: Admission Summary, RN 1 recorded .Will notify MD/PA of arrival and review medication list as well as any other new orders. - [DATE] 4:20 a.m. Skin Wound Note: Resident continued to pulling packed gauze out and threw on the floor .wet to dry dressing re-applied. - [DATE] 10:05 a.m., Daily Skilled Note: LVN 2 recorded .She (CR #1) had 5 staples midline abdomen and open wound below staples with necrotic tissue around the edges. Wound cleaned and covered with bandage until wound care can further evaluate . - [DATE] 10:41 p.m., Skin wound note: Late Entry: Resident noted to have open wound to abdomen with approx 5 staples midline above int. Wound is beefy red with areas of necrotic black tissue around the edges. wound cleansed with normal saline. Applied ABD pad until further assessment by wound care . - [DATE] 06:45 a.m. Health Status Note: LVN 3 recorded the following Late entry: Upon rounds nurse observed wound to abdomen was dehisced approximately ,[DATE] inches open, resident had her fingers in it writer spoke to family member to ask how she was when she left the hospital and that it looked like she may have some fungal areas around the wound edging to the back. Did telemedicine with NP, NP stated it looked as if there was infection and the wound VAC was ordered to be put on the day before on ,[DATE]. Immediately found the wound VAC and was preparing to apply to wound when family member called back and insisted the mom go back to the hospital. I then cleansed the wound and dressed it to prepare for transfer. Review of the Provider Report Investigation Summary dated [DATE] by Administrator revealed in part When CR #1's clinical referral was sent to us for approval on [DATE], there wasn't a wound VAC needed then. The clinical information didn't mention about the wound VAC until the nurse received report on Sunday and that said the patient would need dressing change until the wound VAC available. The patient was admitted to our facility on Sunday night [DATE]. When the patient arrived to the facility, on the (discharge) d/c orders, there wasn't any order for wound On Monday morning the unit manager reviewed the d/c orders from the hospital and the hospital record, the d/c orders from hospital didn't have orders related to the patient wounds except her medications. There is a page stated about the wound VAC and it was not included in the discharged order and it didn't say whether this sound be continued or discontinued like the rest of the orders. The nurse manager clarified the order and received verbal order to start the wound VAC . Review of written statements included in Provider Report revealed the following: -Written statement by LVN 2, .on [DATE] nurse was providing care to CR #1 .She also had a open wound midline abdomen with approx. 5 staples in place above the beginning of the wound opening. The wound was beefy red, minimal amount of serous drainage, proximal edges with small specs of black necrotic tissue around the edges I then cleaned wound with normal saline, pat dry, and applied ABD pads to cover the wound.: -Written statement by LVN 4 . on [DATE] .Tissue looks bright beefy red but no bleeding or purulent drainage noted during shift. Incision edge red but straight and well-formed, surrounding tissues looks normal. Rinsed with sterile saline water and covered with dry dressing, awaiting wound VAC . Interview on [DATE] at 10:15 a.m., LVN 5, when asked what steps were done when admitting a new resident, she said assess skin, if there is a wound we would make sure there is an order. In a telephone interview on [DATE] at 4:30 p.m., LVN 1 said CR #1 had clusters of rash all over her body. Upon admission, the abdominal wound had dressing in place and it was packed. Resident was admitted on a Sunday, usually the wound doctor rounds the next day. LVN 1 said CR #1 did not have a wound VAC order. CR #1 was placed in the 100 Hall, Isolation. The transfer packet was taken care of by nurse at the nurse station. Sometimes they would make a copy for the nurses in the Isolation hall. Usually the ,[DATE] supervisor was in charge of the transfer orders. When asked how did you know about the wound VAC, she said, the EMS mentioned CR #1 had a large abdominal surgical wound and needed a wound vac. Interview on [DATE] at 2:30 p.m., when asked what would a nurse who was admitting a resident with a wound and no order for treatment do, LVN 6, said he would call the MD to get an order. LVN 6 said the facility had a wound care nurse who rounded every morning. The facility had a wound care supply room and usually had wound vac equipment. Interview on [DATE] at 2:35 p.m., when asked the what would a nurse who was admitting a resident with a wound and no order for treatment do, LVN 7 said she would call and get an order. LVN 7 said if wound care was needed, she would get an order for [REDACTED]. A weekday order would arrive the same day. Interview on [DATE] at 2:40 p.m., when asked where were verbal orders recorded, the MDS Nurse said it would be put into PCC (point click care). Interview on [DATE] at 3:05 p.m., the DON said she reviewed the pre admission assessment forms for CR #1 on Thursday ([DATE]) and there were no orders for wound vac. She talked to the doctor on Monday and received a verbal order. When asked where were the verbal orders recorded, she said we don't enter into system because we were waiting for the device. CR #1 was admitted with wet to dry and the nurses cleaned the wound. The device came on Tuesday. She said it was miscommunication, no order from hospital. When asked how did nurses know to do wet to dry dressings for CR #1, the DON said because she came with that. When asked who reviewed CR #1's transfer papers, the DON said the admitting nurse was supposed to review. In a telephone interview on [DATE] at 9:10 a.m., CR #1's family member said the wound care nurse sent her the photos (of the abdominal surgical wound). The photos were taken on the day she was sent back out to the hospital. She said CR #1 called her and said my wound is really bad, they have not turned me all weekend or changed me. She understood CR #1 was sent to this facility was because they could provide a wound VAC. The hospital told her where ever CR #1 went, she was going to need a wound VAC. The family member said on ,[DATE], the hospital social worker told her the wound VAC care would be coordinated with the facility. CR #1 had a wound VAC in the hospital. On [DATE] she was sent back to the hospital. After the hospital, she went to another facility, ultimately into hospice care. CR #1 died on [DATE]. Interview on [DATE] at 11:00 a.m., when asked what was purpose of the hospital final report, the DON said it was a summary, included a medication list, and sometimes they will include History and Physical. When asked how nurses knew how to take care of the surgical wound, she said hospital nurses would report and facility nurses used any paperwork that arrived with the resident. They based care on the documents that came with resident, but they needed something in the meantime. She said she got verbal order from doctor around 2 p.m. Monday afternoon to start wound VAC upon arrival. In a telephone interview on [DATE] at 2:30 p.m., the NP said CR #1 came to the facility with wound VAC orders on [DATE]. She told the nurse to start wound VAC on ,[DATE] and did not remember which nurse. She said she saw CR #1 on [DATE] and saw the wound VAC orders that came with the discharge orders. Review of facility policy and procedure for Wound Care, Level III, 2001 MED-PASS, Inc. (Revised [DATE]) revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure

Based on interview and record review the facility failed, based on the comprehensive assessment ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (CR #1) of three residents reviewed for quality of care. The facility failed to provide CR #1 surgical wound care according to physician's orders. This failure could affect residents by placing them at risk of not receiving essential care and treatment services, consistent with the resident's mental and physical needs. Findings include: Review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. uterus. On [DATE] she was sent back to the hospital. Review of CR #1's Admission MDS assessment dated [DATE] revealed a BIMS score 15, indicating she had intact cognitive skills. She required extensive assistance from 2 people for bed mobility; extensive assistance from one person for dressing and toileting; and limited assistance from 2 people for personal grooming. The skin ulceration and treatment section of the MDS, indicated she required surgical wound care. Review of CR #1's consolidated physician orders dated [DATE] revealed no order for surgical wound site care. Record review of CR #1's treatment administration record (TAR) for [DATE] revealed no treatments for surgical wound site care. Review of CR #1's care plan dated [DATE] revealed in part Focus, CR #1 [MEDICAL CONDITION]. Interventions included document/report to the doctor (MD) as needed (PRN) any signs or symptoms of infection, encourage fluid intake and adequate rest, give antibiotic as ordered, monitor/document/report to MD PRN abnormal laboratory values, use universal precautions to prevent infection. There were no interventions to cleanse CR #1's wound or to use wet to dry dressing. Review of CR #1's pre-admission assessment, with referral date [DATE] revealed in part .Skin: the box for wound was checked surgical procedures: exploratory laparotomy, total abdominal hysterectomy, bilateral, salpingo oophorectomy, omentectomy, staging biopsy. Review of CR #1's hospital discharge papers included a Discharge Summary Final Report dated [DATE], revealed in part, Physical Examination .Gastrointestinal: Soft, Incision with wound vac Discharge Summary Plan .Orders: Wet to dry for transfer and wound VAC to be placed at SNF (skilled nursing facility) upon arrival . (A Wound VAC is negative-pressure wound therapy, also known as a vacuum assisted closure (VAC). It is a suction pump, tubing and dressing to remove excess exudate and promote healing in acute or chronic wounds). Record review of CR #1's progress notes revealed the following entries revealed: - [DATE] 4:15 p.m.: (admission) Assessments: LVN 1 recorded: .incision to midline, 5 staples present, wound is approximately 7 inches deep at 6 o'clock , 4 inches deep at 4 o'clock pending wound VAC arrival, wet to dry dressing in place. - [DATE] 6:33 p.m.: Admission Summary, RN 1 recorded .Will notify MD/PA of arrival and review medication list as well as any other new orders. - [DATE] 4:20 a.m. Skin Wound Note: Resident continued to pulling packed gauze out and threw on the floor .wet to dry dressing re-applied. - [DATE] 10:05 a.m., Daily Skilled Note: LVN 2 recorded .She (CR #1) had 5 staples midline abdomen and open wound below staples with necrotic tissue around the edges. Wound cleaned and covered with bandage until wound care can further evaluate . - [DATE] 10:41 p.m., Skin wound note: Late Entry: Resident noted to have open wound to abdomen with approx 5 staples midline above int. Wound is beefy red with areas of necrotic black tissue around the edges. wound cleansed with normal saline. Applied ABD pad until further assessment by wound care . - [DATE] 06:45 a.m. Health Status Note: LVN 3 recorded the following Late entry: Upon rounds nurse observed wound to abdomen was dehisced approximately ,[DATE] inches open, resident had her fingers in it writer spoke to family member to ask how she was when she left the hospital and that it looked like she may have some fungal areas around the wound edging to the back. Did telemedicine with NP, NP stated it looked as if there was infection and the wound VAC was ordered to be put on the day before on ,[DATE]. Immediately found the wound VAC and was preparing to apply to wound when family member called back and insisted the mom go back to the hospital. I then cleansed the wound and dressed it to prepare for transfer. Review of the Provider Report Investigation Summary dated [DATE] by Administrator revealed in part When CR #1's clinical referral was sent to us for approval on [DATE], there wasn't a wound VAC needed then. The clinical information didn't mention about the wound VAC until the nurse received report on Sunday and that said the patient would need dressing change until the wound VAC available. The patient was admitted to our facility on Sunday night [DATE]. When the patient arrived to the facility, on the (discharge) d/c orders, there wasn't any order for wound On Monday morning the unit manager reviewed the d/c orders from the hospital and the hospital record, the d/c orders from hospital didn't have orders related to the patient wounds except her medications. There is a page stated about the wound VAC and it was not included in the discharged order and it didn't say whether this sound be continued or discontinued like the rest of the orders. The nurse manager clarified the order and received verbal order to start the wound VAC . Review of written statements included in Provider Report revealed the following: -Written statement by LVN 2, .on [DATE] nurse was providing care to CR #1 .She also had a open wound midline abdomen with approx. 5 staples in place above the beginning of the wound opening. The wound was beefy red, minimal amount of serous drainage, proximal edges with small specs of black necrotic tissue around the edges I then cleaned wound with normal saline, pat dry, and applied ABD pads to cover the wound.: -Written statement by LVN 4 . on [DATE] .Tissue looks bright beefy red but no bleeding or purulent drainage noted during shift. Incision edge red but straight and well-formed, surrounding tissues looks normal. Rinsed with sterile saline water and covered with dry dressing, awaiting wound VAC . Interview on [DATE] at 10:15 a.m., LVN 5, when asked what steps were done when admitting a new resident, she said assess skin, if there is a wound we would make sure there is an order. In a telephone interview on [DATE] at 4:30 p.m., LVN 1 said CR #1 had clusters of rash all over her body. Upon admission, the abdominal wound had dressing in place and it was packed. Resident was admitted on a Sunday, usually the wound doctor rounds the next day. LVN 1 said CR #1 did not have a wound VAC order. CR #1 was placed in the 100 Hall, Isolation. The transfer packet was taken care of by nurse at the nurse station. Sometimes they would make a copy for the nurses in the Isolation hall. Usually the ,[DATE] supervisor was in charge of the transfer orders. When asked how did you know about the wound VAC, she said, the EMS mentioned CR #1 had a large abdominal surgical wound and needed a wound vac. Interview on [DATE] at 2:30 p.m., when asked what would a nurse who was admitting a resident with a wound and no order for treatment do, LVN 6, said he would call the MD to get an order. LVN 6 said the facility had a wound care nurse who rounded every morning. The facility had a wound care supply room and usually had wound vac equipment. Interview on [DATE] at 2:35 p.m., when asked the what would a nurse who was admitting a resident with a wound and no order for treatment do, LVN 7 said she would call and get an order. LVN 7 said if wound care was needed, she would get an order for [REDACTED]. A weekday order would arrive the same day. Interview on [DATE] at 2:40 p.m., when asked where were verbal orders recorded, the MDS Nurse said it would be put into PCC (point click care). Interview on [DATE] at 3:05 p.m., the DON said she reviewed the pre admission assessment forms for CR #1 on Thursday ([DATE]) and there were no orders for wound vac. She talked to the doctor on Monday and received a verbal order. When asked where were the verbal orders recorded, she said we don't enter into system because we were waiting for the device. CR #1 was admitted with wet to dry and the nurses cleaned the wound. The device came on Tuesday. She said it was miscommunication, no order from hospital. When asked how did nurses know to do wet to dry dressings for CR #1, the DON said because she came with that. When asked who reviewed CR #1's transfer papers, the DON said the admitting nurse was supposed to review. In a telephone interview on [DATE] at 9:10 a.m., CR #1's family member said the wound care nurse sent her the photos (of the abdominal surgical wound). The photos were taken on the day she was sent back out to the hospital. She said CR #1 called her and said my wound is really bad, they have not turned me all weekend or changed me. She understood CR #1 was sent to this facility was because they could provide a wound VAC. The hospital told her where ever CR #1 went, she was going to need a wound VAC. The family member said on ,[DATE], the hospital social worker told her the wound VAC care would be coordinated with the facility. CR #1 had a wound VAC in the hospital. On [DATE] she was sent back to the hospital. After the hospital, she went to another facility, ultimately into hospice care. CR #1 died on [DATE]. Interview on [DATE] at 11:00 a.m., when asked what was purpose of the hospital final report, the DON said it was a summary, included a medication list, and sometimes they will include History and Physical. When asked how nurses knew how to take care of the surgical wound, she said hospital nurses would report and facility nurses used any paperwork that arrived with the resident. They based care on the documents that came with resident, but they needed something in the meantime. She said she got verbal order from doctor around 2 p.m. Monday afternoon to start wound VAC upon arrival. In a telephone interview on [DATE] at 2:30 p.m., the NP said CR #1 came to the facility with wound VAC orders on [DATE]. She told the nurse to start wound VAC on ,[DATE] and did not remember which nurse. She said she saw CR #1 on [DATE] and saw the wound VAC orders that came with the discharge orders. Review of facility policy and procedure for Wound Care, Level III, 2001 MED-PASS, Inc. (Revised [DATE]) revealed, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure

Based on interviews and record reviews the facility did not provide, in writing, a Bed-hold notice upon transfer at the time of transfer of a resident to a hospital or for therapeutic leave, for one resident (Resident #1) reviewed for transfers and discharge. The facility failed to provide bed-hold notification to Resident #1's representative when he was transferred to the hospital. This failure could affect all residents in the facility subjecting them to an unsafe discharge. Record review of Resident #1's face sheet revealed a [AGE] year old man admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Primary payer is Medicaid. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS score of 3 indicating he had severely impaired cognitive skills. Review of Resident #1's care plan dated 11/19/2019 revealed he had ADL self care performance deficit. He required 1 staff assistance for toilet use, bed mobility, bathing, personal hygiene and dressing. Record review of Resident #1's progress notes dated 04/13/2020 at 10:59 a.m. revealed a Behavior Note revealed in part .Resident having several episodes of attempted elopement, combative with multiple staff members, staff attempts to re-direct but unsuccessful, PRN [MEDICATION NAME] given not effective. MD informed, received verbal order to send to hospital for psych eval . Interview on 08/24/2020 at 11:00 a.m., the DON said that Resident #1 was sent out to hospital because of elopement behavior. He was transferred to the ER and then we heard he was admitted to hospital. Interview on 08/24/2020 at 12:00 p.m., when Administrator was asked for the notice of bed hold given to the Resident #1's responsible party when he went to the hospital on April 13, The Administrator said they did not give a notice to the family. The reason they did not provide one, was because Resident #1 was not discharged on [DATE]. He said it was a standard transfer because Resident #1 was sent to the hospital for elopement behaviors. Review of HHSC Fair Hearing - Nursing Facility Discharge letter dated August 13, 2020 revealed in part .VI. Conclusions of Law .based on the findings of fact and applicable authority, the Hearings Officer concludes that: Conclusion to Law 2: .In this case, Appellant was not allowed to return to Park Manor of The Woodlands. Agency did not comply with Texas Administrative Code 19.503 Notice of Bed Hold Policy and Re-admission. Agency did not notify Appellant and his family of the bed-hold policy Review of facility policy for Bed-Holds and Returns, 2001 MED-PASS, Inc. (Revised March 2017) revealed in part Policy Statement: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Policy Interpretation and Implementation 1. Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy. 2. The current bed-hold and return policy established by the stat (if applicable) will apply to Medicaid residents in the facility. 3. Prior to transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed holds .d. The details of the transfer (per Notice of Transfer) .7. The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is no tan available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available . The resident roster dated 08/19/2020 provided by the Administrator reflected 86 as the total census.

Based on interviews and record reviews the facility failed to follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State Plan, is readmitted to the facility immediately upon the first availability of a bed for one resident (Resident #1) reviewed for transfer/discharge. The facility failed to allow Resident #1 to be readmitted back to facility as instructed at Fair Hearing by Texas Health and Human Services. This failure could affect all residents in the facility subjecting them to an unsafe discharge. Record review of Resident #1's face sheet revealed a [AGE] year old man admitted to the facility on [DATE] His [DIAGNOSES REDACTED]. Primary payer is Medicaid. Review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating he had severely impaired cognitive skills. Review of Resident #1's care plan dated 11/19/2019 revealed he had ADL self care performance deficit. He required 1 staff assistance for toilet use, bed mobility, bathing, personal hygiene and dressing. Record review of Resident #1's progress notes dated 04/13/2020 at 10:59 a.m., a Behavior Note revealed in part .Resident having several episodes of attempted elopement, combative with multiple staff members, staff attempts to re-direct but unsuccessful, PRN [MEDICATION NAME] given not effective. MD informed, received verbal order to send to hospital for psychiatric evaluation . In a telephone interview on 08/19/2020 at 2:38 p.m., Resident #1's responsible party said the facility was supposed to take him back and they had not done so. His belongings were still at the facility. Neither the Administrator or DON returned her calls. She said the last time she talked to Administrator, he said he would do an pre-admission assessment of Resident #1. She said she had not heard back about the assessment. She said she could not take care of him and wanted him to return to facility. Interview on 08/19/2020 at 11:30 a.m., the Administrator said Resident #1's behavior had been going on for 8 months. His behavior had been escalating. Resident #1 was aggressive to residents and staff; and he wandered to places in the faclity he should not be and eloped from the building. He needed one-on-one supervision or a memory care unit. The Administrator was not appropriate for here. But because HHSC said the facility must readmit him, he could return when a vacant bed in the quarantine unit was available. Interview on 08/24/2020 at 11:00 a.m., the DON said that Resident #1 was sent to the hospital because of eloping and other behavior. He was transferred to the hospital emergency room and then the facility was notified that he was admitted to Hospital. Interview on 08/24/2020 at 12:00 p.m., when Administrator was asked for the notice of bed hold given to the Resident #1's responsible party when he went to the hospital on April 13, The Administrator said they did not give a notice to the family. The reason they did not provide one, was because Resident #1 was not discharged on [DATE]. He said it was a standard transfer because Resident #1 was sent to the hospital for elopement behaviors. Review of HHSC Fair Hearing - Nursing Facility Discharge letter dated August 13, 2020 revealed in part .Order, Instructions: In accordance with this decision, Park Manor of The Woodlands is instructed to allow Appellant to be readmitted back into its facility if the Appellant or his authorized representative so desires, and not transfer or discharge Appellant from the facility. Park Manor of The Woodlands must report compliance with this order within 10 days from the date of this decision VI. Conclusions of Law .based on the findings of fact and applicable authority, the Hearings Officer concludes that: Conclusion to Law 2: .In this case, Appellant was not allowed to return to Park Manor of The Woodlands. Agency did not comply with Texas Administrative Code 19.503 Notice of Bed Hold Policy and Re-admission. Agency did not notify Appellant and his family of the bed-hold policy Review of facility policy for Bed-Holds and Returns, 2001 MED-PASS, Inc. (Revised March 2017) revealed in part Policy Statement: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Policy Interpretation and Implementation 1. Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy. 2. The current bed-hold and return policy established by the stat (if applicable) will apply to Medicaid residents in the facility. 3. Prior to transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed holds .d. The details of the transfer (per Notice of Transfer) .7. The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available . The resident roster dated 08/19/2020 provided by the Administrator reflected 86 as the total census.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was an accident involving the resident which resulted in injury and had the potential of requiring physician intervention for one of 17 residents (CR #1) in that: CR #1, who routinely took blood thinning medication, fell and hit her head and facility staff did not consult with the physician for more than 7 hours. CR #1 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy at a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. This failure could affect any resident who receives blood thinning medications. Findings include: Review of CR #1's face sheet revealed a female resident that was 92-years-old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was admitted to a hospital on [DATE] and died on [DATE]. Record review of CR #1's MDS assessment dated [DATE], revealed a BI[CONDITION] score of 12, indicating resident had moderate cognitive impairment. CR #1's MDS further revealed she required supervision for bed mobility, transfers, bathing, and toileting. Resident used a wheelchair for mobility. Record review of CR #1's consolidated physician orders [REDACTED]. -aspirin 81 milligrams per day for cardiac health. [MEDICATION NAME] Bi[MED] (generic form of [MEDICATION NAME]) [AGE] milligrams every day for [MEDICAL CONDITION]. Record review of CR #1's care plan dated [DATE] revealed she was a high risk for falls. The interventions included anticipating her needs; and ensuring the call light was in reach. Record review of CR #1's online medical record revealed resident had an episode of hallucinations on [DATE] at 3:42 p.m. CR #1's Physician A was notified by RN B. CR #1 had a fall later the same day at 10:45 p.m. There was no documentation in CR #1's medical record that the resident's physician was consulted after the resident fell . Record review of the incident report #3231 completed by RN A revealed Physician A was not notified about CR #1's fall until [DATE] at 6:01 a.m., more than 7 hours after the fall. Record review of CR #1's nurses' note revealed RN C documented on [DATE] at 7:14 a.m. that the resident was found on the floor in her room, close to her bed, laying on her left side at 10:45 p.m. Resident was assessed by RN C and was noted to have a skin tear to the left elbow and a hematoma to her left cheek area. Interview on [DATE] at 10:42 a.m. with RN C revealed she was the attending nurse the night CR #1 fell in her room. RN C said she observed a skin tear to the elbow and applied ice to the bruised area on her cheek. RN C said she notified Physician A at 6:01 a.m. on [DATE]. When she notified Physician A, she also informed him about the skin tear and bruise to the cheek. RN C said she did not call the Physician immediately because she was doing other things and time caught up with her. RN C said she did not know CR #1 was on blood thinners. RN C said she could not recall much about the incident but felt like she should have sent CR #1 to the hospital. She said, I always check for blood thinners. It is something I always do. I don't know why I didn't. Further review of CR #1's medical record revealed the following nursing notes: - Nurse note on [DATE] at 7:11 a.m. by LVN B assessed CR #1 with confusion and hallucinations. - Nurse note on [DATE] at 8:40 a.m. by LVN B assessed CR #1 with hallucinations and confusion. - Nurse notes on [DATE] at 8:46 a.m. by LVN B assessed CR #1 with increased confusion and restlessness. CR #1 refused neurological assessment and was pulling off a bandage. - Nurse note on [DATE] at 4:19 p.m. revealed a urine analysis was sent to the laboratory. - Nurse note on [DATE] at 5:05 p.m. by RN A revealed resident with episodes of increased confusion and agitation. Resident with continued confusion talking inappropriately to staff and not remembering staff names unlike her baseline. New order for [MEDICATION NAME] Q 12 prn agitation. - Nurse note on [DATE] at 12:54 p.m. by LVN B revealed that CR #1 refused her pupil check but was alert with confusion. No hallucinations this shift but sleeping most of shift. Not as agitated this shift. - Nurse note on [DATE] at 3:01 p.m. by RN A revealed that the resident had an increased confusion and unlike personality and agitation calling out. - Nurse note on [DATE] at 3:04 p.m. revealed that CR #1 Physician A gave the order to send her to the ER. Resident sent to local hospital. Interview on [DATE] at 9:04 a.m. with LVN B revealed CR #1 had a fall on [DATE]. LVN B was caring for CR #1 the next shift after the fall. LVN B said when she went to see CR #1 she found her with a change of condition. She said she did a regular assessment and neurological assessments and made sure her call light was in reach. She said the resident had a bruise on her left cheek and a skin tear. During that shift, CR #1 was hallucinating and told LVN B not to knock over the plants behind her and there were no plants in the room. LVN B said these hallucinations were new to CR #1. LVN B said she notified the PA about CR #1's altered mental status and received a new order to collect a urinalysis ([DATE]). Interview on [DATE] at 9:33 a.m. the DON revealed CR #1 had a fall on [DATE] and she saw the resident on the morning of [DATE]. When the DON saw CR #1, she noted the bruise on her left cheek. DON said CR #1 was taking [MEDICATION NAME] and Aspirin as blood thinners. DON said Physician A and PA had ordered labs and a urinalysis on [DATE] and everything came back normal. On [DATE] when CR #1 continued with confusion, DON talked to the family and CR #1 was sent to the hospital. Interview on [DATE] at 10:06 a.m. with LVN B revealed after a fall and assessment, the nurse should immediately notify the physician and family as soon as the resident was stable. LVN B stated immediately was usually within 30 minutes of the resident being stable. Interview on [DATE] at 10:32 a.m. with RN B revealed she cared for CR #1 the shift prior to the fall. RN B said notification to the physician after a fall usually occurs within the first ,[DATE] minutes. RN B said if a resident hit their head when they fall she would send them to the hospital. RN B said she would initiate neurological assessments but felt residents that hit their head should be sent to the hospital. RN B said residents on blood thinners that hit their head were at a higher risk for bleeding and should be sent to the hospital. Interview on [DATE] at 10:55. a.m. the DON said physician notification post incident should be within 24 hours. DON said if a resident loses consciousness the nurse should notify the physician right away. However, if it is a skin tear, sometimes nurses will notify the physician at the end of the shift. If it is at night and the resident is ok, you don't want to wake the physician up and make them mad. DON said if a resident begins hallucinating after a fall, it was a change of condition. Interview on [DATE] at 12:20 p.m. with Physician A and PA revealed Physician A or PA come to the facility almost daily. Physician A said he knew CR #1 very well and she recently had aortic wall heart surgery prior to admission. Physician A said CR #1 would have good days and some days that were not good. Physician A said CR #1 was on [MEDICATION NAME] and Aspirin as blood thinners because of recent heart surgery. Physician A said that PA saw CR #1 on [DATE]. Physician said they did a urinalysis because they felt like CR #1 had a urinary tract infection. Physician A said on the [DATE] she was not doing much better and on the morning of the 8th she had a more noticeable decline. Physician A verified he received a call regarding CR#1's fall at 6:01 a.m. on [DATE]. He was unable to recall if he was told about the bruise to her cheek during that call. Physician A said he instructed the nurse to do neurological assessments. Physician said when he saw CR #1 he was concerned because of the bruising. Physician A said if you are on a blood thinner, you will bruise. Physician A said CR #1 passed away this morning ([DATE]). Physician A said CR #1 had a brain bleed. Record review of CR #1's hospital medical records dated [DATE] revealed the following assessment: [AGE] year old female with PMH as above presents for evaluation of: Subdural hemorrhage; traumatic and bilateral L>R Subarachnoid hemorrhage, traumatic Hypertension Rib and vertebral fractures Rt ,[DATE]th ribs and T11-T12 S/p TAVR; on ASA and [MEDICATION NAME] AKI; creatinine 0.[AGE] at BSLMC on [DATE] Rhabdo, mild Metabolic [MEDICAL CONDITION] Debility Record review of hospital records indicate CR #1 had a fall at the nursing home on [DATE] and had begun hallucination and showed agitation, which was new to her. CR #1 was admitted to the hospital ICU and later received comfort care measures. CR #1 expired on [DATE]. Record review of the policy titled Change in a Resident's Condition or Status, revised [DATE], revealed the following: The facility shall promptly notify the resident, his or her Attending physical and representative sponsor) of changes in the residents medical/mental condition and/or status (e.g. changes in level of care, billing//payments, resident rights, etc). The facility Administrator was notified of the IJ on [DATE] at 3:40 p.m.; given the completed IJ template; and a plan of removal was requested. After one revision, the POR was accepted on [DATE] at 3:10 p.m. The POR included the following: The facility submits the following plan of removal for the alleged failure to have an effective system in identifying and notifying the physician of a change in condition. Each resident will receive and the facility will provide the necessary treatment to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Communicating changes in resident condition protocol is as follows. The facility has implemented the following: 1. The DON/ Licensed Nurses in the facility shall promptly notify the resident, his or her Attending Physician, and resident responsible party of changes in the resident's medical/mental condition and/or status. The DON/Licensed Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: - A significant change in the resident's physical/emotional/mental condition; - A need to alter the resident's medical treatment significantly; - A need to transfer the resident to a hospital/treatment center; Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or responsible party when: A significant change of condition is a decline or improvement in the resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting); -Impacts more than one area of the resident's health status; -The final decision regarding what constitutes a significant change in status is based on the judgment of the clinical staff and the guidance of the Physician. -The DON/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. CR #1 no longer resides in the facility. 2. On [DATE], the facility completed an audit of residents currently residing in the facility who are currently on anticoagulant therapy. 17 residents were identified as receiving anticoagulant therapy and were assessed by the DNS/designee for injuries and no issues were noted. 3. On [DATE], an audit of residents who have had falls in the past 30 days was completed to ensure any possible injuries were properly addressed by the nursing staff including notification to the physician. No issues were noted. 4. On [DATE], the Clinical Services Director in-serviced the Director of Nursing and the Nurse Managers regarding timely physician notification of resident changes in condition based on the resident's clinical assessment and resident rights. 5. On [DATE], the DON/designee initiated an in-service with the Licensed Nurses regarding timely physician notification of resident changes in condition based on the resident's clinical assessment and resident rights. Licensed Nurses not receiving this in-service on [DATE] will not be allowed to work until the in-service is completed. On [DATE] the licensed nurses were in-serviced by the DNS that if a physician does not respond to them in an emergent situation within an hour they are to notify the facilities Medical Director. If no response from the Medical Director the facility is to notify the DNS and/or Administrator. 6. Newly hired Licensed Nurses will be in-serviced on timely physician notification of resident changes in condition based on the resident's clinical assessment and resident rights at the time of hire and annually thereafter. Newly hired licensed nurses will be in-serviced that if a physician does not respond to them in an emergent situation within an hour, they are to notify the facilities Medical Director. If no response from the Medical Director, the facility is to notify the DNS and/or Administrator. 7. On [DATE], the Regional Vice President and the Clinical Services Director in-serviced the Administrator and the Director of Nurses to review changes in condition, to include falls, daily Monday through Friday to ensure that timely physician notification has occurred. Any discrepancy will be immediately addressed, and the physician notified. On Saturday and Sunday, the Weekend Supervisor will review changes in condition, to include falls, to ensure that timely physician notification has occurred. Any discrepancy will be immediately addressed, and the physician notified. 8. On [DATE] the DNS initiated an in-service with licensed nursing staff on emergent conditions that require sending the patient out prior to notifying the physician. In addition, the DNS in-serviced the licensed nursing staff on the InterAct 4.0 tool that identifies immediate and non-immediate conditions requiring physician notification. 9. The DNS initiated an in-service with facility CNAs regarding identifying a change in condition, utilizing the Stop and Watch tool and turning it into the charge nurse and carbon copy to the nurse manager. 10. The Nurse Manager will ensure that proper interventions and follow up are completed to include timely physician notification. DNS and/or designee will review Stop and Watch tools Monday through Friday during the daily clinical meeting to ensure that proper interventions and follow up are completed to include timely physician notification. The Weekend Supervisor will review the Stop and Watch tools on Saturday and Sunday to ensure that proper interventions and follow up are completed to include timely physician notification. 11. Administrator, Director of Nurses and/or designee will be attending the daily stand up meeting a minimum of five times weekly to ensure that any falls that result in a resident with increased confusion are reviewed to ensure proper interventions are implemented. The facilities weekend supervisor will be reviewing any changes in condition throughout the weekends to ensure proper interventions are reviewed and implemented. 12. An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. An impromptu QAPI meeting was completed on [DATE] with the Medical Director to review the revised plan of removal and the Medical Director has reviewed and agrees with this plan. Surveyors monitored the plan of removal between [DATE] through [DATE] : During monitoring, Nurses, LVN M, RN N, LVN O, RN P, LVN Q, LVN R, and LVN S were asked the following questions: -What do you do if there is any change in resident's condition? All the nurses said that they would assess and document the resident's condition; and then notify the physician. -When do you notify the resident's physician? All of the nurses said immediately or as soon as possible. -What do you do if the physician does not respond to an emergent condition within 1 hours? The nurses all answered that they would contact the medical director. Some of them added that they would contact the DON. -What are emergent conditions? Some of the nurses' responses were: fall with a fracture or dislocation; or bleeding; pain without relief; change in vitals; chest pain; respiratory distress; and signs of stroke. -Would emergent situations require waiting for the physician's response prior to sending the resident to the hospital? The answers include: -LVN M said that she would send a resident to the hospital without a doctor's order for a fracture, head injury, elevated temperature, and cardiac distress. -RN N said she can send a resident to the hospital any time a physician does not respond. -LVN O said that she would send a resident to the hospital and notify the doctor later any time that the assessment warranted this action. -RN P, LVN Q, and LVN S said they send residents to the hospital, 911, and then tell the doctor for emergent condition. During monitoring CNA T, CNA U, CNA V, CNA W, and CNA X were asked the following questions: -What do you do if you see something different with a resident? CNAs answered that they would tell the nurse and complete the Stop and Watch form. Some of the aides indicated they would also document the change in the plan of care computer system. -What are examples of thing you may have to notify the nurse about? The answers included: changes in eating or drinking, activity, mobility, speech, or sleep patterns; agitation; weight loss; falls; weakness or lethargy; and changes in toileting patterns or output. -How soon do you notify the nurse. The aides all answered immediately or as soon as possible. Record review of the QAPI meeting minutes dated [DATE] verified the facility completed an audit of residents currently receiving anticoagulant medications. Record review of the QAPI meeting minutes dated [DATE] verified the facility completed an audit of the clinical records for residents who had falls in the last 30 days. Record review of the in-services provided since the IJ was called revealed the staff attended training in: incidents, changes in condition, physician notification resident rights, initiating interventions for residents with acute changes in condition, reporting resident changes in condition, communication forms, resident rights, and when to notify physicians immediately and non-immediate. The Administrator and the DON were notified on [DATE] at 2:23 p.m. that the IJ was lowered. The facility remains out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness.

Based on observation, interview and record review, the facility failed to ensure CR #1 received prompt medical treatment and care in accordance with professional standards for one (CR #1) of 17 residents reviewed for quality of care. - The facility failed to ensure CR #1 received prompt medical treatment after she fell , hitting her head, on [DATE] at 10:45 p.m. She was sent to the hospital on [DATE] for a brain bleed and died there on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. This failure could affect any resident who receives blood thinning medications. Findings include: Review of CR #1's face sheet revealed a female resident that was 92-years-old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was admitted to a hospital on [DATE] and died on [DATE]. Record review of CR #1's MDS assessment dated [DATE], revealed a BI[CONDITION] score of 12, indicating resident had moderate cognitive impairment. CR #1's MDS further revealed she required supervision for bed mobility, transfers, bathing, and toileting. Resident used a wheelchair for mobility. Record review of CR #1's care plan dated [DATE] revealed she was a high risk for falls. The interventions included anticipating her needs; and ensuring the call light was in reach. Record review of CR #1's consolidated physician orders [REDACTED]. -aspirin 81 milligrams per day for cardiac health. [MEDICATION NAME] Bi[MED] (generic form of [MEDICATION NAME]) [AGE] milligrams every day for [MEDICAL CONDITION]. Record review of CR #1's online medical record revealed resident had an episode of hallucinations on [DATE] at 3:42 p.m. CR #1's Physician A was notified by RN B. CR #1 had a fall later the same day at 10:45 p.m. There was no documentation in CR #1's medical record that the resident's physician was consulted after the resident fell . Record review of the incident report #3231 completed by RN A revealed Physician A was not notified about CR #1's fall until [DATE] at 6:01 a.m., more than 7 hours after the fall. Record review of CR #1's nurses' note revealed RN C documented on [DATE] at 7:14 a.m. that the resident was found on the floor in her room, close to her bed, laying on her left side at 10:45 p.m. Resident was assessed by RN C and was noted to have a skin tear to the left elbow and a hematoma to her left cheek area. Interview on [DATE] at 10:42 a.m. with RN C revealed she was the attending nurse the night CR #1 fell in her room. RN C said she observed a skin tear to the elbow and applied ice to the bruised area on her cheek. RN C said she notified Physician A at 6:01 a.m. on [DATE]. When she notified Physician A, she also informed him about the skin tear and bruise to the cheek. RN C said she did not call the Physician immediately because she was doing other things and time caught up with her. RN C said she did not know CR #1 was on blood thinners. RN C said she could not recall much about the incident but felt like she should have sent CR #1 to the hospital. She said, I always check for blood thinners. It is something I always do. I don't know why I didn't. Further review of CR #1's medical record revealed the following nursing notes: - Nurse note on [DATE] at 7:11 a.m. by LVN B assessed CR #1 with confusion and hallucinations. - Nurse note on [DATE] at 8:40 a.m. by LVN B assessed CR #1 with hallucinations and confusion. - Nurse notes on [DATE] at 8:46 a.m. by LVN B assessed CR #1 with increased confusion and restlessness. CR #1 refused neurological assessment and was pulling off a bandage. - Nurse note on [DATE] at 4:19 p.m. revealed a urine analysis was sent to the laboratory. - Nurse note on [DATE] at 5:05 p.m. by RN A revealed resident with episodes of increased confusion and agitation. Resident with continued confusion talking inappropriately to staff and not remembering staff names unlike her baseline. New order for [MEDICATION NAME] Q 12 prn agitation. - Nurse note on [DATE] at 12:54 p.m. by LVN B revealed that CR #1 refused her pupil check but was alert with confusion. No hallucinations this shift but sleeping most of shift. Not as agitated this shift. - Nurse note on [DATE] at 3:01 p.m. by RN A revealed that the resident had an increased confusion and unlike personality and agitation calling out. - Nurse note on [DATE] at 3:04 p.m. revealed that CR #1 Physician A gave the order to send her to the ER. Resident sent to local hospital. Interview on [DATE] at 9:04 a.m. with LVN B revealed CR #1 had a fall on [DATE]. LVN B was caring for CR #1 the next shift after the fall. LVN B said when she went to see CR #1 she found her with a change of condition. She said she did a regular assessment and neurological assessments and made sure her call light was in reach. She said the resident had a bruise on her left cheek and a skin tear. During her shift, CR #1 was hallucinating and told LVN B not to knock over the plants behind her and there were no plants in the room. LVN B said these hallucinations were new to CR #1. LVN B said she notified the PA about CR #1's altered mental status and received a new order to collect a urinalysis ([DATE]). Interview on [DATE] at 9:33 a.m. the DON revealed CR #1 had a fall on [DATE] and she saw the resident on the morning of [DATE]. When the DON saw CR #1, she noted the bruise on her left cheek. DON said CR #1 was taking [MEDICATION NAME] and Aspirin as blood thinners. DON said Physician A and PA had ordered labs and a urinalysis on [DATE] and everything came back normal. On [DATE] when CR #1 continued with confusion, DON talked to the family and CR #1 was sent to the hospital. Interview on [DATE] at 10:06 a.m. with LVN B revealed after a fall and assessment, the nurse should immediately notify the physician and family as soon as the resident was stable. LVN B stated immediately was usually within 30 minutes of the resident being stable. Interview on [DATE] at 10:32 a.m. with RN B revealed she cared for CR #1 the shift prior to the fall. RN B said notification to the physician after a fall usually occurs within the first ,[DATE] minutes. RN B said if a resident hit their head when they fall she would send them to the hospital. RN B said she would initiate neurological assessments but felt residents that hit their head should be sent to the hospital. RN B said residents on blood thinners that hit their head were at a higher risk for bleeding and should be sent to the hospital. Interview on [DATE] at 10:55. a.m. the DON said physician notification post incident should be within 24 hours. DON said if a resident loses consciousness the nurse should notify the physician right away. However, if it is a skin tear, sometimes nurses will notify the physician at the end of the shift. If it is at night and the resident is ok, you don't want to wake the physician up and make them mad. DON said if a resident begins hallucinating after a fall, it was a change of condition. Interview on [DATE] at 12:20 p.m. with Physician A and PA revealed Physician A or PA come to the facility almost daily. Physician A said he knew CR #1 very well and she recently had aortic wall heart surgery prior to admission. Physician A said CR #1 would have good days and some days that were not good. Physician A said CR #1 was on [MEDICATION NAME] and Aspirin as blood thinners because of recent heart surgery. Physician A said that PA saw CR #1 on [DATE]. Physician said they did a urinalysis because they felt like CR #1 had a urinary tract infection. Physician A said on the [DATE] she was not doing much better and on the morning of the 8th she had a more noticeable decline. Physician A verified he received a call regarding CR#1's fall at 6:01 a.m. on [DATE]. He was unable to recall if he was told about the bruise to her cheek during that call. Physician A said he instructed the nurse to do neurological assessments. Physician said when he saw CR #1 he was concerned because of the bruising. Physician A said if you are on a blood thinner, you will bruise. Physician A said CR #1 passed away this morning ([DATE]). Physician A said CR #1 had a brain bleed. Record review of CR #1's hospital medical records dated [DATE] revealed the following assessment: [AGE] year old female with PMH as above presents for evaluation of: Subdural hemorrhage; traumatic and bilateral L>R Subarachnoid hemorrhage, traumatic Hypertension Rib and vertebral fractures Rt ,[DATE]th ribs and T11-T12 S/p TAVR; on ASA and [MEDICATION NAME] AKI; creatinine 0.[AGE] at BSLMC on [DATE] Rhabdo, mild Metabolic [MEDICAL CONDITION] Debility Record review of hospital records indicate CR #1 had a fall at the nursing home on [DATE] and had begun hallucination and showed agitation, which was new to her. CR #1 was admitted to the hospital ICU and later received comfort care measures. CR #1 expired on [DATE]. Record review of the policy titled Change in a Resident's Condition or Status, revised [DATE], revealed the following: The facility shall promptly notify the resident, his or her Attending physical and representative sponsor) of changes in the residents medical/mental condition and/or status (e.g. changes in level of care, billing//payments, resident rights, etc). The facility Administrator was notified of the IJ on [DATE] at 3:40 p.m.; they were given the IJ template; and a plan of removal was requested. After one revision, the POR was accepted on [DATE] at 3:10 p.m. The POR included the following: The facility submits the following plan of removal for the alleged failure to have an effective system in identifying and notifying the physician of a change in condition. Each resident will receive and the facility will provide the necessary treatment to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Communicating changes in resident condition protocol is as follows. The facility has implemented the following: 1. The DON/ Licensed Nurses in the facility shall promptly notify the resident, his or her Attending Physician, and resident responsible party of changes in the resident's medical/mental condition and/or status. The DON/Licensed Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: - A significant change in the resident's physical/emotional/mental condition; - A need to alter the resident's medical treatment significantly; - A need to transfer the resident to a hospital/treatment center; Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or responsible party when: A significant change of condition is a decline or improvement in the resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting); -Impacts more than one area of the resident's health status; -The final decision regarding what constitutes a significant change in status is based on the judgment of the clinical staff and the guidance of the Physician. -The DON/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. CR #1 no longer resides in the facility. 2. On [DATE], the facility completed an audit of residents currently residing in the facility who are currently on anticoagulant therapy. 17 residents were identified as receiving anticoagulant therapy and were assessed by the DNS/designee for injuries and no issues were noted. 3. On [DATE], an audit of residents who have had falls in the past 30 days was completed to ensure any possible injuries were properly addressed by the nursing staff including notification to the physician. No issues were noted. 4. On [DATE], the Clinical Services Director in-serviced the Director of Nursing and the Nurse Managers regarding timely physician notification of resident changes in condition based on the resident's clinical assessment and resident rights. 5. On [DATE], the DON/designee initiated an in-service with the Licensed Nurses regarding timely physician notification of resident changes in condition based on the resident's clinical assessment and resident rights. Licensed Nurses not receiving this in-service on [DATE] will not be allowed to work until the in-service is completed. On [DATE] the licensed nurses were in-serviced by the DNS that if a physician does not respond to them in an emergent situation within an hour they are to notify the facilities Medical Director. If no response from the Medical Director the facility is to notify the DNS and/or Administrator. 6. Newly hired Licensed Nurses will be in-serviced on timely physician notification of resident changes in condition based on the resident's clinical assessment and resident rights at the time of hire and annually thereafter. Newly hired licensed nurses will be in-serviced that if a physician does not respond to them in an emergent situation within an hour, they are to notify the facilities Medical Director. If no response from the Medical Director, the facility is to notify the DNS and/or Administrator. 7. On [DATE], the Regional Vice President and the Clinical Services Director in-serviced the Administrator and the Director of Nurses to review changes in condition, to include falls, daily Monday through Friday to ensure that timely physician notification has occurred. Any discrepancy will be immediately addressed, and the physician notified. On Saturday and Sunday, the Weekend Supervisor will review changes in condition, to include falls, to ensure that timely physician notification has occurred. Any discrepancy will be immediately addressed, and the physician notified. 8. On [DATE] the DNS initiated an in-service with licensed nursing staff on emergent conditions that require sending the patient out prior to notifying the physician. In addition, the DNS in-serviced the licensed nursing staff on the InterAct 4.0 tool that identifies immediate and non-immediate conditions requiring physician notification. 9. The DNS initiated an in-service with facility CNAs regarding identifying a change in condition, utilizing the Stop and Watch tool and turning it into the charge nurse and carbon copy to the nurse manager. 10. The Nurse Manager will ensure that proper interventions and follow up are completed to include timely physician notification. DNS and/or designee will review Stop and Watch tools Monday through Friday during the daily clinical meeting to ensure that proper interventions and follow up are completed to include timely physician notification. The Weekend Supervisor will review the Stop and Watch tools on Saturday and Sunday to ensure that proper interventions and follow up are completed to include timely physician notification. 11. Administrator, Director of Nurses and/or designee will be attending the daily stand up meeting a minimum of five times weekly to ensure that any falls that result in a resident with increased confusion are reviewed to ensure proper interventions are implemented. The facilities weekend supervisor will be reviewing any changes in condition throughout the weekends to ensure proper interventions are reviewed and implemented. 12. An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. An impromptu QAPI meeting was completed on [DATE] with the Medical Director to review the revised plan of removal and the Medical Director has reviewed and agrees with this plan. Surveyors monitored the plan of removal between [DATE] through [DATE] : During monitoring, Nurses, LVN M, RN N, LVN O, RN P, LVN Q, LVN R, and LVN S were asked the following questions: -What do you do if there is any change in resident's condition? All the nurses said that they would assess and document the resident's condition; and then notify the physician. -When do you notify the resident's physician? All of the nurses said immediately or as soon as possible. -What do you do if the physician does not respond to an emergent condition within 1 hours? The nurses all answered that they would contact the medical director. Some of them added that they would contact the DON. -What are emergent conditions? Some of the nurses' responses were: fall with a fracture or dislocation; or bleeding; pain without relief; change in vitals; chest pain; respiratory distress; and signs of stroke. -Would emergent situations require waiting for the physician's response prior to sending the resident to the hospital? The answers include: -LVN M said that she would send a resident to the hospital without a doctor's order for a fracture, head injury, elevated temperature, and cardiac distress. -RN N said she can send a resident to the hospital any time a physician does not respond. -LVN O said that she would send a resident to the hospital and notify the doctor later any time that the assessment warranted this action. -RN P, LVN Q, and LVN S said they send residents to the hospital, 911, and then tell the doctor for emergent condition. During monitoring CNA T, CNA U, CNA V, CNA W, and CNA X were asked the following questions: -What do you do if you see something different with a resident? CNAs answered that they would tell the nurse and complete the Stop and Watch form. Some of the aides indicated they would also document the change in the plan of care computer system. -What are examples of thing you may have to notify the nurse about? The answers included: changes in eating or drinking, activity, mobility, speech, or sleep patterns; agitation; weight loss; falls; weakness or lethargy; and changes in toileting patterns or output. -How soon do you notify the nurse. The aides all answered immediately or as soon as possible. Record review of the QAPI meeting minutes dated [DATE] verified the facility completed an audit of residents currently receiving anticoagulant medications. Record review of the QAPI meeting minutes dated [DATE] verified the facility completed an audit of the clinical records for residents who had falls in the last 30 days. Record review of the in-services provided since the IJ was called revealed the staff attended training in: incidents, changes in condition, physician notification resident rights, initiating interventions for residents with acute changes in condition, reporting resident changes in condition, communication forms, resident rights, and when to notify physicians immediately and non-immediate. The Administrator and the DON were notified on [DATE] at 2:23 p.m. that the IJ was lowered. The facility remains out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness.

Based on observation, interview and record review, the facility failed to implement their policy on neglect for three of eleven residents (CR #2, Resident #1 and Resident #6) reviewed for neglect, as evidenced by: -The facility failed to implement measures to avoid significant weight loss. CR#2 dietary recommendations were not completely and timely followed. CR #2 was admitted to a local hospital per RP request and was diagnosed with [REDACTED].#2 required a gastrostomy tube due to severe dysphagia (difficulty swallowing foods or liquids). -The facility failed to provide the appropriate treatment, complete assessment and implement preventive measures to avoid the development of new pressure sores for CR #2 and Resident #6. CR #2 was admitted to the hospital with [REDACTED]. Escherichia-coli (bacteria commonly found in the intestines of people) and Resident #6's was found with two new open areas on her buttocks that were not identified by the staff and her sacral pressure sore had deteriorated to an unstageable and had increased in size. -Resident #1 was left naked and unsupervised by a licensed or certified personnel in the shower room resulting in a fall with injury to his head. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/13/16. While the IJ was removed on 07/15/2016, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected 1 CR and 2 current residents identified with unplanned significant weight loss/gain, pressure sores and at risk for falls, and has the potential to affect the 1 resident at the facility identified with unplanned significant weight loss/gain, the other 5 residents with pressure ulcers and the 12 other residents dependent on staff for tranferrings, at risk for continued weight loss and decline in health related to poor nutrition, at risk for unidentified pressure sores, worsening of existing pressure sores, and at risk for injuries related to falls. Findings include: CR #2 Record review of the medical record face sheet revealed CR #2 was admitted on [DATE] and most recently re-admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. CR#2 was transferred to a local hospital on [DATE] per RP request. Record review of the significant change in status MDS assessment reference date of 04/18/2016 revealed CR #2 had a BIMS score of 13 out of a possible 15. CR #2 required extensive assistance for bed mobility, transfers, walking, locomotion, dressing, personal hygiene, bathing and toilet use and supervision with set up only for eating. CR #2 was frequently incontinent of both bowel and bladder. Her assessment noted she had sign and symptoms of holding food in mouth/cheeks or residual food in mouth after meals. CR #2 did not have weight loss and was not on a physician prescribed weight loss regimen. CR#2 weighed 175 pounds and measured 65 inches in height. Further record review revealed CR#2 did not have a pressure ulcer and she was not at risk of developing a pressure ulcer. CR #2 was not on a pressure reducing device for a chair and she was not on a turning /repositioning program. Record review revealed comprehensive plan of care revised 7/17/2014 with target date 8/1/2016, revealed in part: -Focus: CR#2 has oral/dental health problems related to difficulty swallowing with mechanically altered diet. CR#2 has nutritional problem related to coughing and/or choking of food with mechanically altered diet. -Goal: CR#2 will have no choking and coughing episodes when eating. -Focus: CR#2 has an ADL self care performance deficit related to dementia. -Interventions: Eating: CR#2 requires supervision and cues from staff with all meals. Care plan did not have information related to CR #2's sign and symptoms of holding food in mouth/cheeks or residual food in mouth after meals with interventions. Further record review of CR#2's care plan revised 4/19/2016 and with target date of 8/1/2016 revealed in part: .-Focus: CR#2 has potential for further pressure ulcer development related to reduced mobility, incontinence status and disease process. -Goal: CR#2 will have minimal to no further skin breakdown through 8/1/2016. -Interventions: Monitor nutritional status. Monitor intake and record . Continued record review of care plan revised 5/3/2016 and with target date of 8/1/2016 revealed in part: .-Focus: Impaired physical mobility as evidenced by: bed mobility, transfers, walking, locomotion related to impaired decision making and amputations of both legs above the knee. -Goal: CR#2 will remain free of complications related to immobility including skin breakdown through 8/1/2016. -Interventions: CR#2 is a 2 person transfer, reposition resident during rounds. Record review of weight record for CR #2 revealed: - 03/09/2016 = 174.0 lbs. (prior to above knee amputations) - 05/03/2016 = 142.0 lbs. (weight upon returning from hospital and status [REDACTED]. Record review of CR #2's electronic consolidated orders as of 6/1/2016 in part; -4/26/2016 - Mechanical Soft texture, Regular consistency, for Diabetes and Cardiovascular disease. -4/26/2016 - Hour sleep snack at bedtime. Record review of CR #2's meal intake for May 2016 revealed that 4 times her meal intake was not monitored during breakfast, lunch and dinner, 19 times she consumed 0 to 25% and 25 times she ate 50% or less of her meals. Record review of CR #2's nutrition progress note dated 05/09/2016, by RD K, read in part: .Readmit. CR#2 with recent hospitalization for amputation. CR#2 is now bilateral above knee [MEDICAL CONDITION]. Re-admit weight 142 lbs. (18.4% for 90 days). Some weight loss was expected related to amputation. Spoke with SLP, CR#2 has not been eating, she is being very resistant to food and must be 1:1 assist at meals. medications: [REDACTED] Recommendations: 1. - Discontinue [MEDICATION NAME] - too high [MEDICAL CONDITION] risk related to amputation. 2. - [MEDICATION NAME] 7.5 mg by mouth every night time (antidepressant that is used as an appetite stimulant). 3. - Resource 2.0 90 ml by mouth four times a day. (is a high calorie, high protein supplement drink). Goal is to increase by mouth intake. Record review of CR#2's document with title Food and Nutritional Service Department dated 5/9/2016 revealed in part: Regarding Dietitian's Recommendations for CR #2.The following is a recommended change or nutritional update for CR#2. 1.- Discontinue [MEDICATION NAME]. 2.- [MEDICATION NAME] 7.5 mg. by mouth every night at hour of sleep. 3.- Resource 2.0 90 cc by mouth four times a day. -Very very poor meal intake and too high risk for [MEDICAL CONDITION] with [MEDICATION NAME]. Further record review revealed that MD agreed with the recommendations and signed them on 5/19/2016. Record review of CR #2's telephone orders dated 5/12/2016 revealed orders; -discontinue [MEDICATION NAME] due to risk of [MEDICAL CONDITION] -[MEDICATION NAME] 7.5 mg by mouth every night at hour of sleep. -Resource 2.0 90cc by mouth every day. Record review of Braden Scale for predicting pressure ulcer risk for CR #2 dated 05/16/2016 revealed a score of 12 indicating high risk. Record review of CR #2's MD progress note dated 5/17/2016 revealed in part: Spoke with RP on phone, concerned about CR#2 decreased in appetite. Will order dietary consult Record review of CR #2's telephone orders dated 5/17/2016 revealed orders for -Dietary consult due to lack of appetite. Continued record review revealed no information that Dietary consult was done. Record review of CR #2's Restorative Care Program document dated 5/18/2016 revealed in part: .-Goals: Maximize by mouth intake and nutrition/hydration status. -Approach/recommendations for implementation of goal: offer puree and finger foods to increase by mouth intake . Record review of the comprehensive plan of care revised 5/23/2016 with target date 8/1/2016, revealed in part: -Focus: CR #2 has a potential nutritional problem related to diet restrictions. 5/23/2016 flagged for significant weight loss of 18.4% in 90 days. status [REDACTED]. -Goal: CR #2 will not develop complications including skin breakdown. -Interventions: RD to evaluate and make diet change recommendations as needed. Monitor intake and record every meal. Provide and serve supplements as ordered. Further record review of weight record for CR #2 revealed: - Week of 05/09/2016 to 05/12/2016= 140.0 lbs. - Week of 05/16/2016 to 05/20/2016= No weight available - Week of 05/23/2016 to 05/27/2016= No weight available - Week of 05/30/2016 to 06/03/2016= 122 lbs. Record review of CR #2's meal intake for June 1st to June 20th, 2016 revealed that 4 times her meal intake was not monitored during dinner, 15 times she consumed 0 to 25% and 18 times she ate 50% or less of her meals. Record review of the skin assessment for CR#2 revealed in part: -06/5/2016 at 11:05 a.m. revealed CR #2's skin was intact. -6/12/2016 at 11:05 a.m. revealed redness to buttocks area ([MEDICATION NAME] (skin protectant) applied). Continued record review revealed no further interventions when CR#2's redness to buttocks area was identified on 6/12/2016. The care plan was not updated to reflect current skin condition and interventions to prevent further skin breakdown. The MD and the RP were not notified. Record review of CR #2's progress/nurses notes / weight change note dated 6/13/2016 at 6:16 p.m. by RD K, revealed in part: .Weight change alert. Monthly weight is 122 lbs. ( -14.1% x 30 days) Weight loss is undesirable. CR #2 has not been eating well since readmission and status [REDACTED]. Skin: no pressure wounds noted. Recommend: 1.- Psych consult 2.- Increase [MEDICATION NAME] to 15 mg 3.- Increase Resource 2.0 to 90 cc by mouth 4 times a day. Goal is weight gain/improved by mouth intake. Record review of CR#2's document with title Food and Nutritional Service Department dated 6/13/2016 revealed in part: Regarding Dietitian's Recommendations for CR #2.The following is a recommended change or nutritional update for CR#2. 1.- Psych consult, 2.- Increase [MEDICATION NAME] to 15 mg, 3.- Increase Resource 2.0 90 cc by mouth four times a day. - Very poor meal intake with significant weight loss and depression. Further record review revealed that MD agreed with the recommendations and signed them on 6/17/2016. Continued record review of CR #2's physician orders [REDACTED].#2 left to the hospital on [DATE]. Record review revealed comprehensive plan of care revised 6/14/2016 with target date 8/1/2016, revealed in part: -Focus: CR #2 uses antidepressant medication ([MEDICATION NAME]) related to poor meal intake. -Goal: CR#2 will show increased episodes of by mouth intake. Further record review of CR#2's skin/wound note dated 6/18/2016 at 6:47 p.m. revealed in part: Stage 2 pressure ulcer on sacrum, buttocks, coccyx. Scant yellow drainage, redness on wound base, periwound normal (the tissue surrounding the wound itself). Odor present. No pain. RP notified. NP with new order for Bactrim DS (antibiotic) by mouth twice a day for 10 days for infection. In an interview on 7/12/2016 at 11:25 a.m. with the Wound Care Nurse A, she stated that CR#2 had only one pressure sore to her sacrum that looked like a stage 3 before she went to the hospital. Record review of CR #2's Wound Treatment and Progress Record assessment dated [DATE] revealed a sacral stage 2 pressure sore measuring 5.0 x 5.0 x 0.1 c.m. -Interventions; reposition and [MEDICATION NAME] Alginate. Further record review of the Wound Treatment and Progress Record assessment revealed; - Cleanse pressure ulcer to sacrum and buttocks with normal saline, Apply [MEDICATION NAME] (medical honey wound dressing) then Alginate (dressing made of seaweed) every day. Record review of CR#2's telephone orders in part; -6/18/2016 at 9:00 p.m. - Bactrim DS (antibiotic, Double Strength) one tablet by mouth twice a day for 10 days for sacral, buttocks and coccyx wound infection. Further record review revealed no wound care orders written for stage 2 pressure ulcer to sacrum. In an interview on 7/12/2016 at 1:19 p.m. with the DON, When asked if facility obtained wound care orders for CR#2 on 6/18/2016 when the stage 2 pressure sore was found, the DON responded I do not know because I was not notified until 6/19/2016. I saw an order for [REDACTED].#2's wound care orders. Documents were not provided at time of exit. Record review of CR #2's consolidated electronic physician orders [REDACTED]. Record review of CR#2's progress/nurses notes revealed in part: -6/19/2016 at 11:13 a.m. Duoderm ([MEDICATION NAME] dressing) applied to coccyx per wound care, will continue monitoring. -6/19/2016 at 11:30 a.m. Skin/Wound note; RP at the bedside. Stage 2 pressure ulcer on sacrum. 50 (%) slough present and 50% granulation. Scant yellow drainage present, redness on wound bed. Periwound normal. Odor present. Pain at 2 out of 10. RP requested transfer to a wound care center. DON informed. New order of Bactrim DS by mouth twice a day for 10 days ongoing. -6/20/2016 at 3:11 p.m. Skin/Wound note; Upon assessment of wound to CR#2's sacrum and buttocks, a stage 3 pressure ulcer was noticed measuring 6.1 x 7.0 x0.1 c.m. Periwound skin normal. Minimal amount of slough, no necrotic tissue, minimal serous drainage Record review of CR #2's MD progress note dated 6/20/2016 revealed in part: Spoke with RP regarding stage 2 pressure ulcer. RP would like some laboratory work and would like a diabetic nutrition shake ordered for CR #2 . Record review of CR #2's telephone orders dated 6/20/2016 revealed orders for complete blood cell count and basic matabolic panel for 6/20/2016 and diabetic nutrition shake three times a day. Further record review of CR #2's progress/nurses notes revealed in part: -6/20/2016 at 8:13 p.m. CR#2 transferred to a local hospital per RP request. Record review of CR #2's hospital history and physical dated 6/21/2016 at 4:39 p.m. revealed in part: -Date of admission: 6/20/2016 at 6:25 p.m. - History of present illness: CR#2 was brought in to the hospital for sacral wound. Further record review of the Wound Report revealed initial assessment dated [DATE]. Unstageable Sacral pressure sore. Measurements 6.0 x 6.0 x 0.2 (Length/Width/Depth). Serosanguinous exudate. 50% Necrotic tissue. Continued record review of the Wound Report revealed that on 7/5/2016 the sacral wound had debridement using a Curette (a surgical instrument used to remove material by a scraping action). Record review of CR #2's hospital nutrition assessment dated [DATE] revealed in part, Anthropometrics: Height: 65 inches, Weight: 120 lbs, IBW: 150 lbs. -Average by mouth intake: poor. Severe malnutrition. Estimated Kcal Needs: 1925 kcal/day. Increased needs related to wound . Record review of CR #2's hospital Consultation report dated 6/21/2016 revealed in part: -Reason for consultation: Infected sacral wound. .admitted last evening for management of a sacral wound. Per report, the weekday wound care nurse stated that CR #2 had some redness in the area on Monday (6/13/2016) but no open wound. RP believes that the wound developed over the course of a few days. -Assessment plan: CR#2 presents with recent development of a sacral wound. There is moderate amount of drainage and foul odor from the wound concerning for wound infection. I will start CR#2 on broad-spectrum antibiotics in the form of [MEDICATION NAME] and Zozyn (antibiotics) . Record review of CR#2's hospital Infectious Diseases progress notes dated 6/22/2016 revealed in part: .Wound Culture dated 6/22/2016. Results: Escherichia-coli. Will start [MEDICATION NAME] IV (antibiotics) . Continued record review of Wound Culture dated 6/22/2016 at 12:44 p.m. revealed in part; -Wound site: Sacral. Final Report: Gram negative rods Escherichia-coli. Record review of CR #2's Consultation report dated 6/22/2016 at 5:00 p.m. revealed in part: .CR#2 admitted with a sacral wound and malnutrition. Admission [DIAGNOSES REDACTED].>Unstageable sacral decubitus and malnutrition. She was admitted for nutritional support as well as wound care . Record review of CR #2's hospital swallow evaluation dated 6/22/2016 revealed in part: .CR#2's presents with severe oral dysphagia, possibly pharyngeal. Marked swallow delay and poor bolus control Record review of CR #2's Consultation report dated 6/22/2016 at 5:00 p.m. revealed in part: .CR#2 admitted with a sacral wound and malnutrition. Admission [DIAGNOSES REDACTED]. She was admitted for nutritional support as well as wound care .Impression: oropharyngeal dysphagia. Recommendations: Gastrostomy tube on 6/27/2016. Nasogastric tube feeding with Glucerna (nutritional formula for patients with Diabetes) until 6/27/2016. Observation on 7/12/2016 at 9:04 a.m. revealed CR #2 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #2 had a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding running at 55 ml/hr of DiabeticSource (nutritional formula for patients with Diabetes) AC and water flush at 40 ml every 1 hours. CR #2 also had a PICC line (is a long, thin, flexible catheter used to give medicines or nutrients for long period of time) to her right upper arm. In continued observation, CR #2 was noted to have a Foley catheter that had approx. 100 cc of clear amber colored urine on the collection drainage bag. CR #2 had a [DEVICE] to her sacral wound (The [DEVICE] draws out fluids from the wound and increases blood flow to the area). In an interview at that time with the hospital RN, she stated that CR#2 was non-verbal and that she was admitted with [DIAGNOSES REDACTED]. She further said that the bacteria found on the sacral pressure sore was Escherichia-coli and that CR#2 had a [DEVICE] on the sacral pressure sore and that the dressings were changed 3 times a week. She then said that CR#2 was receiving her nutrition via gastrostomy tube. In an interview on 7/12/2016 at 11:25 a.m. with Wound Care Nurse A, she stated that CR#2 had her skin intact and that on 6/13/2016 she assessed her after lunch had finished and that she noted redness to her buttocks area. She further said that she did not call the MD or notify the family because it was redness from just being sitting down on her chair too long on her buttocks and further said CR#2 would get up on her chair from breakfast time and would go to bed until after lunch. She then would get up again for dinner and do not know for how long. When asked if she followed up on the redness later or the next day to see if the skin was clear, the Wound Care Nurse A replied No, I did not see her skin again until the day she left to the hospital on [DATE]. CR#2 had only one pressure sore that looked like a stage 3 on her sacrum. I was asking the staff what happened because I was not aware that her skin was open. On 6/13/2016 I only documented on the weekly skin report that her buttocks were red and did not update the care plan or notified the family because was only redness. Further interview at that time, The Wound Care Nurse A said that for changes in condition of the skin the MD and family needed to be notified and that she was responsible to update the care plan and further said CR#2's redness was not a change of condition because the redness on her buttocks was just from being sitting too long on her butt. It was normal redness from being on her chair for a significant amount of time and she was not able to move on her chair at all. It was her routine, to get up at breakfast and go to bed after lunch. Whatever happened to her, it was on the weekend. I saw her on 6/13/2016 (Monday) because her weekly assessments were not done on the weekend, Wound Care Nurse B who worked on the weekends called in sick. Record review of the care plan revealed no information related to CR#2 spending long hours seated on her chair and interventions for CR#2 to be repositioned when up on her chair to prevent skin breakdown. Continued interview with the Wound Care Nurse A on 7/12/2016 at 11:40 a.m. when asked if the facility obtained any wound care orders on 6/18/2016 when CR#2 was found with the stage 2 pressure sore, the Wound Care Nurse A responded That's the weekend, I don't know. CR#2 had a TAR on the book . When asked when was CR#2's pressure sore assessed on 6/20/2016 (Monday) when she returned to work, the Wound Care Nurse A responded I did not get to see her until after lunch. I couldn't see her earlier. When I saw her pressure sore, it was a stage 2 and was covered with about 10% of slough but did not have necrotic tissue. I just dressed the wound and went to see another resident and CR#2 eventually left to the hospital. Further interview at that time, the Wound Care Nurse A said C.N.A's are supposed to complete 'stop and watch' papers and are supposed to be given to the wound care nurse or the charge nurses . She continued saying that she did not remember seeing any 'stop and watch' papers related to the pressure sore of CR#2. Attempted an interview on 7/12/2016 at 12:09 p.m. with the Wound Care Nurse B (weekend nurse) but she did not return call to surveyor. Wound Care Nurse A stated at that time that Wound Care Nurse B was out of the country. In an interview on 7/12/2016 at 12:30 p.m. with ADON L, she stated that she was in charge of monitoring weights on the residents and to follow up on the dietary recommendations. She further said that CR#2 had dietary recommendations because she had poor food intake. When asked regarding the dietary recommendation dated 5/9/2016 for Resource 2.0 that was written every day when the MD had agreed for four times a day, ADON L responded I am almost positive that the recommendation was for every day. I wrote the order. I need to check my notes. When asked if the RD was made aware of CR #2's orders for dietary consult on 5/17/2016, the ADON L responded that she was not sure and that she was going to find information for surveyor. ADON L further said RD gave more recommendations to CR #2 due to weight loss and poor food intake right before CR #2 went to the hospital but we were not able to carry them because she went to the hospital. In an interview on 7/12/2016 at 1:00 p.m. with the DON, she stated that CR#2's sacral pressure sore had 50% slough and necrotic tissue and that was an unstageable pressure sore on 6/20/2016 before going to hospital. DON further said I saw CR#2's pressure sore with Wound Care Nurse A. When asked if the facility had trained the nurses on staging pressure sores, pressure sore prevention and treatment, the DON responded I haven't set up a wound care training yet. We want them to go to a wound care course. I already made some phone calls and they are supposed to call me back. Further interview with the DON at that time, she stated that she was not aware of CR#2 having any redness on her buttocks prior to developing a pressure sore and that on 6/19/2016 (Sunday), CR #2's RP wanted to speak to her and that she was very upset because she had seeing the pressure sore to CR#2 for the first time on 6/19/2016 and that she was not aware of her love one having any pressure sores. DON further said I talked to Wound Care Nurse A and she said that she assessed CR#2's skin and that her buttocks were red because she was sitting on her chair and that it was just redness. Continued interview with the DON on 7/12/2016 at 1:19 p.m. she stated that any skin problems are supposed to be reported by completing a stop and watch form and that one copy goes to the wound care nurse. DON further said I looked for any stop and watch papers for CR #2 and I could not find any. When asked if facility obtained wound care orders for CR#2 on 6/18/2016 when the stage 2 pressure sore was found, the DON responded I do not know because I was not notified until 6/19/2016. I saw an order for [REDACTED].#2's had a duoderm dressing on her pressure sore on 6/19/2016, the DON responded I already talked to the responsible nurses and did a 1:1 training. Requested copy of CR#2's wound care orders and the 1:1 training with nurses who applied the wrong treatment. Documents were not provided at time of exit. Further interview with ADON L on 7/12/2016 at 2:25 p.m., she stated that she had spoken to the RD K and that she had said that the recommendation for Resource 2.0 90 cc was supposed to be done every day and not four times a day. ADON L then said CR #2 had poor appetite. She just went downhill. CR #2 would not open her mouth to eat, she was depressed. If someone is not eating, we would involve the RD so she can give recommendations. Then, I would call the MD to notify the recommendations, would carry the orders and would notify the family. CR #2 was on weekly weights, so we were monitoring her weights. She had psychologist consult and speech therapy involvement. Requested documentation of psychologist consultation. Documentation for psychologist consultation was not provided by exit time. Continued interview with the ADON L at that time, she stated that she was not aware of CR #2's MD orders for dietary consult given on 5/17/2016. In an interview on 7/12/2016 at 3:19 p.m. with RNA M, she stated that she was in charge of doing the weekly weights and that she would give the completed weights to ADON L. RNA M further said that CR #2 was eating 45 to 50% of her meals when she returned from the hospital but later she gradually would eat less. RNA M continued saying CR #2 would forget to eat and she would not eat. She would just pocket her foot, she was on RNA feeding. When asked about CR #2's weight record, RNA M stated that she did not have weights for CR #2 for May 16 to May 20 and May 23 to May 27, 2016 because she was on vacation during that time and she was not sure who had done the weights. Further interview and record review of the weight record with RNA M at that time revealed that the spaces for CR #2's weights for May 16 to May 20 and May 23 to May 27, 2016 were clear with no information to indicate why the weights were not completed. RNA M then said that CR #2's weight recorder for June 1st, 2016 was 121.6 lbs. In an interview on 7/12/2016 at 3:40 p.m. with the Speech Language Pathologist, she said that she saw CR #2 from the end of April thru May, 18, 2016. She further said that CR #2 was being seeing due to pocketing her food, had poor by mouth intake and concerns of weight loss. Speech Language Pathologist continued saying that she spoke with different nurses about CR #2's concerns of not eating well and being resistant to eat and that she had given recommendations to provide pureed food and finger foods to CR #2. Further interview at that time with the Speech Language Pathologist, she said that CR #2 did not have problems choking, that the problem was her dementia and that she had observed that CR #2 was doing very well with finger foods and had spoken to the nurses about it including ADON L. She continued saying that CR #2 was discontinued from her services on May 18, 2016 due to lack of progress and that on CR #2's situation, it was just for her to give recommendations. In an interview on 7/13/2016 at 8:49 a.m. with Wound Care Nurse A, she stated that she did not remember the Braden Scale score for CR#2 but that she should had been a high risk for pressure sore development because CR#2 couldn't maneuver herself and further said even before she had the amputations, she should had been high risk. She should had been repositioned every 2 hours even on her chair. When asked if CR #2 care plan was updated for resident to be repositioned every 2 hours when she was on her chair to prevent development of the pressure sores, the Wound Care Nurse A responded It should be automatic. C.N.A's should be repositioning the residents . When asked who was responsible of monitoring the C.N.A's to make sure residents were repositioned when up on their chairs, the Wound Care Nurse A responded everybody, the C.N.A's, the nurses and the wound care nurses. In an interview on 7/13/2016 at 9:05 a.m. C.N.A. C stated that CR#2 would get up every morning at around 7:00 a.m. for breakfast and would not go to bed until 11 a.m. and then would get up again at around 12 p.m. for lunch and would be up the rest of the afternoon for activities. When asked if CR#2 was repositioned on her chair when she was up on her chair and said no, she had a cushion. In a phone interview on 7/13/2016 at 2:48 p.m. with the RD K, she stated that CR #2 had weight loss, was not eating well and that she was depressed. RD K then said that she had done some recommendations on 5/9/2016 for Resource 2.0 90 cc 4 times a day and that on her visit of 6/13/2016 she had noticed that CR #2 was on Resource 2.0 90cc only once a day and that she made recommendations again to increase it to 4 times a day. RD K further said Resource 2.0 was a high protein drink that had vitamins and minerals and every 90 cc was equivalent to 180 calories and when given it 4 times a day CR #2 would have received 720 calories. I always meant for CR #2 to get it 4 times a day because she was not eating. Further interview at that time, RD K said CR #2 was on weekly weights and the staff was monitoring her weights. When asked if she was able to see the weekly weights for CR #2 during the last two weeks of May 2016, RD K responded The facility has the weekly weights on a separate system, weekly weights are not on the computer, so I don't get to see them. They would let me know if any variances. Continued interview at that time with the RD K, she stated that she had written a recommendation for CR #2 to be seeing by a psychologist on 6/13/2016 because she was depressed but that she did not know if the facility followed up with the recommendation. In an interview on 7/13/2016 at 3:09 p.m. with the DON, she stated that the RNA's were responsible of doing the weekly weights and the ADON L was in charge of monitoring the weekly weights on the residents and follow up on the weights and the dietary recommendations. In an interview on 7/13/2016 at 3:15 p.m. with ADON L, she stated that CR #2 was on weekly weights. Requested CR #2's weekly weights for the last 2 weeks of May 2016. Weights were not provided by the exit time. In an interview on 7/14/2016 at 9:20 a.m. with RNA N, she stated that CR #2 was not eating well, that she w

Based on observation, interview and record review, the facility failed to implement their written policy that prohibited neglect for three of eleven residents (CR #2, Resident #6 and Resident #1) reviewed for neglect, as evidenced by: -The facility failed to implement measures to avoid significant weight loss. CR#2 dietary recommendations were not completely and timely followed. CR #2 was admitted to a local hospital per RP request and was diagnosed with [REDACTED].#2 required a gastrostomy tube due to severe dysphagia (difficulty swallowing foods or liquids). -The facility failed to provide the appropriate treatment, complete assessment and implement preventive measures to avoid the development of new pressure sores for CR #2 and Resident #6. CR #2 was admitted to the hospital with [REDACTED]. Escherichia-coli (bacteria commonly found in the intestines of people) and Resident #6's was found with two new open areas on her buttocks that had not being identified by the staff and her sacral pressure sore had deteriorated to an unstageable and had increased in size. -Resident #1 was left naked and unsupervised by a licensed or certified personnel in the shower room resulting in a fall with injury to his head. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/13/16. While the IJ was removed on 07/15/2016, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected 1 CR and 2 current residents identified with unplanned significant weight loss/gain, pressure sores and at risk for falls, and has the potential to affect the 1 resident at the facility identified with unplanned significant weight loss/gain, the other 5 residents with pressure ulcers and the 12 other residents dependent on staff for tranferrings, at risk for continued weight loss and decline in health related to poor nutrition, at risk for unidentified pressure sores, worsening of existing pressure sores, and at risk for injuries related to falls. Findings include: Record review of the facility's policy and procedure with title Abuse and Neglect - Clinical Protocol revised April 2007 revealed in part: .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. -Treatment /Management: The facility management and staff will institute measures to address the needs of residents and minimize the possibility of neglect. -The Medical Director will advise facility management and staff about systems to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately CR #2 Record review of the medical record face sheet revealed CR #2 was admitted on [DATE] and most recently re-admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. CR#2 was transferred to a local hospital on [DATE] per RP request. Record review of the significant change in status MDS assessment reference date of 04/18/2016 revealed CR #2 had a BIMS score of 13 out of a possible 15. CR #2 required extensive assistance for bed mobility, transfers, walking, locomotion, dressing, personal hygiene, bathing and toilet use and supervision with set up only for eating. CR #2 was frequently incontinent of both bowel and bladder. Her assessment noted she had sign and symptoms of holding food in mouth/cheeks or residual food in mouth after meals. CR #2 did not have weight loss and was not on a physician prescribed weight loss regimen. CR#2 weighed 175 pounds and measured 65 inches in height. Further record review revealed CR#2 did not have a pressure ulcer and she was not at risk of developing a pressure ulcer. CR #2 was not on a pressure reducing device for a chair and she was not on a turning /repositioning program. Record review revealed comprehensive plan of care revised 7/17/2014 with target date 8/1/2016, revealed in part: -Focus: CR#2 has oral/dental health problems related to difficulty swallowing with mechanically altered diet. CR#2 has nutritional problem related to coughing and/or choking of food with mechanically altered diet. -Goal: CR#2 will have no choking and coughing episodes when eating. -Focus: CR#2 has an ADL self care performance deficit related to dementia. -Interventions: Eating: CR#2 requires supervision and cues from staff with all meals. Care plan did not have information related to CR #2's sign and symptoms of holding food in mouth/cheeks or residual food in mouth after meals with interventions. Further record review of CR#2's care plan revised 4/19/2016 and with target date of 8/1/2016 revealed in part: .-Focus: CR#2 has potential for further pressure ulcer development related to reduced mobility, incontinence status and disease process. -Goal: CR#2 will have minimal to no further skin breakdown through 8/1/2016. -Interventions: Monitor nutritional status. Monitor intake and record . Continued record review of care plan revised 5/3/2016 and with target date of 8/1/2016 revealed in part: .-Focus: Impaired physical mobility as evidenced by: bed mobility, transfers, walking, locomotion related to impaired decision making and amputations of both legs above the knee. -Goal: CR#2 will remain free of complications related to immobility including skin breakdown through 8/1/2016. -Interventions: CR#2 is a 2 person transfer, reposition resident during rounds. Continued record review of the care plan revealed no information related to CR#2 spending long hours seated on her chair and interventions for CR#2 to be repositioned when up on her chair to prevent skin breakdown. Record review of weight record for CR #2 revealed: - 03/09/2016 = 174.0 lbs. (prior to above knee amputations) - 05/03/2016 = 142.0 lbs. (weight upon returning from hospital and status [REDACTED]. Record review of CR #2's electronic consolidated orders as of 6/1/2016 in part; -4/26/2016 - Mechanical Soft texture, Regular consistency, for Diabetes and Cardiovascular disease. -4/26/2016 - Hour sleep snack at bedtime. Record review of CR #2's meal intake for May 2016 revealed that 4 times her meal intake was not monitored during breakfast, lunch and dinner, 19 times she consumed 0 to 25% and 25 times she ate 50% or less of her meals. Record review of CR #2's nutrition progress note dated 05/09/2016, by RD K, read in part: .Readmit. CR#2 with recent hospitalization for amputation. CR#2 is now bilateral above knee [MEDICAL CONDITION]. Re-admit weight 142 lbs. (18.4% for 90 days). Some weight loss was expected related to amputation. Spoke with SLP, CR#2 has not been eating, she is being very resistant to food and must be 1:1 assist at meals. medications: [REDACTED] Recommendations: 1. - Discontinue [MEDICATION NAME] - too high [MEDICAL CONDITION] risk related to amputation. 2. - [MEDICATION NAME] 7.5 mg by mouth every night time (antidepressant that is used as an appetite stimulant). 3. - Resource 2.0 90 ml by mouth four times a day. (is a high calorie, high protein supplement drink). Goal is to increase by mouth intake. Record review of CR#2's document with title Food and Nutritional Service Department dated 5/9/2016 revealed in part: Regarding Dietitian's Recommendations for CR #2.The following is a recommended change or nutritional update for CR#2. 1.- Discontinue [MEDICATION NAME]. 2.- [MEDICATION NAME] 7.5 mg. by mouth every night at hour of sleep. 3.- Resource 2.0 90 cc by mouth four times a day. -Very very poor meal intake and too high risk for [MEDICAL CONDITION] with [MEDICATION NAME]. Further record review revealed that MD agreed with the recommendations and signed them on 5/19/2016. Record review of CR #2's telephone orders dated 5/12/2016 revealed orders; -discontinue [MEDICATION NAME] due to risk of [MEDICAL CONDITION] -[MEDICATION NAME] 7.5 mg by mouth every night at hour of sleep. -Resource 2.0 90cc by mouth every day. Record review of Braden Scale for predicting pressure ulcer risk for CR #2 dated 05/16/2016 revealed a score of 12 indicating high risk. Record review of CR #2's MD progress note dated 5/17/2016 revealed in part: Spoke with RP on phone, concerned about CR#2 decreased in appetite. Will order dietary consult Record review of CR #2's telephone orders dated 5/17/2016 revealed orders for -Dietary consult due to lack of appetite. Continued record review revealed no information that Dietary consult was done. Record review of CR #2's Restorative Care Program document dated 5/18/2016 revealed in part: .-Goals: Maximize by mouth intake and nutrition/hydration status. -Approach/recommendations for implementation of goal: offer puree and finger foods to increase by mouth intake . Record review of the comprehensive plan of care revised 5/23/2016 with target date 8/1/2016, revealed in part: -Focus: CR #2 has a potential nutritional problem related to diet restrictions. 5/23/2016 flagged for significant weight loss of 18.4% in 90 days. status [REDACTED]. -Goal: CR #2 will not develop complications including skin breakdown. -Interventions: RD to evaluate and make diet change recommendations as needed. Monitor intake and record every meal. Provide and serve supplements as ordered. Further record review of the care plan revealed no information of the recommendations of the Restorative Care Program to offer puree and finger foods to increase her intake. Further record review of weight record for CR #2 revealed: - Week of 05/09/2016 to 05/12/2016= 140.0 lbs. - Week of 05/16/2016 to 05/20/2016= No weight available - Week of 05/23/2016 to 05/27/2016= No weight available - Week of 05/30/2016 to 06/03/2016= 122 lbs. Record review of CR #2's meal intake for June 1st to June 20th, 2016 revealed that 4 times her meal intake was not monitored during dinner, 15 times she consumed 0 to 25% and 18 times she ate 50% or less of her meals. Record review of the skin assessment for CR#2 revealed in part: -06/5/2016 at 11:05 a.m. revealed CR #2's skin was intact. -6/12/2016 at 11:05 a.m. revealed redness to buttocks area ([MEDICATION NAME] (skin protectant) applied). Continued record review revealed no further interventions when CR#2's redness to buttocks area was identified on 6/12/2016. The care plan was not updated to reflect current skin condition and interventions to prevent further skin breakdown. The MD and the RP were not notified. Record review of CR #2's progress/nurses notes / weight change note dated 6/13/2016 at 6:16 p.m. by RD K, revealed in part: .Weight change alert. Monthly weight is 122 lbs. ( -14.1% x 30 days) Weight loss is undesirable. CR #2 has not been eating well since readmission and status [REDACTED]. Skin: no pressure wounds noted. Recommend: 1.- Psych consult 2.- Increase [MEDICATION NAME] to 15 mg 3.- Increase Resource 2.0 to 90 cc by mouth 4 times a day. Goal is weight gain/improved by mouth intake. Record review of CR#2's document with title Food and Nutritional Service Department dated 6/13/2016 revealed in part: Regarding Dietitian's Recommendations for CR #2.The following is a recommended change or nutritional update for CR#2. 1.- Psych consult, 2.- Increase [MEDICATION NAME] to 15 mg, 3.- Increase Resource 2.0 90 cc by mouth four times a day. - Very poor meal intake with significant weight loss and depression. Further record review revealed that MD agreed with the recommendations and signed them on 6/17/2016. Continued record review of CR #2's physician orders [REDACTED].#2 left to the hospital on [DATE]. Record review revealed comprehensive plan of care revised 6/14/2016 with target date 8/1/2016, revealed in part: -Focus: CR #2 uses antidepressant medication ([MEDICATION NAME]) related to poor meal intake. -Goal: CR#2 will show increased episodes of by mouth intake. Further record review of CR#2's skin/wound note dated 6/18/2016 at 6:47 p.m. revealed in part: Stage 2 pressure ulcer on sacrum, buttocks, coccyx. Scant yellow drainage, redness on wound base, periwound normal (the tissue surrounding the wound itself). Odor present. No pain. RP notified. NP with new order for Bactrim DS (antibiotic) by mouth twice a day for 10 days for infection. In an interview on 7/12/2016 at 11:25 a.m. with the Wound Care Nurse A, she stated that CR#2 had only one pressure sore to her sacrum that looked like a stage 3 before she went to the hospital. Record review of CR #2's Wound Treatment and Progress Record assessment dated [DATE] revealed a sacral stage 2 pressure sore measuring 5.0 x 5.0 x 0.1 c.m. -Interventions; reposition and [MEDICATION NAME] Alginate. Further record review of the Wound Treatment and Progress Record assessment revealed; - Cleanse pressure ulcer to sacrum and buttocks with normal saline, Apply [MEDICATION NAME] (medical honey wound dressing) then Alginate (dressing made of seaweed) every day. Record review of CR#2's telephone orders in part; -6/18/2016 at 9:00 p.m. - Bactrim DS (antibiotic, Double Strength) one tablet by mouth twice a day for 10 days for sacral, buttocks and coccyx wound infection. Further record review revealed no wound care orders written for stage 2 pressure ulcer to sacrum. In an interview on 7/12/2016 at 1:19 p.m. with the DON, When asked if facility obtained wound care orders for CR#2 on 6/18/2016 when the stage 2 pressure sore was found, the DON responded I do not know because I was not notified until 6/19/2016. I saw an order for [REDACTED].#2's wound care orders. Documents were not provided at time of exit. Record review of CR #2's consolidated electronic physician orders [REDACTED]. Record review of CR#2's progress/nurses notes revealed in part: -6/19/2016 at 11:13 a.m. Duoderm ([MEDICATION NAME] dressing) applied to coccyx per wound care, will continue monitoring. -6/19/2016 at 11:30 a.m. Skin/Wound note; RP at the bedside. Stage 2 pressure ulcer on sacrum. 50 (%) slough present and 50% granulation. Scant yellow drainage present, redness on wound bed. Periwound normal. Odor present. Pain at 2 out of 10. RP requested transfer to a wound care center. DON informed. New order of Bactrim DS by mouth twice a day for 10 days ongoing. -6/20/2016 at 3:11 p.m. Skin/Wound note; Upon assessment of wound to CR#2's sacrum and buttocks, a stage 3 pressure ulcer was noticed measuring 6.1 x 7.0 x0.1 c.m. Periwound skin normal. Minimal amount of slough, no necrotic tissue, minimal serous drainage Record review of CR #2's MD progress note dated 6/20/2016 revealed in part: Spoke with RP regarding stage 2 pressure ulcer. RP would like some laboratory work and would like a diabetic nutrition shake ordered for CR #2 . Record review of CR #2's telephone orders dated 6/20/2016 revealed orders for complete blood cell count and basic matabolic panel for 6/20/2016 and diabetic nutrition shake three times a day. Further record review of CR #2's progress/nurses notes revealed in part: -6/20/2016 at 8:13 p.m. CR#2 transferred to a local hospital per RP request. Record review of CR #2's hospital history and physical dated 6/21/2016 at 4:39 p.m. revealed in part: -Date of admission: 6/20/2016 at 6:25 p.m. - History of present illness: CR#2 was brought in to the hospital for sacral wound. Further record review of the Wound Report revealed initial assessment dated [DATE]. Unstageable Sacral pressure sore. Measurements 6.0 x 6.0 x 0.2 (Length/Width/Depth). Serosanguinous exudate. 50% Necrotic tissue. Continued record review of the Wound Report revealed that on 7/5/2016 the sacral wound had debridement using a Curette (a surgical instrument used to remove material by a scraping action). Record review of CR #2's hospital nutrition assessment dated [DATE] revealed in part, Anthropometrics: Height: 65 inches, Weight: 120 lbs, IBW: 150 lbs. -Average by mouth intake: poor. Severe malnutrition. Estimated Kcal Needs: 1925 kcal/day. Increased needs related to wound . Record review of CR #2's hospital Consultation report dated 6/21/2016 revealed in part: -Reason for consultation: Infected sacral wound. .admitted last evening for management of a sacral wound. Per report, the weekday wound care nurse stated that CR #2 had some redness in the area on Monday (6/13/2016) but no open wound. RP believes that the wound developed over the course of a few days. -Assessment plan: CR#2 presents with recent development of a sacral wound. There is moderate amount of drainage and foul odor from the wound concerning for wound infection. I will start CR#2 on broad-spectrum antibiotics in the form of [MEDICATION NAME] and Zozyn (antibiotics) . Record review of CR#2's hospital Infectious Diseases progress notes dated 6/22/2016 revealed in part: .Wound Culture dated 6/22/2016. Results: Escherichia-coli. Will start [MEDICATION NAME] IV (antibiotics) . Continued record review of Wound Culture dated 6/22/2016 at 12:44 p.m. revealed in part; -Wound site: Sacral. Final Report: Gram negative rods Escherichia-coli. Record review of CR #2's Consultation report dated 6/22/2016 at 5:00 p.m. revealed in part: .CR#2 admitted with a sacral wound and malnutrition. Admission [DIAGNOSES REDACTED].>Unstageable sacral decubitus and malnutrition. She was admitted for nutritional support as well as wound care . Record review of CR #2's hospital swallow evaluation dated 6/22/2016 revealed in part: .CR#2's presents with severe oral dysphagia, possibly pharyngeal. Marked swallow delay and poor bolus control Record review of CR #2's Consultation report dated 6/22/2016 at 5:00 p.m. revealed in part: .CR#2 admitted with a sacral wound and malnutrition. Admission [DIAGNOSES REDACTED]. She was admitted for nutritional support as well as wound care .Impression: oropharyngeal dysphagia. Recommendations: Gastrostomy tube on 6/27/2016. Nasogastric tube feeding with Glucerna (nutritional formula for patients with Diabetes) until 6/27/2016. Observation on 7/12/2016 at 9:04 a.m. revealed CR #2 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #2 had a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding running at 55 ml/hr of DiabeticSource (nutritional formula for patients with Diabetes) AC and water flush at 40 ml every 1 hours. CR #2 also had a PICC line (is a long, thin, flexible catheter used to give medicines or nutrients for long period of time) to her right upper arm. In continued observation, CR #2 was noted to have a Foley catheter that had approx. 100 cc of clear amber colored urine on the collection drainage bag. CR #2 had a [DEVICE] to her sacral wound (The wund vacuum draws out fluids from the wound and increases blood flow to the area). In an interview at that time with the hospital RN, she stated that CR#2 was non-verbal and that she was admitted with [DIAGNOSES REDACTED]. She further said that the bacteria found on the sacral pressure sore was Escherichia-coli and that CR#2 had a [DEVICE] on the sacral pressure sore and that the dressings were changed 3 times a week. She then said that CR#2 was receiving her nutrition via gastrostomy tube. In an interview on 7/12/2016 at 11:25 a.m. with Wound Care Nurse A, she stated that CR#2 had her skin intact and that on 6/13/2016 she assessed her after lunch had finished and that she noted redness to her buttocks area. She further said that she did not call the MD or notify the family because it was redness from just being sitting down on her chair too long on her buttocks and further said CR#2 would get up on her chair from breakfast time and would go to bed until after lunch. She then would get up again for dinner and do not know for how long. When asked if she followed up on the redness later or the next day to see if the skin was clear, the Wound Care Nurse A replied No, I did not see her skin again until the day she left to the hospital on [DATE]. CR#2 had only one pressure sore that looked like a stage 3 on her sacrum. I was asking the staff what happened because I was not aware that her skin was open. On 6/13/2016 I only documented on the weekly skin report that her buttocks were red and did not update the care plan or notified the family because was only redness. Further interview at that time, The Wound Care Nurse A said that for changes in condition of the skin the MD and family needed to be notified and that she was responsible to update the care plan and further said CR#2's redness was not a change of condition because the redness on her buttocks was just from being sitting too long on her butt. It was normal redness from being on her chair for a significant amount of time and she was not able to move on her chair at all. It was her routine, to get up at breakfast and go to bed after lunch. Whatever happened to her, it was on the weekend. I saw her on 6/13/2016 (Monday) because her weekly assessments were not done on the weekend, Wound Care Nurse B who worked on the weekends called in sick. Continued record review of the care plan revealed no information related to CR#2 spending long hours seated on her chair and interventions for CR#2 to be repositioned when up on her chair to prevent skin breakdown. Continued interview with the Wound Care Nurse A on 7/12/2016 at 11:40 a.m. when asked if the facility obtained any wound care orders on 6/18/2016 when CR#2 was found with the stage 2 pressure sore, the Wound Care Nurse A responded That's the weekend, I don't know. CR#2 had a TAR on the book . When asked when was CR#2's pressure sore assessed on 6/20/2016 (Monday) when she returned to work, the Wound Care Nurse A responded I did not get to see her until after lunch. I couldn't see her earlier. When I saw her pressure sore, it was a stage 2 and was covered with about 10% of slough but did not have necrotic tissue. I just dressed the wound and went to see another resident and CR#2 eventually left to the hospital. Further interview at that time, the Wound Care Nurse A said C.N.A's are supposed to complete 'stop and watch' papers and are supposed to be given to the wound care nurse or the charge nurses . She continued saying that she did not remember seeing any 'stop and watch' papers related to the pressure sore of CR#2. Attempted an interview on 7/12/2016 at 12:09 p.m. with the Wound Care Nurse B (weekend nurse) but she did not return call to surveyor. Wound Care Nurse A stated at that time that Wound Care Nurse B was out of the country. In an interview on 7/12/2016 at 12:30 p.m. with ADON L, she stated that she was in charge of monitoring weights on the residents and to follow up on the dietary recommendations. She further said that CR#2 had dietary recommendations because she had poor food intake. When asked regarding the dietary recommendation dated 5/9/2016 for Resource 2.0 that was written every day when the MD had agreed for four times a day, ADON L responded I am almost positive that the recommendation was for every day. I wrote the order. I need to check my notes. When asked if the RD was made aware of CR #2's orders for dietary consult on 5/17/2016, the ADON L responded that she was not sure and that she was going to find information for surveyor. ADON L further said RD gave more recommendations to CR #2 due to weight loss and poor food intake right before CR #2 went to the hospital but we were not able to carry them because she went to the hospital. In an interview on 7/12/2016 at 1:00 p.m. with the DON, she stated that CR#2's sacral pressure sore had 50% slough and necrotic tissue and that was an unstageable pressure sore on 6/20/2016 before going to hospital. DON further said I saw CR#2's pressure sore with Wound Care Nurse A. When asked if the facility had trained the nurses on staging pressure sores, pressure sore prevention and treatment, the DON responded I haven't set up a wound care training yet. We want them to go to a wound care course. I already made some phone calls and they are supposed to call me back. Further interview with the DON at that time, she stated that she was not aware of CR#2 having any redness on her buttocks prior to developing a pressure sore and that on 6/19/2016 (Sunday), CR #2's RP wanted to speak to her and that she was very upset because she had seeing the pressure sore to CR#2 for the first time on 6/19/2016 and that she was not aware of her love one having any pressure sores. DON further said I talked to Wound Care Nurse A and she said that she assessed CR#2's skin and that her buttocks were red because she was sitting on her chair and that it was just redness. Continued interview with the DON on 7/12/2016 at 1:19 p.m. she stated that any skin problems are supposed to be reported by completing a stop and watch form and that one copy goes to the wound care nurse. DON further said I looked for any stop and watch papers for CR #2 and I could not find any. When asked if facility obtained wound care orders for CR#2 on 6/18/2016 when the stage 2 pressure sore was found, the DON responded I do not know because I was not notified until 6/19/2016. I saw an order for [REDACTED].#2's had a duoderm dressing on her pressure sore on 6/19/2016, the DON responded I already talked to the responsible nurses and did a 1:1 training. Requested copy of CR#2's wound care orders and the 1:1 training with nurses who applied the wrong treatment. Documents were not provided at time of exit. Further interview with ADON L on 7/12/2016 at 2:25 p.m., she stated that she had spoken to the RD K and that she had said that the recommendation for Resource 2.0 90 cc was supposed to be done every day and not four times a day. ADON L then said CR #2 had poor appetite. She just went downhill. CR #2 would not open her mouth to eat, she was depressed. If someone is not eating, we would involve the RD so she can give recommendations. Then, I would call the MD to notify the recommendations, would carry the orders and would notify the family. CR #2 was on weekly weights, so we were monitoring her weights. She had psychologist consult and speech therapy involvement. Requested documentation of psychologist consultation. Documentation for psychologist consultation was not provided by exit time. Continued interview with the ADON L at that time, she stated that she was not aware of CR #2's MD orders for dietary consult given on 5/17/2016. In an interview on 7/12/2016 at 3:19 p.m. with RNA M, she stated that she was in charge of doing the weekly weights and that she would give the completed weights to ADON L. RNA M further said that CR #2 was eating 45 to 50% of her meals when she returned from the hospital but later she gradually would eat less. RNA M continued saying CR #2 would forget to eat and she would not eat. She would just pocket her foot, she was on RNA feeding. When asked about CR #2's weight record, RNA M stated that she did not have weights for CR #2 for May 16 to May 20 and May 23 to May 27, 2016 because she was on vacation during that time and she was not sure who had done the weights. Further interview and record review of the weight record with RNA M at that time revealed that the spaces for CR #2's weights for May 16 to May 20 and May 23 to May 27, 2016 were clear with no information to indicate why the weights were not completed. RNA M then said that CR #2's weight recorder for June 1st, 2016 was 121.6 lbs. In an interview on 7/12/2016 at 3:40 p.m. with the Speech Language Pathologist, she said that she saw CR #2 from the end of April thru May, 18, 2016. She further said that CR #2 was being seeing due to pocketing her food, had poor by mouth intake and concerns of weight loss. Speech Language Pathologist continued saying that she spoke with different nurses about CR #2's concerns of not eating well and being resistant to eat and that she had given recommendations to provide pureed food and finger foods to CR #2. Further interview at that time with the Speech Language Pathologist, she said that CR #2 did not have problems choking, that the problem was her dementia and that she had observed that CR #2 was doing very well with finger foods and had spoken to the nurses about it including ADON L. She continued saying that CR #2 was discontinued from her services on May 18, 2016 due to lack of progress and that on CR #2's situation, it was just for her to give recommendations. In an interview on 7/13/2016 at 8:49 a.m. with Wound Care Nurse A, she stated that she did not remember the Braden Scale score for CR#2 but that she should had been a high risk for pressure sore development because CR#2 couldn't maneuver herself and further said even before she had the amputations, she should had been high risk. She should had been repositioned every 2 hours even on her chair. When asked if CR #2 care plan was updated for resident to be repositioned every 2 hours when she was on her chair to prevent development of the pressure sores, the Wound Care Nurse A responded It should be automatic. C.N.A's should be repositioning the residents . When asked who was responsible of monitoring the C.N.A's to make sure residents were repositioned when up on their chairs, the Wound Care Nurse A responded everybody, the C.N.A's, the nurses and the wound care nurses. In an interview on 7/13/2016 at 9:05 a.m. C.N.A. C stated that CR#2 would get up every morning at around 7:00 a.m. for breakfast and would not go to bed until 11 a.m. and then would get up again at around 12 p.m. for lunch and would be up the rest of the afternoon for activities. When asked if CR#2 was repositioned on her chair when she was up on her chair and said no, she had a cushion. In a phone interview on 7/13/2016 at 2:48 p.m. with the RD K, she stated that CR #2 had weight loss, was not eating well and that she was depressed. RD K then said that she had done some recommendations on 5/9/2016 for Resource 2.0 90 cc 4 times a day and that on her visit of 6/13/2016 she had noticed that CR #2 was on Resource 2.0 90cc only once a day and that she made recommendations again to increase it to 4 times a day. RD K further said Resource 2.0 was a high protein drink that had vitamins and minerals and every 90 cc was equivalent to 180 calories and when given it 4 times a day CR #2 would have received 720 calories. I always meant for CR #2 to get it 4 times a day because she was not eating. Further interview at that time, RD K said CR #2 was on weekly weights and the staff was monitoring her weights. When asked if she was

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure ulcers and to promote the healing of pressure ulcers for 2 of 11 residents (CR #2 and Resident #6) who were reviewed for pressure ulcer care and management as evidenced by: -The facility failed to provide the appropriate treatment, complete assessment and implement preventive measures to avoid the development of new pressure sores for CR #2 and Resident #6. CR #2 was admitted to the hospital with [REDACTED]. Escherichia-coli (bacteria commonly found in the intestines of people) and Resident #6's was found with two new open areas on her buttocks that had not being identified by the staff and her sacral pressure sore had deteriorated to an unstageable and had increased in size. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/13/16. While the IJ was removed on 07/15/2016, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice affected 1 CR and 1 resident residing in the facility and had the potential to place 5 residents identified with pressure ulcers at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and pain. Findings included: CR # 2 Record review of the medical record face sheet revealed CR #2 was admitted on [DATE] and most recently re-admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. CR#2 was transferred to a local hospital on [DATE] per RP request. Record review of the significant change in status MDS assessment reference date of 04/18/2016 revealed CR #2 had a BIMS score of 13 out of a possible 15. CR #2 required extensive assistance for bed mobility, transfers, walking, locomotion, dressing, personal hygiene, bathing and toilet use and supervision with set up only for eating. CR #2 was frequently incontinent of both bowel and bladder. Further record review revealed CR#2 did not have a pressure ulcer and she was not at risk of developing a pressure ulcer. CR #2 was not on a pressure reducing device for a chair and she was not on a turning /repositioning program. Record review of CR#2's care plan revised 4/19/2016 and with target date of 8/1/2016 revealed in part: .-Focus: CR#2 has potential for further pressure ulcer development related to reduced mobility, incontinence status and disease process. -Goal: CR#2 will have minimal to no further skin breakdown through 8/1/2016. -Interventions: Monitor nutritional status. Monitor intake and record . Further record review of care plan revised 5/3/2016 and with target date of 8/1/2016 revealed in part: .-Focus: Impaired physical mobility as evidenced by: bed mobility, transfers, walking, locomotion related to impaired decision making and amputations of both legs above the knee. -Goal: CR#2 will remain free of complications related to immobility including skin breakdown through 8/1/2016. -Interventions: CR#2 is a 2 person transfer, reposition resident during rounds. Record review of Braden Scale for predicting pressure ulcer risk for CR #2 dated 05/16/2016 revealed a score of 12 indicating high risk. Record review of the skin assessment for CR#2 revealed in part: -06/5/2016 at 11:05 a.m. revealed CR #2's skin was intact. -6/12/2016 at 11:05 a.m. revealed redness to buttocks area ([MEDICATION NAME] (skin protectant) applied). Continued record review revealed no further interventions when CR#2's redness to buttocks area was identified on 6/12/2016. The care plan was not updated to reflect current skin condition and interventions to prevent further skin breakdown. The MD and the RP were not notified. Further record review of CR#2's skin/wound note dated 6/18/2016 at 6:47 p.m. revealed in part: Stage 2 pressure ulcer on sacrum, buttocks, coccyx. Scant yellow drainage, redness on wound base, periwound normal (the tissue surrounding the wound itself). Odor present. No pain. RP notified. NP with new order for Bactrim DS (antibiotic) by mouth twice a day for 10 days for infection. In an interview on 7/12/2016 at 11:25 a.m. with the Wound Care Nurse A, she stated that CR#2 had only one pressure sore to her sacrum that looked like a stage 3 before going to the hospital. Record review of CR #2's Wound Treatment and Progress Record assessment dated [DATE] revealed a sacral stage 2 pressure sore measuring 5.0 x 5.0 x 0.1 c.m. -Interventions; reposition and [MEDICATION NAME] Alginate. Further record review of the Wound Treatment and Progress Record assessment revealed; - Cleanse pressure ulcer to sacrum and buttocks with normal saline, Apply [MEDICATION NAME] (medical honey wound dressing) then Alginate (dressing made of seaweed) every day. Record review of CR#2's telephone orders in part; -6/18/2016 at 9:00 p.m. - Bactrim DS (antibiotic, Double Strength) one tablet by mouth twice a day for 10 days for sacral, buttocks and coccyx wound infection. Further record review revealed no wound care orders written for stage 2 pressure ulcer to sacrum. In an interview on 7/12/2016 at 1:19 p.m. with the DON, When asked if facility obtained wound care orders for CR#2 on 6/18/2016 when the stage 2 pressure sore was found, the DON responded I do not know because I was not notified until 6/19/2016. I saw an order for [REDACTED].#2's wound care orders. Documents were not provided at time of exit. Record review of CR #2's consolidated electronic physician orders for June 2016 revealed no wound care orders for pressure sore to sacrum. Record review of CR#2's progress/nurses notes revealed in part: -6/19/2016 at 11:13 a.m. Duoderm ([MEDICATION NAME] dressing) applied to coccyx per wound care, will continue monitoring. -6/19/2016 at 11:30 a.m. Skin/Wound note; RP at the bedside. Stage 2 pressure ulcer on sacrum. 50 (%) slough present and 50% granulation. Scant yellow drainage present, redness on wound bed. Periwound normal. Odor present. Pain at 2 out of 10. RP requested transfer to a wound care center. DON informed. New order of Bactrim DS by mouth twice a day for 10 days ongoing. -6/20/2016 at 3:11 p.m. Skin/Wound note; Upon assessment of wound to CR#2's sacrum and buttocks, a stage 3 pressure ulcer was noticed measuring 6.1 x 7.0 x0.1 c.m. Periwound skin normal. Minimal amount of slough, no necrotic tissue, minimal serous drainage Record review of CR #2's MD progress note dated 6/20/2016 revealed in part: Spoke with RP regarding stage 2 pressure ulcer. RP would like some laboratory work and would like a diabetic nutrition shake ordered for CR #2 . Record review of CR #2's telephone orders dated 6/20/2016 revealed orders for complete blood cell count and basic matabolic panel for 6/20/2016 and diabetic nutrition shake three times a day. Further record review of CR #2's progress/nurses notes revealed in part: -6/20/2016 at 8:13 p.m. CR#2 transferred to a local hospital per RP request. Record review of CR #2's hospital history and physical dated 6/21/2016 at 4:39 p.m. revealed in part: -Date of admission: 6/20/2016 at 6:25 p.m. - History of present illness: CR#2 was brought in to the hospital for sacral wound. Further record review of the Wound Report revealed initial assessment dated [DATE]. Unstageable Sacral pressure sore. Measurements 6.0 x 6.0 x 0.2 (Length/Width/Depth). Serosanguinous exudate. 50% Necrotic tissue. Continued record review of the Wound Report revealed that on 7/5/2016 the sacral wound had debridement using a Curette (a surgical instrument used to remove material by a scraping action). Record review of CR #2's hospital Consultation report dated 6/21/2016 revealed in part: -Reason for consultation: Infected sacral wound. .admitted last evening for management of a sacral wound. Per report, the weekday wound care nurse stated that CR #2 had some redness in the area on Monday (6/13/2016) but no open wound. RP believes that the wound developed over the course of a few days. -Assessment plan: CR#2 presents with recent development of a sacral wound. There is moderate amount of drainage and foul odor from the wound concerning for wound infection. I will start CR#2 on broad-spectrum antibiotics in the form of [MEDICATION NAME] and Zozyn (antibiotics) . Record review of CR#2's hospital Infectious Diseases progress notes dated 6/22/2016 revealed in part: .Wound Culture dated 6/22/2016. Results: Escherichia-coli. Will start [MEDICATION NAME] IV (antibiotics) . Continued record review of Wound Culture dated 6/22/2016 at 12:44 p.m. revealed in part; -Wound site: Sacral. Final Report: Gram negative rods Escherichia-coli. Record review of CR #2's Consultation report dated 6/22/2016 at 5:00 p.m. revealed in part: .CR#2 admitted with a sacral wound and malnutrition. Admission [DIAGNOSES REDACTED].>Unstageable sacral decubitus and Malnutrition. She was admitted for nutritional support as well as wound care . Observation on 7/12/2016 at 9:04 a.m. revealed CR #2 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #2 had a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding running at 55 ml/hr of DiabeticSource (nutritional formula for patients with Diabetes) AC and water flush at 40 ml every 1 hours. CR #2 also had a PICC line (is a long, thin, flexible catheter used to give medicines or nutrients for long period of time) to her right upper arm. In continued observation, CR #2 was noted to have a Foley catheter that had approx. 100 cc of clear amber colored urine on the collection drainage bag. CR #2 had a [DEVICE] to her sacral wound (The [DEVICE] draws out fluids from the wound and increases blood flow to the area). In an interview at that time with the hospital RN, she stated that CR#2 was non-verbal and that she was admitted with [DIAGNOSES REDACTED]. She further said that the bacteria found on the sacral pressure sore was Escherichia-coli. RN continued saying that CR#2 had a [DEVICE] on the sacral pressure sore and that the dressings were changed 3 times a week. In an interview on 7/12/2016 at 11:25 a.m. with Wound Care Nurse A, she stated that CR#2 had her skin intact and that on 6/13/2016 she assessed her after lunch had finished and that she noted redness to her buttocks area. She further said that she did not call the MD or notify the family because it was redness from just being sitting down on her chair too long on her buttocks and further said CR#2 would get up on her chair from breakfast time and would go to bed until after lunch. She then would get up again for dinner and do not know for how long. When asked if she followed up on the redness later or the next day to see if the skin was clear, the Wound Care Nurse A replied No, I did not see her skin again until the day she left to the hospital on [DATE]. CR#2 pressure sore looked like a stage 3. I was asking the staff what happened because I was not aware that her skin was open. On 6/13/2016 I only documented on the weekly skin report that her buttocks were red and did not update the care plan or notified the family because was only redness. Further interview at that time, The Wound Care Nurse A said that for changes in condition of the skin the MD and family needed to be notified and that she was responsible to update the care plan and further said CR#2's redness was not a change of condition because the redness on her buttocks was just from being sitting too long on her butt. It was normal redness from being on her chair for a significant amount of time and she was not able to move on her chair at all. It was her routine, to get up at breakfast and go to bed after lunch. Whatever happened to her, it was on the weekend. I saw her on 6/13/2016 (Monday) because her weekly assessments were not done on the weekend, Wound Care Nurse B who worked on the weekends called in sick. Record review of the care plan revealed no information related to CR#2 spending long hours seated on her chair and interventions for CR#2 to be repositioned when up on her chair to prevent skin breakdown. Continued interview with the Wound Care Nurse A on 7/12/2016 at 11:40 a.m. when asked if the facility obtained any wound care orders on 6/18/2016 when CR#2 was found with the stage 2 pressure sore, the Wound Care Nurse A responded That's the weekend, I don't know. CR#2 had a TAR on the book . When asked when was CR#2's pressure sore assessed on 6/20/2016 (Monday) when she returned to work, the Wound Care Nurse A responded I did not get to see her until after lunch. I couldn't see her earlier. When I saw her pressure sore, it was a stage 2 and was covered with about 10% of slough but did not have necrotic tissue. I just dressed the wound and went to see another resident and CR#2 eventually left to the hospital. Further interview at that time, the Wound Care Nurse A said C.N.A's are supposed to complete 'stop and watch' papers and are supposed to be given to the wound care nurse or the charge nurses . She continued saying that she did not remember seeing any 'stop and watch' papers related to the pressure sore of CR#2. Attempted an interview on 7/12/2016 at 12:09 p.m. with the Wound Care Nurse B (weekend nurse) but she did not return call to surveyor. Wound Care Nurse A stated at that time that Wound Care Nurse B was out of the country. In an interview on 7/12/2016 at 1:00 p.m. with the DON, she stated that CR#2's sacral pressure sore had 50% slough and necrotic tissue and that was an unstageable pressure sore on 6/20/2016 before going to hospital. DON further said I saw CR#2's pressure sore with Wound Care Nurse A. When asked if the facility had trained the nurses on staging pressure sores, pressure sore prevention and treatment, the DON responded I haven't set up a wound care training yet. We want them to go to a wound care course. I already made some phone calls and they are supposed to call me back. Further interview with the DON at that time, she stated that she was not aware of CR#2 having any redness on her buttocks prior to developing a pressure sore and that on 6/19/2016 (Sunday), CR #2's RP wanted to speak to her and that she was very upset because she had seeing the pressure sore to CR#2 for the first time on 6/19/2016 and that she was not aware of her love one having any pressure sores. DON further said I talked to Wound Care Nurse A and she said that she assessed CR#2's skin and that her buttocks were red because she was sitting on her chair and that it was just redness. Continued interview with the DON on 7/12/2016 at 1:19 p.m. she stated that any skin problems are supposed to be reported by completing a stop and watch form and that one copy goes to the wound care nurse. DON further said I looked for any stop and watch papers for CR #2 and I could not find any. When asked if facility obtained wound care orders for CR#2 on 6/18/2016 when the stage 2 pressure sore was found, the DON responded I do not know because I was not notified until 6/19/2016. I saw an order for [REDACTED].#2's had a duoderm dressing on her pressure sore on 6/19/2016, the DON responded I already talked to the responsible nurses and did a 1:1 training. Requested copy of CR#2's wound care orders and the 1:1 training with nurses who applied the wrong treatment. Documents were not provided at time of exit. In an interview on 7/13/2016 at 9:05 a.m. C.N.A. C stated that CR#2 would get up every morning at around 7:00 a.m. for breakfast and would not go to bed until 11 a.m. and then would get up again at around 12 p.m. for lunch and would be up the rest of the afternoon for activities. When asked if CR#2 was repositioned on her chair when she was up on her chair and said no, she had a cushion. In an interview on 7/13/2016 at 8:49 a.m. with Wound Care Nurse A, she stated that she did not remember the Braden Scale score for CR#2 but that she should had been a high risk for pressure sore development because CR#2 couldn't maneuver herself and further said even before she had the amputations, she should had been high risk. She should had been repositioned every 2 hours even on her chair. When asked if CR #2 care plan was updated for resident to be repositioned every 2 hours when she was on her chair to prevent development of the pressure sores, the Wound Care Nurse A responded It should be automatic. C.N.A's should be repositioning the residents . When asked who was responsible of monitoring the C.N.A's to make sure residents were repositioned when up on their chairs, the Wound Care Nurse A responded everybody, the C.N.A's, the nurses and the wound care nurses. Resident #6 Record review of the medical record face sheet revealed Resident #6 was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #6's care plan revised 5/07/2015 and with target date of 8/19/2016 revealed in part: .-Focus: Resident #6 has potential for pressure ulcer development related to reduced mobility and incontinence. -Goal: Resident #6 will have intact skin, free of redness, blisters or discoloration. -Interventions: Educate the resident/family/caregivers as to causes of skin breakdown . Record review of the skin assessment for Resident #6 revealed in part: -5/25/2016 Admit/re-admit assessment indicated that Resident #6's skin was intact. Further record review revealed no skin assessments for week of June 4rd 2016 and week of June 11th 2016. Record review of pressure ulcer risk - Braden Scale for predicting pressure ulcer risk for Resident #6 dated 05/26/2016 revealed a score of 16 indicating low risk. Record review of the quarterly MDS assessment reference date of 06/15/2016 revealed Resident #6 had a BIMS score of 6 out of a possible 15 indicating she had moderate cognitive impairment. Resident #6 required extensive assistance for all her activities of daily living. Resident #6 was always incontinent of both bowel and bladder. Further record review revealed Resident #6 did not have a pressure ulcer and she was at risk of developing a pressure ulcer. Resident #6 was not on a pressure reducing device for a chair or bed and she was not on a turning /repositioning program. Further record review of the skin assessments for Resident #6 in part; -06/18/2016 at 8:34 p.m. revealed Resident #6 had redness to her sacrum area. Duoderm intact. -6/19/2016 at 6:00 p.m. revealed pressure ulcer stage 2 on sacrum and coccyx. 8 x 4 c.m. Treatment in place. Further record review revealed no wound assessments for the two weeks prior to having skin breakdown . (June 4rd 2016 and week of June 11th 2016). Further record review of Resident #6's skin/wound note in part: -6/19/2016 at 5:52 p.m. Redness on sacrum. Barrier cream on . -6/26/2016 at 8:59 p.m. Pressure ulcer on sacrum with serous drain. Periwound red. New orders for [MEDICATION NAME] (antibiotic) 100 mg by mouth twice a day for 10 days (wound infection) . Record review of Resident #6's electronic consolidated orders orders in part; -6/19/2016 - turn and reposition every 2 hours. -6/26/2016 - Air Mattress for sacral pressure ulcer. -7/2/2016 - Apply [MEDICATION NAME] (skin protectant ointment)cream to redness on sacral area until healed. -7/2/2016 - Cleanse pressure ulcer to sacrum with normal saline. Pat dry. Apply [MEDICATION NAME] and cover with dry dressing every day. Record review of Resident #6's Wound Treatment and Progress Record assessment in part: -7/05/2016 Pressure ulcer, stage 2. Picture had a hand written circle on the buttocks area. Measures 3.3 x 3.7 c.m. (Length and Width) Minimal drainage. Further record review revealed no assessment of the description of the pressure sore. Wound assessment was signed by Wound Care Nurse A. -7/11/2016 Measurements 3.3 x 3.7 c.m. Further record review revealed no assessments of the wound or stage of the wound. Wound assessment was signed by Wound Care Nurse A. Observation on 7/13/2016 at 9:10 a.m. revealed Resident #6 was up on her chair. Further observation revealed that she did not have an air mattress on her bed. In an interview on 7/13/2016 at 10:10 a.m. with C.N.A. C, she stated that Resident #6 has been up since 6 a.m. and that she was going to do incontinent care. Further observation at that time during incontinent care to Resident #6 revealed that she had a large dressing to her upper buttocks area and the lower part of the dressing was coming off. Continued observation revealed open areas to bilateral buttocks underneath the part of the dressing that was coming off. Resident #6's entire buttocks area was reddened. In an interview on 7/13/2016 at 10:20 a.m. with Wound Care Nurse A, she stated that Resident #6 had only one pressure sore stage 2 to her sacrum and further said Resident #6's buttocks area is OK, no open areas. Further interview on 7/13/2016 at 10:43 a.m. the Wound Care Nurse A stated that she was not responsible of doing the weekly skin assessments on the hallway of Resident #6 and that she did not know why Resident #6 did not have weekly skin assessments after she was readmitted to the facility on [DATE]. She further said that the weekend Wound Care Nurse B was responsible. When asked who was responsible to complete the weekly assessments of the pressure sores, the Wound Care Nurse A responded that she was responsible. When asked for the assessments of the pressure sore for Resident #6 after she acquired a stage 2 on her sacrum, the Wound Care Nurse responded that the weekend Wound Care Nurse was also responsible of completing assessments of the pressure sores. Continued interview with the Wound Care Nurse A she stated that weekly wound assessments of the pressure sores were supposed to be completed with the description of the wound, the stage, any drainage or any additional information related to the wound. When asked who assessed the pressure of Resident #6 on 7/11/2016, the Wound Care Nurse stated she was the one that assessed the wound. When asked regarding no other information on the wound assessments but the measurements of the wound of Resident #6's weekly pressure sore assessment, the Wound Care Nurse A responded I guess I can write down more information when I do my assessments, but Resident #6 had a stage 2 pressure sore on her sacrum. Observation on 7/13/2016 at 11:50 a.m. during wound care to Resident #6 revealed that Resident #6 had a large reddened area from her sacrum to her buttocks. She had an open area to each of her buttocks and the sacrum pressure sore was covered with 50% of yellow slough. Further observation and interview at that time, the Wound Care Nurse A stated that the sacral pressure sore looked bigger and had slough on it and that Resident #6 did not have pressure sores to her buttocks before and then said she was going to measure the open areas. Further observation and interview at that time, the Wound Care Nurse stated as she measured each open area the right buttocks open area is 1.5 x 1.8 c.m. with wound base red and irregular, the left buttocks open area is 1.4 x 1.0 c.m., the reddened excoriated area is 12.8 x 10.8 c.m. and the sacral pressure sore is 4.0 x 4.0 c.m. with 50% of yellow slough in the middle, surrounding site is red and macerated. I will call the MD about the new slough and the new open areas. Resident #6 already has orders for the reddened areas. Continued observation at that time revealed no drainage noted from the open areas. Continued interview with the Wound Care Nurse A on 7/13/2016 at 12:30 p.m. she stated that she did not know Resident #6 had orders for an air mattress and further said Wound Care Nurse B from the weekend wrote the orders and did not notify anyone. In an interview on 7/13/2016 at 1:25 p.m. with the DON, she stated that the facility follows standard protocols to prevent and treat pressure sores like turning and repositioning, keeping residents dry, skin barriers to help prevent skin breakdown and off- loading. DON further said that Braden Scale for predicting pressure ulcer risk are done by the wound care nurses and further said We just started looking into training on assessing the skin and turning and repositioning. We identified problems and we are writing a POC for skin system. Further interview at that time, the DON said Resident #6's open areas should had been identified during skin assessments, we just put skin shower sheets on 6/22/2016. We just started that system. DON, ADON and Wound Care nurse will be responsible to monitor the new program. Wound Care Nurse A told me already about the 2 open areas found on Resident #6's buttocks. Continued interview and observation with the DON on 7/13/2016 at 1:38 p.m. when asked if she could describe Resident #6's pressure wound assessment done on 7/5/2016 and 7/11/2016 by reading the Wound Treatment and Progress Record, the DON responded as she hold the report in front of her No, I can not describe the wounds by looking at this. (assessment). DON further said Wound Care Nurse A probably wrote a complete assessment of the wounds on her nursing notes, let me see. After reviewing information on the computer, the DON stated there are no notes on 7/5/2016 or 7/11/2016. Further interview with the DON on 7/13/2016 at 1:45 p.m., she stated that she did not know that Resident #6 had orders for an air mattress and said Resident #6 should not have air mattress, but now that the pressure sore had progressed worse, she can now have an air mattress. Record review of a facility's policy and procedure revised March 2005 with title Pressure Ulcer Risk Assessment revealed in part: .The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. -Preparations: Review the resident ' s care plan to assess for any special needs of the resident. -General guidelines: 1.- Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. 4.- If pressure ulcers are not treated when discovered, they quickly get larger, became very painful for the resident, and often times become infected. 5.- Pressure sores are often made worse by continual pressure, decline in nutrition and hydration status. 10.- Routinely assess and document the condition of the resident ' s skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. -Assessment: 2.- Skin Assessment will be assessed for the presence of developing pressure ulcers frequently as indicated. 4.- Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have intervention implemented promptly to attempt to prevent pressure ulcers. Record review of the facility policy and procedure revised December 2007 with title Pressure ulcer treatment revealed in part: .The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. -General guidelines: 1.- The pressure ulcer treatment program should focus on the following strategies: a.- Assessing the resident and the pressure ulcer, b.- Managing tissue loads . Definitions and descriptions: Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) . The facility Administrator and DON were notified on 07/13/16 at 4:15 PM that an IJ situation had been identified due to above failures. The Plan of Removal was submitted by the Administrator on 07/13/16. The final Plan of Removal was accepted on 07/15/16 at 10:00 AM. Plan of Removal 1.- Head to toe skin assessments on 100% of residents initiated on 7/13/2016. Any residents with an issue identified during these assessments had interventions ordered and implemented on 7/13/2016. The resident's physician and responsible parties were notified of the changes in condition. Resident care plans were updated to reflect interventions. Any residents with skin issues were referred to the Registered Dietitian if warranted. 2.- During the 100% audit of head to toe skin assessments the following residents were identified with new or worsening pressure ulcers and the following interventions were implemented: A.- Resident identified by surveyor, Resident #6, received a head to toe skin assessment on 7/13/2016 with a new area identified. Wound Care physician was in facility and saw Resident #6.New orders received and carried out. B.- A stage 1 pressure was identified on the right great toe of Resident # 8 on 7/13/2016. MD and family were notified and the MD orders received for new treatment. C.- A stage 1 pressure ulcer was identified on the right buttocks of Resident #9 on 7/13/2016. The MD and family were notified. New orders were received and initiated on 7/13/2016. 3.- Skin concerns were placed on the 24 hours report to communicate changes in condition to Licensed Nurses in relation to wounds on 7/13/2016. The 24 hour report is reviewed daily by the DON/designee and the nursing management team Monday - Friday during the morning clinical meeting. 4.- An in-service was initiated for C.N.A's on 7/13/2016 by DON, on utilizing the Stop and Watch tool to report skin concerns. The Stop and Watch tool is a C.N.A. communication sheet used to identify changes in resident condition. The Stop and Watch tool will be turned into the Licensed Nurse at the time the change is noted and a copy of the tool will be given to the DON for follow up. The in-service was completed by 7/14/2016 and any staff who did not attend the initial training will be required to receive the in-service prior to returning to work. 5.- The Licensed Nurses in-serviced, by the DON, on completing a head to toes skin assessment of residents upon admission/readmission on 7/13/2016 and these assessments were initiated with all new admissions/readmission on 7/13/2016. The charge nurses also received education in regards to the staging of wounds. The treatment nurse/designee will perform a head to toe skin assessment after admission, preferable within 24 hours. The treatment nurse/designee will set the schedule for the weekly skin assessments beginning 7/13/2016. The treatment nurse received a one to one in-service on 7/13/2016 by the DON on completing weekly skin assessments and documenting them in the clinical record. The in-services were completed by 7/14/2016 and any sta

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as body weight for one of eleven residents (CR#2) reviewed for weight loss and dietary recommendations. -The facility failed to implement measures to avoid significant weight loss. CR#2 dietary recommendations were not completely followed after CR #2 experienced a decrease in food intake on 5/9/2016. - The facility failed to monitor weekly weights for CR #2, who was having poor food intake. CR #2 had a significant weight loss of 14.1 % in 30 days during the time her weights were not being monitored. - CR #2 was admitted to a local hospital on [DATE] per RP request and was diagnosed with [REDACTED].#2 required a gastrostomy tube due to severe dysphagia (difficulty swallowing foods or liquids). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/13/16. While the IJ was removed on 07/15/2016, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected 1 CR and could place 1 current resident identified with unplanned significant weight loss/gain at risk for continued weight loss and decline in health related to poor nutrition. Findings include: Record review of the medical record face sheet revealed CR #2 was admitted on [DATE] and most recently re-admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. CR#2 was transferred to a local hospital on [DATE] per RP request. Record review of the significant change in status MDS assessment reference date of 04/18/2016 revealed CR #2 had a BIMS score of 13 out of a possible 15. CR #2 required extensive assistance for bed mobility, transfers, walking, locomotion, dressing, personal hygiene, bathing and toilet use and supervision with set up only for eating. CR #2 was frequently incontinent of both bowel and bladder. Her assessment noted she had sign and symptoms of holding food in mouth/cheeks or residual food in mouth after meals. CR #2 did not have weight loss and was not on a physician prescribed weight loss regimen. CR#2 weighed 175 pounds and measured 65 inches in height. Record review of CR #2's electronic consolidated orders as of 6/1/2016 in part; -4/26/2016 - Mechanical Soft texture, Regular consistency, for Diabetes and Cardiovascular disease. -4/26/2016 - Hour sleep snack at bedtime. Record review revealed comprehensive plan of care revised 7/17/2014 with target date 8/1/2016, revealed in part: -Focus: CR#2 has oral/dental health problems related to difficulty swallowing with mechanically altered diet. CR#2 has nutritional problem related to coughing and/or choking of food with mechanically altered diet. -Goal: CR#2 will have no choking and coughing episodes when eating. -Focus: CR#2 has an ADL self care performance deficit related to dementia. -Interventions: Eating: CR#2 requires supervision and cues from staff with all meals. Care plan did not have information related to CR #2's sign and symptoms of holding food in mouth/cheeks or residual food in mouth after meals with interventions. Record review of weight record for CR #2 revealed: - 03/09/2016 = 174.0 lbs. (prior to above knee amputations) - 05/03/2016 = 142.0 lbs. (weight upon returning from hospital and status [REDACTED]. Record review of CR #2's nutrition progress note dated 05/09/2016, by RD K, read in part: .Readmit. CR#2 with recent hospitalization for amputation. CR#2 is now bilateral above knee [MEDICAL CONDITION]. Re-admit weight 142 lbs. (18.4% for 90 days). Some weight loss was expected related to amputation. Spoke with SLP, CR#2 has not been eating, she is being very resistant to food and must be 1:1 assist at meals. medications: [REDACTED] Recommendations: 1. - Discontinue [MEDICATION NAME] - too high [MEDICAL CONDITION] risk related to amputation. 2. - [MEDICATION NAME] 7.5 mg by mouth every night time (antidepressant that is used as an appetite stimulant). 3. - Resource 2.0 90 ml by mouth four times a day. (is a high calorie, high protein supplement drink). Goal is to increase by mouth intake. Record review of CR#2's document with title Food and Nutritional Service Department dated 5/9/2016 revealed in part: Regarding Dietitian's Recommendations for CR #2.The following is a recommended change or nutritional update for CR#2. 1.- Discontinue [MEDICATION NAME]. 2.- [MEDICATION NAME] 7.5 mg. by mouth every night at hour of sleep. 3.- Resource 2.0 90 cc by mouth four times a day. -Very very poor meal intake and too high risk for [MEDICAL CONDITION] with [MEDICATION NAME]. Further record review revealed that MD agreed with the recommendations and signed them on 5/19/2016. Record review of CR #2's telephone orders dated 5/12/2016 revealed orders; -discontinue [MEDICATION NAME] due to risk of [MEDICAL CONDITION] -[MEDICATION NAME] 7.5 mg by mouth every night at hour of sleep. -Resource 2.0 90cc by mouth every day. Record review of CR #2's meal intake for May 2016 revealed that 4 times her meal intake was not monitored during breakfast, lunch and dinner, 19 times she consumed 0 to 25% and 25 times she ate 50% or less of her meals. Record review of CR #2's MD progress note dated 5/17/2016 revealed in part: Spoke with RP on phone, concerned about CR#2 decreased in appetite. Will order dietary consult Record review of CR #2's telephone orders dated 5/17/2016 revealed orders for -Dietary consult due to lack of appetite. Continued record review revealed no information that Dietary consult was done. Record review of CR #2's Restorative Care Program document dated 5/18/2016 revealed in part: .-Goals: Maximize by mouth intake and nutrition/hydration status. -Approach/recommendations for implementation of goal: offer puree and finger foods to increase by mouth intake . Record review of the comprehensive plan of care revised 5/23/2016 with target date 8/1/2016, revealed in part: -Focus: CR #2 has a potential nutritional problem related to diet restrictions. 5/23/2016 flagged for significant weight loss of 18.4% in 90 days. status [REDACTED]. -Goal: CR #2 will not develop complications including skin breakdown. -Interventions: RD to evaluate and make diet change recommendations as needed. Monitor intake and record every meal. Provide and serve supplements as ordered. Further record review of the care plan revealed no information of the recommendations of the Restorative Care Program to offer puree and finger foods to increase her intake. Further record review of weight record for CR #2 revealed: - Week of 05/09/2016 to 05/12/2016= 140.0 lbs. - Week of 05/16/2016 to 05/20/2016= No weight available - Week of 05/23/2016 to 05/27/2016= No weight available - Week of 05/30/2016 to 06/03/2016= 122 lbs. Record review of CR #2's meal intake for June 1st to June 20th, 2016 revealed that 4 times her meal intake was not monitored during dinner, 15 times she consumed 0 to 25% and 18 times she ate 50% or less of her meals. Record review of CR #2's progress/nurses notes / weight change note dated 6/13/2016 at 6:16 p.m. by RD K, revealed in part: .Weight change alert. Monthly weight is 122 lbs. ( -14.1% x 30 days) Weight loss is undesirable. CR #2 has not been eating well since readmission and status [REDACTED]. Skin: no pressure wounds noted. Recommend: 1.- Psych consult 2.- Increase [MEDICATION NAME] to 15 mg 3.- Increase Resource 2.0 to 90 cc by mouth 4 times a day. Goal is weight gain/improved by mouth intake. Record review of CR#2's document with title Food and Nutritional Service Department dated 6/13/2016 revealed in part: Regarding Dietitian's Recommendations for CR #2.The following is a recommended change or nutritional update for CR#2. 1.- Psych consult, 2.- Increase [MEDICATION NAME] to 15 mg, 3.- Increase Resource 2.0 90 cc by mouth four times a day. - Very poor meal intake with significant weight loss and depression. Further record review revealed that MD agreed with the recommendations and signed them on 6/17/2016. Continued record review of CR #2's physician orders [REDACTED].#2 left to the hospital on [DATE]. Record review revealed comprehensive plan of care revised 6/14/2016 with target date 8/1/2016, revealed in part: -Focus: CR #2 uses antidepressant medication ([MEDICATION NAME]) related to poor meal intake. -Goal: CR#2 will show increased episodes of by mouth intake. Record review of CR #2's MD progress note dated 6/20/2016 revealed in part: Spoke with RP regarding stage 2 pressure ulcer. RP would like some laboratory work and would like a diabetic nutrition shake ordered for CR #2 . Record review of CR #2's telephone orders revealed in part: -6/20/2016 -Complete blood cell count and basic metabolic panel today (laboratory) and diabetic nutrition shake three times a day. Record review of CR#2's progress/nurses notes revealed in part: -6/20/2016 at 8:13 p.m. CR#2 transferred to a local hospital per RP request . Record review of CR #2's hospital nutrition assessment dated [DATE] revealed in part, Anthropometrics: Height: 65 inches, Weight: 120 lbs, IBW: 150 lbs. -Average by mouth intake: poor. Severe Malnutrition. Estimated Kcal Needs: 1925 kcal/day. Increased needs related to wound . Record review of CR #2's hospital swallow evaluation dated 6/22/2016 revealed in part: .CR#2's presents with severe oral dysphagia, possibly pharyngeal. Marked swallow delay and poor bolus control Record review of CR #2's Consultation report dated 6/22/2016 at 5:00 p.m. revealed in part: .CR#2 admitted with a sacral wound and malnutrition. Admission [DIAGNOSES REDACTED]. She was admitted for nutritional support as well as wound care .Impression: oropharyngeal dysphagia. Recommendations: Gastrostomy tube on 6/27/2016. Nasogastric tube feeding with Glucerna (nutritional formula for patients with Diabetes) until 6/27/2016. Observation on 7/12/2016 at 9:04 a.m. revealed CR #2 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #2 had a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding running at 55 ml/hr of DiabeticSource (nutritional formula for patients with Diabetes) AC and water flush at 40 ml every 1 hours. CR #2 also had a PICC line (is a long, thin, flexible catheter used to give medicines or nutrients for long period of time) to her right upper arm. In continued observation, CR #2 was noted to have a Foley catheter that had approx. 100 cc of clear amber colored urine on the collection drainage bag. CR #2 had a [DEVICE] to her sacral wound (Negative-pressure is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds. The continued vacuum draws out fluids from the wound and increases blood flow to the area). In an interview at that time with the hospital RN, she stated that CR#2 was non-verbal and that she was admitted with [DIAGNOSES REDACTED]. She further said that CR#2 was receiving her nutrition via gastrostomy tube. In an interview on 7/12/2016 at 12:30 p.m. with ADON L, she stated that she was in charge of monitoring weights on the residents and to follow up on the dietary recommendations. She further said that CR#2 had dietary recommendations because she had poor food intake. When asked regarding the dietary recommendation dated 5/9/2016 for Resource 2.0 that was written every day when the MD had agreed for four times a day, ADON L responded I am almost positive that the recommendation was for every day. I wrote the order. I need to check my notes. When asked if the RD was made aware of CR #2's orders for dietary consult on 5/17/2016, the ADON L responded that she was not sure and that she was going to find information for surveyor. ADON L further said RD gave more recommendations to CR #2 due to weight loss and poor food intake right before CR #2 went to the hospital but we were not able to carry them because she went to the hospital. Further interview with ADON L on 7/12/2016 at 2:25 p.m., she stated that she had spoken to the RD K and that she had said that the recommendation for Resource 2.0 90 cc was supposed to be done every day and not four times a day. ADON L then said CR #2 had poor appetite. She just went downhill. CR #2 would not open her mouth to eat, she was depressed. If someone is not eating, we would involve the RD so she can give recommendations. Then, I would call the MD to notify the recommendations, would carry the orders and would notify the family. CR #2 was on weekly weights, so we were monitoring her weights. She had psychologist consult and speech therapy involvement. Requested documentation of psychologist consultation. Documentation for psychologist consultation was not provided by exit time. Continued interview with the ADON L at that time, she stated that she was not aware of CR #2's MD orders for dietary consult given on 5/17/2016. In an interview on 7/12/2016 at 3:19 p.m. with RNA M, she stated that she was in charge of doing the weekly weights and that she would give the completed weights to ADON L. RNA M further said that CR #2 was eating 45 to 50% of her meals when she returned from the hospital but later she gradually would eat less. RNA M continued saying CR #2 would forget to eat and she would not eat. She would just pocket her foot, she was on RNA feeding. When asked about CR #2's weight record, RNA M stated that she did not have weights for CR #2 for May 16 to May 20 and May 23 to May 27, 2016 because she was on vacation during that time and she was not sure who had done the weights. Further interview and record review of the weight record with RNA M at that time revealed that the spaces for CR #2's weights for May 16 to May 20 and May 23 to May 27, 2016 were clear with no information to indicate why the weights were not completed. RNA M then said that CR #2's weight recorder for June 1st, 2016 was 121.6 lbs. In an interview on 7/12/2016 at 3:40 p.m. with the Speech Language Pathologist, she said that she saw CR #2 from the end of April thru May, 18, 2016. She further said that CR #2 was being seeing due to pocketing her food, had poor by mouth intake and concerns of weight loss. Speech Language Pathologist continued saying that she spoke with different nurses about CR #2's concerns of not eating well and being resistant to eat and that she had given recommendations to provide pureed food and finger foods to CR #2. Further interview at that time with the Speech Language Pathologist, she said that CR #2 did not have problems choking, that the problem was her dementia and that she had observed that CR #2 was doing very well with finger foods and had spoken to the nurses about it including ADON L. She continued saying that CR #2 was discontinued from her services on May 18, 2016 due to lack of progress and that on CR #2's situation, it was just for her to give recommendations. In a phone interview on 7/13/2016 at 2:48 p.m. with the RD K, she stated that CR #2 had weight loss, was not eating well and that she was depressed. RD K then said that she had done some recommendations on 5/9/2016 for Resource 2.0 90 cc 4 times a day and that on her visit of 6/13/2016 she had noticed that CR #2 was on Resource 2.0 90cc only once a day and that she made recommendations again to increase it to 4 times a day. RD K further said Resource 2.0 was a high protein drink that had vitamins and minerals and every 90 cc was equivalent to 180 calories and when given it 4 times a day CR #2 would have received 720 calories. I always meant for CR #2 to get it 4 times a day because she was not eating. Further interview at that time, RD K said CR #2 was on weekly weights and the staff was monitoring her weights. When asked if she was able to see the weekly weights for CR #2 during the last two weeks of May 2016, RD K responded The facility has the weekly weights on a separate system, weekly weights are not on the computer, so I don't get to see them. They would let me know if any variances. Continued interview at that time with the RD K, she stated that she had written a recommendation for CR #2 to be seeing by a psychologist on 6/13/2016 because she was depressed but that she did not know if the facility followed up with the recommendation. In an interview on 7/13/2016 at 3:09 p.m. with the DON, she stated that the RNA's were responsible of doing the weekly weights and the ADON L was in charge of monitoring the weekly weights on the residents and follow up on the weights and the dietary recommendations. In an interview on 7/13/2016 at 3:15 p.m. with ADON L, she stated that CR #2 was on weekly weights. Requested CR #2's weekly weights for the last 2 weeks of May 2016. Weights were not provided by the exit time. In an interview on 7/14/2016 at 9:20 a.m. with RNA N, she stated that CR #2 was not eating well, that she would pocket her food, then would hold her mouth close and would not eat. When asked if CR #2 was provided a different type of food when she would refused to eat, the RNA N said we try to give her shakes but she would blow into the straw. The nurses knew about it. In an interview on 7/14/2016 at 2:15 p.m. with the Dietary Manager and the Regional Training Manager, the Dietary Manager said that he would randomly check on the residents and will communicate with the aides, therapist if any problems with residents on their swallowing. He further said that he would also talk to the residents and for those residents who were not eating, he would find out the reason why they were not eating and would try to help them. He then said that he communicated with the Dietitian on a regular basis about the residents. Further interview at that time, the Dietary Manager stated that he did not remember CR #2 having any problems with her eating. He then said that he remembered talking to her but did not remember when. He continued saying that he would stop once in a while with CR #2 to say hello and that he did not notice any problems with her eating. Dietary Manager continued saying that he remembered that one day he came and that staff was talking on the morning meeting about CR #2 being sent to the hospital but that he did not know the reason. Continued interview at that time with the Dietary Manager, he said that he was not aware of any changes on CR #2's appetite and that he did not remember getting any dietary communication forms from nursing asking to add a magic cup (nutritional supplement) or a health shake. He further said that he was never aware of CR #2 having any weight changes or weight loss and then said I don't remember the Speech Language Pathologist sharing any recommendation with the kitchen about CR #2. In an interview on 7/14/2016 at 2:26 p.m. with the Dietary Manager, he further said that communication forms is a form of communication between nursing staff and kitchen staff regarding diet changes or any special needs for the residents. He then said that communication forms were used to notify the kitchen if a resident was not eating well or if the facility had concerns with weight loss on certain resident. He continued saying that he attended the morning meetings with the department heads every morning and that he did remember a discussion regarding CR #2 about an issue that he did not remember but that it was never discussed regarding CR#2's weight or appetite or anything related to dietary. In a followed up interview on 7/14/2016 at 2:36 p.m. with the Dietary Manager on his office, he stated that he was not able to find any communication forms related to CR #2. In an interview on 7/14/2016 at 3:30 p.m. with ADON L, she stated that she attended the morning meetings with the department heads in the facility and that they had discussions about CR #2's depression, that she wasn't herself and that CR #2's RP was concern that CR #2 was groggy and not wanting to eat and not taking her food. ADON L further said that she did not remember getting any recommendations for CR #2 from the Speech Language Pathologist. In an interview on 7/15/2016 at 1:00 p.m. with the DON, requested policy and procedure for changes in appetite in residents, weight protocol, documentation of meal intake and Nutrition protocol. Protocols were not provided by exit time. Record review of the facility's Weight Assessment and Intervention revised December 2008 revealed in part: - The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Care Planning 1.- Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist and the resident or resident's legal surrogate. 2.- Individualized care plans shall address, to the extent possible: a.- The identified causes of weight loss, b.- Goals and benchmarks for improvement and c.- Time frames and parameters for monitoring and reassessment. The facility Administrator and DON were notified on 07/13/16 at 4:15 PM that an IJ situation had been identified due to above failures. The Plan of Removal was submitted by the Administrator on 07/13/16. The final Plan of Removal was accepted on 07/15/16 at 10:00 AM. Plan of Removal: 11.- Nurse management team completed a 100% audit of dietary recommendations on 7/13/2016. Any unaddressed recommendations identified were completed and followed through by the assistant director of nurses at that time. No new residents with significant weight/ loss gain were identified and no transcription errors of dietary recommendations were identified. 12.- The Director of Nurses conducted an in-service on 7/13/2016 with the Assistant Director of Nurses and nurse management team on timely completion of dietary recommendations, preferably within seventy two hours of receipt from dietician. This in-service included the following of physician orders [REDACTED]. 13.- A one to one in-service with the assistant director of nurses was performed by the Director of Nurses on 7/13/2016 regarding completing weekly weights in accordance with the facility policy and procedure. This included the notification of family/physician with unplanned significant weight loss/gain of 5% in 30 days, 7.5% in 90 days and 10% in 180 days, completion of dietary recommendations/communication with dietician and proper care planning in regards to unplanned significant weight loss/gain with interventions. 14.- The Director of Nurses and / or designee will review the monthly/weekly weights with the assistant director of nurse or designee to ensure the above tasks are completed and the education provided is effective. If discrepancies are identified further training and/or progressive disciplinary action will occur. 15.- The facility Medical Director was notified of the Immediate Jeopardy on 7/13/2016 related to pressure ulcers and an impromptu QAPI (Quality Assurance and Performance Improvement) meeting was held. The Medical Director has approved this plan. In an interview on 7/15/2016 at 2:30 p.m. with LVN D, she stated she had been training on pressure sores, assessments, prevention and monitor C.N.A's that they complete the stop and watch form. She further said that she was also trained on dietary consultation and the Nutrition book. In an interview on 7/15/2016 at 3:00 p.m. with LVN E, she stated that she had been trained on wound assessments, skin assessments, staging a wound, interventions to prevent and treat pressure sores including dietary consults, laboratory, Nutrition book and documentation. In an interview on 07/15/2016 at 3:05 p.m. with MA F, she stated that she had been trained on completing the stop and watch form for changes in skin conditions and changes in appetite in residents. In an interview on 07/15/2016 at 3:10 p.m. with LVN G, she stated that facility had provided training on dietary consults, laboratory, Nutrition book and documentation. In an interview on 7/15/2016 at 3:16 p.m. with RN H, she stated that she had been trained on wound assessments, skin assessments, staging a wound, interventions to prevent and treat pressure sores including dietary consults, laboratory, Nutrition book and documentation. She further said that the training was given by the wound specialist. In an interview on 7/15/2016 at 3:20 p.m. with C.N.A. I, she stated that she received training on reporting skin conditions and changes in resident ' s appetite on the stop and watch form. In an interview on 7/15/2016 at 3:24 p.m. with C.N.A. J, she stated that she received training on the stop and watch forms and how to reporting skin conditions and changes in the resident's appetite. Record review of facility In-service Training Attendance record dated 07/13/2016 revealed that nursing staff were educated regarding meal intake monitoring on the residents included offering alternates if a resident eat less than 50% of meals and if noted a change in their eating habits to complete a stop and watch tool form. Attached were the signatures of staff attending the training Record review of facility In-service Training Attendance record dated 7/13/2016 revealed training on weekly weights, notification to MD and RP, dietary recommendations and proper care planning in regards to unplanned significant weight loss. Attached were the signatures of staff attending the training. Further record review of facility In-service Training Attendance record dated 07/14/2016 revealed that nursing staff were educated regarding dietary recommendations that included information on addressing recommendations in a 72 hour frame and to ensure orders obtained are followed through and transcribed accurately. Attached were the signatures of staff attending the training. On 07/15/16 at 3:30 PM, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. According to CMS 672, the facility had 1 resident with unplanned significant weight loss/gain.

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for two of eleven residents (CR #2 and Resident #6) reviewed for administration. The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect for CR #2 and Resident #6. The Administrator failed to ensure the DON carried out her responsibilities in the areas of staff training/monitoring, to implement measures to avoid significant weight loss and to provide the appropriate treatment, complete assessment and implement preventive measures to avoid the development of new pressure sores. The DON failed to provide staff training/monitoring, to implement measures to avoid significant weight loss and to provide the appropriate treatment, complete assessment and implement preventive measures to avoid the development of new pressure sores. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/13/16. While the IJ was removed on 07/15/2016, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected 1 CR and could place 1 current resident identified with unplanned significant weight loss/gain at risk for continued weight loss and decline in health related to poor nutrition and had the potential to place 5 residents identified with pressure ulcers at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and pain. Findings include: In an interview on 7/14/2016 at 1:40 p.m. with the DON, when asked how did she think this incident of IJ came about, she stated We need to make sure we have our checks in place to avoid RD recommendation discrepancies. Residents receiving nutritional recommendations every day instead of four times a day could make a difference in their nutrition. We are also working on our weekly weights system. DON further said that the follow up from the initial assessment when CR #2 had the redness and the open area to her sacrum was far in between. Further interview with the DON at that time, she stated that she had just called the wound care MD and had requested access to the wound care assessments because the facility did not have access to the wound MD notes and that she had received a call this morning from the wound care MD and that he was in the process to set up a webinar for the DON to demostrate how to use the system and how to read the wound care MD notes. DON then said that she was not sure when the webinar was going to take place. Continued interview with the DON, she said that previously she was working on a wound care training for the nurses including the Wound Care Nurses and that she had made some calls but had not received a response yet from some of the companies she had called. In an interview on 7/14/2016 at 2:50 p.m. with the Administrator, when asked how did she think this incident of IJ came about, she replied I was not aware of the situation. I thought things were implemented in a timely manner. Administrator further said RD is over the kitchen, RD communicates with the Dietary Supervisor and nursing to make sure the changes are implemented in the kitchen. ADON L is in charge of weight loss interventions and RD recommendations, but not sure how the process worked. Further interview with the Administrator at that time, she stated that facility had daily morning clinical meetings where the staff reviewed records, changes in contidion and pertinent information about the residents. When asked if she remembered any discussion regarding CR #2 and Resident #6. Administrator responded I don't remember specifics. On a Monday I remember there was a discussion about a wound of CR #2 and on one Quality Assurance meeting we had a discussion about weight loss and different interventions but ADON L was there and she would had being in charge of any interventions. CR #2 Record review of the medical record face sheet revealed CR #2 was admitted on [DATE] and most recently re-admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. CR#2 was transferred to a local hospital on [DATE] per RP request. Record review of the significant change in status MDS assessment reference date of 04/18/2016 revealed CR #2 had a BIMS score of 13 out of a possible 15. CR #2 required extensive assistance for bed mobility, transfers, walking, locomotion, dressing, personal hygiene, bathing and toilet use and supervision with set up only for eating. CR #2 was frequently incontinent of both bowel and bladder. Her assessment noted she had sign and symptoms of holding food in mouth/cheeks or residual food in mouth after meals. CR #2 did not have weight loss and was not on a physician prescribed weight loss regimen. CR#2 weighed 175 pounds and measured 65 inches in height. Further record review revealed CR#2 did not have a pressure ulcer and she was not at risk of developing a pressure ulcer. CR #2 was not on a pressure reducing device for a chair and she was not on a turning /repositioning program. Record review revealed comprehensive plan of care revised 7/17/2014 with target date 8/1/2016, revealed in part: -Focus: CR#2 has oral/dental health problems related to difficulty swallowing with mechanically altered diet. CR#2 has nutritional problem related to coughing and/or choking of food with mechanically altered diet. -Goal: CR#2 will have no choking and coughing episodes when eating. -Focus: CR#2 has an ADL self care performance deficit related to dementia. -Interventions: Eating: CR#2 requires supervision and cues from staff with all meals. Care plan did not have information related to CR #2's sign and symptoms of holding food in mouth/cheeks or residual food in mouth after meals with interventions. Further record review of CR#2's care plan revised 4/19/2016 and with target date of 8/1/2016 revealed in part: .-Focus: CR#2 has potential for further pressure ulcer development related to reduced mobility, incontinence status and disease process. -Goal: CR#2 will have minimal to no further skin breakdown through 8/1/2016. -Interventions: Monitor nutritional status. Monitor intake and record . Continued record review of care plan revised 5/3/2016 and with target date of 8/1/2016 revealed in part: .-Focus: Impaired physical mobility as evidenced by: bed mobility, transfers, walking, locomotion related to impaired decision making and amputations of both legs above the knee. -Goal: CR#2 will remain free of complications related to immobility including skin breakdown through 8/1/2016. -Interventions: CR#2 is a 2 person transfer, reposition resident during rounds. Record review of weight record for CR #2 revealed: - 03/09/2016 = 174.0 lbs. (prior to above knee amputations) - 05/03/2016 = 142.0 lbs. (weight upon returning from hospital and status [REDACTED]. Record review of CR #2's electronic consolidated orders as of 6/1/2016 in part; -4/26/2016 - Mechanical Soft texture, Regular consistency, for Diabetes and Cardiovascular disease. -4/26/2016 - Hour sleep snack at bedtime. Record review of CR #2's meal intake for May 2016 revealed that 4 times her meal intake was not monitored during breakfast, lunch and dinner, 19 times she consumed 0 to 25% and 25 times she ate 50% or less of her meals. Record review of CR #2's nutrition progress note dated 05/09/2016, by RD K, read in part: .Readmit. CR#2 with recent hospitalization for amputation. CR#2 is now bilateral above knee [MEDICAL CONDITION]. Re-admit weight 142 lbs. (18.4% for 90 days). Some weight loss was expected related to amputation. Spoke with SLP, CR#2 has not been eating, she is being very resistant to food and must be 1:1 assist at meals. medications: [REDACTED] Recommendations: 1. - Discontinue [MEDICATION NAME] - too high [MEDICAL CONDITION] risk related to amputation. 2. - [MEDICATION NAME] 7.5 mg by mouth every night time (antidepressant that is used as an appetite stimulant). 3. - Resource 2.0 90 ml by mouth four times a day. (is a high calorie, high protein supplement drink). Goal is to increase by mouth intake. Record review of CR#2's document with title Food and Nutritional Service Department dated 5/9/2016 revealed in part: Regarding Dietitian's Recommendations for CR #2.The following is a recommended change or nutritional update for CR#2. 1.- Discontinue [MEDICATION NAME]. 2.- [MEDICATION NAME] 7.5 mg. by mouth every night at hour of sleep. 3.- Resource 2.0 90 cc by mouth four times a day. -Very very poor meal intake and too high risk for [MEDICAL CONDITION] with [MEDICATION NAME]. Further record review revealed that MD agreed with the recommendations and signed them on 5/19/2016. Record review of CR #2's telephone orders dated 5/12/2016 revealed orders; -discontinue [MEDICATION NAME] due to risk of [MEDICAL CONDITION] -[MEDICATION NAME] 7.5 mg by mouth every night at hour of sleep. -Resource 2.0 90cc by mouth every day. Record review of Braden Scale for predicting pressure ulcer risk for CR #2 dated 05/16/2016 revealed a score of 12 indicating high risk. Record review of CR #2's MD progress note dated 5/17/2016 revealed in part: Spoke with RP on phone, concerned about CR#2 decreased in appetite. Will order dietary consult Record review of CR #2's telephone orders dated 5/17/2016 revealed orders for -Dietary consult due to lack of appetite. Continued record review revealed no information that Dietary consult was done. Record review of CR #2's Restorative Care Program document dated 5/18/2016 revealed in part: .-Goals: Maximize by mouth intake and nutrition/hydration status. -Approach/recommendations for implementation of goal: offer puree and finger foods to increase by mouth intake . Record review of the comprehensive plan of care revised 5/23/2016 with target date 8/1/2016, revealed in part: -Focus: CR #2 has a potential nutritional problem related to diet restrictions. 5/23/2016 flagged for significant weight loss of 18.4% in 90 days. status [REDACTED]. -Goal: CR #2 will not develop complications including skin breakdown. -Interventions: RD to evaluate and make diet change recommendations as needed. Monitor intake and record every meal. Provide and serve supplements as ordered. Further record review of the care plan revealed no information of the recommendations of the Restorative Care Program to offer puree and finger foods to increase her intake. Further record review of weight record for CR #2 revealed: - Week of 05/09/2016 to 05/12/2016= 140.0 lbs. - Week of 05/16/2016 to 05/20/2016= No weight available - Week of 05/23/2016 to 05/27/2016= No weight available - Week of 05/30/2016 to 06/03/2016= 122 lbs. Record review of CR #2's meal intake for June 1st to June 20th, 2016 revealed that 4 times her meal intake was not monitored during dinner, 15 times she consumed 0 to 25% and 18 times she ate 50% or less of her meals. Record review of the skin assessment for CR#2 revealed in part: -06/5/2016 at 11:05 a.m. revealed CR #2's skin was intact. -6/12/2016 at 11:05 a.m. revealed redness to buttocks area ([MEDICATION NAME] (skin protectant) applied). Continued record review revealed no further interventions when CR#2's redness to buttocks area was identified on 6/12/2016. The care plan was not updated to reflect current skin condition and interventions to prevent further skin breakdown. The MD and the RP were not notified. Record review of CR #2's progress/nurses notes / weight change note dated 6/13/2016 at 6:16 p.m. by RD K, revealed in part: .Weight change alert. Monthly weight is 122 lbs. ( -14.1% x 30 days) Weight loss is undesirable. CR #2 has not been eating well since readmission and status [REDACTED]. Skin: no pressure wounds noted. Recommend: 1.- Psych consult 2.- Increase [MEDICATION NAME] to 15 mg 3.- Increase Resource 2.0 to 90 cc by mouth 4 times a day. Goal is weight gain/improved by mouth intake. Record review of CR#2's document with title Food and Nutritional Service Department dated 6/13/2016 revealed in part: Regarding Dietitian's Recommendations for CR #2.The following is a recommended change or nutritional update for CR#2. 1.- Psych consult, 2.- Increase [MEDICATION NAME] to 15 mg, 3.- Increase Resource 2.0 90 cc by mouth four times a day. - Very poor meal intake with significant weight loss and depression. Further record review revealed that MD agreed with the recommendations and signed them on 6/17/2016. Continued record review of CR #2's physician orders [REDACTED].#2 left to the hospital on [DATE]. Record review revealed comprehensive plan of care revised 6/14/2016 with target date 8/1/2016, revealed in part: -Focus: CR #2 uses antidepressant medication ([MEDICATION NAME]) related to poor meal intake. -Goal: CR#2 will show increased episodes of by mouth intake. Further record review of CR#2's skin/wound note dated 6/18/2016 at 6:47 p.m. revealed in part: Stage 2 pressure ulcer on sacrum, buttocks, coccyx. Scant yellow drainage, redness on wound base, periwound normal (the tissue surrounding the wound itself). Odor present. No pain. RP notified. NP with new order for Bactrim DS (antibiotic) by mouth twice a day for 10 days for infection. In an interview on 7/12/2016 at 11:25 a.m. with the Wound Care Nurse A, she stated that CR#2 had only one pressure sore to her sacrum that looked like a stage 3 before she went to the hospital. Record review of CR #2's Wound Treatment and Progress Record assessment dated [DATE] revealed a sacral stage 2 pressure sore measuring 5.0 x 5.0 x 0.1 c.m. -Interventions; reposition and [MEDICATION NAME] Alginate. Further record review of the Wound Treatment and Progress Record assessment revealed; - Cleanse pressure ulcer to sacrum and buttocks with normal saline, Apply [MEDICATION NAME] (medical honey wound dressing) then Alginate (dressing made of seaweed) every day. Record review of CR#2's telephone orders in part; -6/18/2016 at 9:00 p.m. - Bactrim DS (antibiotic, Double Strength) one tablet by mouth twice a day for 10 days for sacral, buttocks and coccyx wound infection. Further record review revealed no wound care orders written for stage 2 pressure ulcer to sacrum. In an interview on 7/12/2016 at 1:19 p.m. with the DON, When asked if facility obtained wound care orders for CR#2 on 6/18/2016 when the stage 2 pressure sore was found, the DON responded I do not know because I was not notified until 6/19/2016. I saw an order for [REDACTED].#2's wound care orders. Documents were not provided at time of exit. Record review of CR #2's consolidated electronic physician orders [REDACTED]. Record review of CR#2's progress/nurses notes revealed in part: -6/19/2016 at 11:13 a.m. Duoderm ([MEDICATION NAME] dressing) applied to coccyx per wound care, will continue monitoring. -6/19/2016 at 11:30 a.m. Skin/Wound note; RP at the bedside. Stage 2 pressure ulcer on sacrum. 50 (%) slough present and 50% granulation. Scant yellow drainage present, redness on wound bed. Periwound normal. Odor present. Pain at 2 out of 10. RP requested transfer to a wound care center. DON informed. New order of Bactrim DS by mouth twice a day for 10 days ongoing. -6/20/2016 at 3:11 p.m. Skin/Wound note; Upon assessment of wound to CR#2's sacrum and buttocks, a stage 3 pressure ulcer was noticed measuring 6.1 x 7.0 x0.1 c.m. Periwound skin normal. Minimal amount of slough, no necrotic tissue, minimal serous drainage Record review of CR #2's MD progress note dated 6/20/2016 revealed in part: Spoke with RP regarding stage 2 pressure ulcer. RP would like some laboratory work and would like a diabetic nutrition shake ordered for CR #2 . Record review of CR #2's telephone orders dated 6/20/2016 revealed orders for complete blood cell count and basic matabolic panel for 6/20/2016 and diabetic nutrition shake three times a day. Further record review of CR #2's progress/nurses notes revealed in part: -6/20/2016 at 8:13 p.m. CR#2 transferred to a local hospital per RP request. Record review of CR #2's hospital history and physical dated 6/21/2016 at 4:39 p.m. revealed in part: -Date of admission: 6/20/2016 at 6:25 p.m. - History of present illness: CR#2 was brought in to the hospital for sacral wound. Further record review of the Wound Report revealed initial assessment dated [DATE]. Unstageable Sacral pressure sore. Measurements 6.0 x 6.0 x 0.2 (Length/Width/Depth). Serosanguinous exudate. 50% Necrotic tissue. Continued record review of the Wound Report revealed that on 7/5/2016 the sacral wound had debridement using a Curette (a surgical instrument used to remove material by a scraping action). Record review of CR #2's hospital nutrition assessment dated [DATE] revealed in part, Anthropometrics: Height: 65 inches, Weight: 120 lbs, IBW: 150 lbs. -Average by mouth intake: poor. Severe malnutrition. Estimated Kcal Needs: 1925 kcal/day. Increased needs related to wound . Record review of CR #2's hospital Consultation report dated 6/21/2016 revealed in part: -Reason for consultation: Infected sacral wound. .admitted last evening for management of a sacral wound. Per report, the weekday wound care nurse stated that CR #2 had some redness in the area on Monday (6/13/2016) but no open wound. RP believes that the wound developed over the course of a few days. -Assessment plan: CR#2 presents with recent development of a sacral wound. There is moderate amount of drainage and foul odor from the wound concerning for wound infection. I will start CR#2 on broad-spectrum antibiotics in the form of [MEDICATION NAME] and Zozyn (antibiotics) . Record review of CR#2's hospital Infectious Diseases progress notes dated 6/22/2016 revealed in part: .Wound Culture dated 6/22/2016. Results: Escherichia-coli. Will start [MEDICATION NAME] IV (antibiotics) . Continued record review of Wound Culture dated 6/22/2016 at 12:44 p.m. revealed in part; -Wound site: Sacral. Final Report: Gram negative rods Escherichia-coli. Record review of CR #2's Consultation report dated 6/22/2016 at 5:00 p.m. revealed in part: .CR#2 admitted with a sacral wound and malnutrition. Admission [DIAGNOSES REDACTED].>Unstageable sacral decubitus and malnutrition. She was admitted for nutritional support as well as wound care . Record review of CR #2's hospital swallow evaluation dated 6/22/2016 revealed in part: .CR#2's presents with severe oral dysphagia, possibly pharyngeal. Marked swallow delay and poor bolus control Record review of CR #2's Consultation report dated 6/22/2016 at 5:00 p.m. revealed in part: .CR#2 admitted with a sacral wound and malnutrition. Admission [DIAGNOSES REDACTED]. She was admitted for nutritional support as well as wound care .Impression: oropharyngeal dysphagia. Recommendations: Gastrostomy tube on 6/27/2016. Nasogastric tube feeding with Glucerna (nutritional formula for patients with Diabetes) until 6/27/2016. Observation on 7/12/2016 at 9:04 a.m. revealed CR #2 was at a local hospital. Further observation revealed that she was lying on an air mattress and was non-verbal. CR #2 had a gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding running at 55 ml/hr of DiabeticSource (nutritional formula for patients with Diabetes) AC and water flush at 40 ml every 1 hours. CR #2 also had a PICC line (is a long, thin, flexible catheter used to give medicines or nutrients for long period of time) to her right upper arm. In continued observation, CR #2 was noted to have a Foley catheter that had approx. 100 cc of clear amber colored urine on the collection drainage bag. CR #2 had a [DEVICE] to her sacral wound (The [DEVICE] draws out fluids from the wound and increases blood flow to the area). In an interview at that time with the hospital RN, she stated that CR#2 was non-verbal and that she was admitted with [DIAGNOSES REDACTED]. She further said that the bacteria found on the sacral pressure sore was Escherichia-coli and that CR#2 had a [DEVICE] on the sacral pressure sore and that the dressings were changed 3 times a week. She then said that CR#2 was receiving her nutrition via gastrostomy tube. In an interview on 7/12/2016 at 11:25 a.m. with Wound Care Nurse A, she stated that CR#2 had her skin intact and that on 6/13/2016 she assessed her after lunch had finished and that she noted redness to her buttocks area. She further said that she did not call the MD or notify the family because it was redness from just being sitting down on her chair too long on her buttocks and further said CR#2 would get up on her chair from breakfast time and would go to bed until after lunch. She then would get up again for dinner and do not know for how long. When asked if she followed up on the redness later or the next day to see if the skin was clear, the Wound Care Nurse A replied No, I did not see her skin again until the day she left to the hospital on [DATE]. CR#2 had only one pressure sore that looked like a stage 3 on her sacrum. I was asking the staff what happened because I was not aware that her skin was open. On 6/13/2016 I only documented on the weekly skin report that her buttocks were red and did not update the care plan or notified the family because was only redness. Further interview at that time, The Wound Care Nurse A said that for changes in condition of the skin the MD and family needed to be notified and that she was responsible to update the care plan and further said CR#2's redness was not a change of condition because the redness on her buttocks was just from being sitting too long on her butt. It was normal redness from being on her chair for a significant amount of time and she was not able to move on her chair at all. It was her routine, to get up at breakfast and go to bed after lunch. Whatever happened to her, it was on the weekend. I saw her on 6/13/2016 (Monday) because her weekly assessments were not done on the weekend, Wound Care Nurse B who worked on the weekends called in sick. Record review of the care plan revealed no information related to CR#2 spending long hours seated on her chair and interventions for CR#2 to be repositioned when up on her chair to prevent skin breakdown. Continued interview with the Wound Care Nurse A on 7/12/2016 at 11:40 a.m. when asked if the facility obtained any wound care orders on 6/18/2016 when CR#2 was found with the stage 2 pressure sore, the Wound Care Nurse A responded That's the weekend, I don't know. CR#2 had a TAR on the book . When asked when was CR#2's pressure sore assessed on 6/20/2016 (Monday) when she returned to work, the Wound Care Nurse A responded I did not get to see her until after lunch. I couldn't see her earlier. When I saw her pressure sore, it was a stage 2 and was covered with about 10% of slough but did not have necrotic tissue. I just dressed the wound and went to see another resident and CR#2 eventually left to the hospital. Further interview at that time, the Wound Care Nurse A said C.N.A's are supposed to complete 'stop and watch' papers and are supposed to be given to the wound care nurse or the charge nurses . She continued saying that she did not remember seeing any 'stop and watch' papers related to the pressure sore of CR#2. Attempted an interview on 7/12/2016 at 12:09 p.m. with the Wound Care Nurse B (weekend nurse) but she did not return call to surveyor. Wound Care Nurse A stated at that time that Wound Care Nurse B was out of the country. In an interview on 7/12/2016 at 12:30 p.m. with ADON L, she stated that she was in charge of monitoring weights on the residents and to follow up on the dietary recommendations. She further said that CR#2 had dietary recommendations because she had poor food intake. When asked regarding the dietary recommendation dated 5/9/2016 for Resource 2.0 that was written every day when the MD had agreed for four times a day, ADON L responded I am almost positive that the recommendation was for every day. I wrote the order. I need to check my notes. When asked if the RD was made aware of CR #2's orders for dietary consult on 5/17/2016, the ADON L responded that she was not sure and that she was going to find information for surveyor. ADON L further said RD gave more recommendations to CR #2 due to weight loss and poor food intake right before CR #2 went to the hospital but we were not able to carry them because she went to the hospital. In an interview on 7/12/2016 at 1:00 p.m. with the DON, she stated that CR#2's sacral pressure sore had 50% slough and necrotic tissue and that was an unstageable pressure sore on 6/20/2016 before going to hospital. DON further said I saw CR#2's pressure sore with Wound Care Nurse A. When asked if the facility had trained the nurses on staging pressure sores, pressure sore prevention and treatment, the DON responded I haven't set up a wound care training yet. We want them to go to a wound care course. I already made some phone calls and they are supposed to call me back. Further interview with the DON at that time, she stated that she was not aware of CR#2 having any redness on her buttocks prior to developing a pressure sore and that on 6/19/2016 (Sunday), CR #2's RP wanted to speak to her and that she was very upset because she had seeing the pressure sore to CR#2 for the first time on 6/19/2016 and that she was not aware of her love one having any pressure sores. DON further said I talked to Wound Care Nurse A and she said that she assessed CR#2's skin and that her buttocks were red because she was sitting on her chair and that it was just redness. Continued interview with the DON on 7/12/2016 at 1:19 p.m. she stated that any skin problems are supposed to be reported by completing a stop and watch form and that one copy goes to the wound care nurse. DON further said I looked for any stop and watch papers for CR #2 and I could not find any. When asked if facility obtained wound care orders for CR#2 on 6/18/2016 when the stage 2 pressure sore was found, the DON responded I do not know because I was not notified until 6/19/2016. I saw an order for [REDACTED].#2's had a duoderm dressing on her pressure sore on 6/19/2016, the DON responded I already talked to the responsible nurses and did a 1:1 training. Requested copy of CR#2's wound care orders and the 1:1 training with nurses who applied the wrong treatment. Documents were not provided at time of exit. Further interview with ADON L on 7/12/2016 at 2:25 p.m., she stated that she had spoken to the RD K and that she had said that the recommendation for Resource 2.0 90 cc was supposed to be done every day and not four times a day. ADON L then said CR #2 had poor appetite. She just went downhill. CR #2 would not open her mouth to eat, she was depressed. If someone is not eating, we would involve the RD so she can give recommendations. Then, I would call the MD to notify the recommendations, would carry the orders and would notify the family. CR #2 was on weekly weights, so we were monitoring her weights. She had psychologist consult and speech therapy involvement. Requested documentation of psychologist consultation. Documentation for psychologist consultation was not provided by exit time. Continued interview with the ADON L at that time, she stated that she was not aware of CR #2's MD orders for dietary consult given on 5/17/2016. In an interview on 7/12/2016 at 3:19 p.m. with RNA M, she stated that she was in charge of doing the weekly weights and that she would give the completed weights to ADON L. RNA M further said that CR #2 was eating 45 to 50% of her meals when she returned from the hospital but later she gradually would eat less. RNA M continued saying CR #2 would forget to eat and she would not eat. She would just pocket her foot, she was on RNA feeding. When asked about CR #2's weight record, RNA M stated that she did not have weights for CR #2 for May 16 to May 20 and May 23 to May 27, 2016 because she was on vacation during that time and she was not sure who had done the weights. Further interview and record review of the weight record with RNA M at that time revealed that the spaces for CR #2's weights for May 16 to May 20 and May 23 to May 27, 2016 were clear with no information to indicate why the weights were not completed. RNA M then said that CR #2's weight recorder for June 1st, 2016 was 121.6 lbs. In an interview on 7/12/2016 at 3:40 p.m. with the Speech Language Pathologist, she said that she saw CR #2 from the end of April thru May, 18, 2016. She further said that CR #2 was being seeing due to pocketing her food, had poor by mouth intake and concerns of weight loss. Speech Language Pathologist continued saying that she spoke with different nurses about CR #2's concerns of not eating well and being resistant to eat and that she had given recommendations to provide pureed food and finger foods to CR #2. Further interview at that time with the Speech Language Pathologist, she said that CR #2 did not have problems choking, that the problem was her dementia and that she had observed that CR #2 was doing very well with finger foods and had spoken to the nurses about it including ADON L. She continued saying that CR #2 was discontinued from her services on May 18, 2016 due to lack of progress and that on CR #2's situation, it was just for her to give recommendations. In an interview on 7/13/2016 at 8:49 a.m. with Wound Care Nurse A, she stated that she did not remember the Braden Scale score for CR#2 but that she should had been a high risk for pressure sore development because CR#2 couldn't maneuver herself and further said even before she had the amputations, she should had been high risk. She should had been repositioned every 2 hours even on her chair. When asked if CR #2 care plan was updated for resident to be repositioned every 2 hours when she was on her chair to prevent development of the pressure sores, the Wound Care Nurse A responded It should be automatic. C.N.A's should be repositioning the residents . When asked who was responsible of monitoring the C.N.A's to make sure residents were repositioned when up on their chairs, the Wound Care Nurse A responded everybody, the C.N.A's, the nurses and the wound care nurses. In an interview on 7/13/2016 at 9:05 a.m. C.N.A. C stated that CR#2 would get up every morning at around 7:00 a.m. for breakfast and would not go to bed until 11 a.m. and then w

Based on observation, interview and record review, the facility failed to ensure that the residents environment remained as free of accidental hazards as possible for one of four residents (Resident #1) reviewed for accidents and supervision as evidenced by: -Resident #1 was left naked and unsupervised by a licensed or certified personnel in the shower room resulting in a fall with injury to his head. This failure affected one resident and had the potential to affect the remaining 27 residents who reside on Hall 100 and place them at risk of injury or death. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year old male who was admitted on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #1 had a [DIAGNOSES REDACTED]. He was able to to complete the BIMS (Basic Interview for Mental Status) and was coded a 6 which indicated moderate cognitive impairment. The MDS also revealed that Resident #1 required physical help in part of bathing activity with one person physical assist. Record review of Resident #1's Care Plan revealed the following: Focus: (Resident #1) is at risk for falls r/t unsteady balance. Date initiated- 3/2/15 and revised on 4/8/16. Goal: (Resident #1) will not sustain serious injury through review, target date- 9/6/16. Interventions: .The resident needs a safe environment: even floors free from spills and/or clutter; .handrails on walls, date initiated- 3/2/15. Record review of Resident #1's Social Service note dated 7/8/16 revealed that he had scored a 12 on his BIMS, which indicated a mild/moderate cognitive impairment. Record review of the facility's investigation report dated 7/6/16 revealed a signed statement by Laundry Staff A, dated on 6/28/16. In the statement, Laundry Staff A revealed that she was asked to watch Resident # 1 while CNA X went to get another resident. Observation of Resident #1 on 7/12/16 at 7:10 a.m. revealed that the resident was in bed, In an interview on 7/12/16 at 7:10 a.m., Resident #1 said, I stood up in the shower while sitting down on bench and the floor was slippery, and I fell and hit my head on the tub, and when I woke up (Laundry Staff A) was standing over me, trying to put my clothes on. In an interview on 7/12/16 at 7:40 a.m. with Laundry Staff A, she revealed that she was asked to watch Resident #1 by CNA X, while CNA X went to get another resident. She stated that she said hello to Resident #1, then turned her back on the resident (who was sitting on the shower bench, naked), to work with the laundry barrels. She stated she heard a thump and when she turned around, she saw Resident #1 lying on the shower room floor, he had blood on his right forehead, and white substance around his mouth. She said, Resident #1 was lying on his right side, he was not moving or talking, she stated she ran to the exit door and yelled for CNA X, but no answer. She said LVN H came running in. When she came back to Resident #1, after getting help , he was shaking. She stated she stayed with the resident until the ambulance arrived. Observation and interview on 7/13/16 at 11:05 a.m., Laundry Staff A went to the shower room on Hall 400 where the incident occurred on 6/28/16. The shower stall was on the left side of the room and the laundry barrels were approximately 20 feet away from the shower stall on the right side of the room. Laundry Staff A stated she had her back to him for about a minute. During an interview on 7/12/16 at 10:40 a.m. with the Social Worker, she confirmed that Resident #1 scored a 12 on his BIMS. In a telephone interview on 7/12/16 at 3:05 p.m. with LVN H, she stated that CNA X had stepped out to get a brief for Resident #1 and LVN H came into the shower room directly after Resident #1 had fallen. She said he was shaking, and had a seizure from 6:30 am to 6:35 a.m. She stated that the laundry lady (Laundry Staff A) said that Resident #1 was shaking and fell forward. She further stated that Resident #1 was coherent, and talking upon completion of the seizure, She stated Resident #1 stated he felt it coming on. She further revealed that she did not know why CNA X did not send the laundry staff out to get the brief, or why CNA X left Resident #1 naked and alone in the shower with an uncertified, or unlicensed person. In an interview with the DON on 7/12/16 at 11:45 a.m., she stated that the incident occurred on 6/28/16 and CNA X was suspended on 6/30/16 after CNA X stated that she thought that it was ok to have the laundry staff watch Resident #1. She further revealed that they did one on one education with CNA X. In an interview with the Administrator on 7/14/16 at 9:25, she stated no where in the policy does it state that the laundry personal can't watch a resident, and someone was in the room, that's all the policy says, not to leave them unattended. She further stated that just because a resident has a history of seizures, we don't provide specialized care. According to the facility census sheet, there were 28 residents on Hall 100.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to prevent the development or worsening of pressure ulcers and to promote the healing of pressure ulcers for 4 of 11 residents (Resident #57, 34, 37, 3 ) who were reviewed for pressure ulcer care and management as evidenced by: - Resident # 57 who was assessed by the facility to be at high risk for developing pressure ulcers and entered the facility with sacral redness, developed multiple pressure ulcers including unstageable suspected deep tissue injuries to the sacrum and right heel, open areas bilaterally behind ears, and redness to abdomen. -Resident # 34 weekly skin assessement 4/11/15 documented a large unstageable pressure sore to the left heel on and a deep tissue injury to his left great toe. He did not have preventative pressure sore measures in his room including a heel lift and bilateral heel protectors until 04/30/2015. -Resident # 37 had a new wound to his right leg below the knee identified as an abrasion. -Resident # 3's wounds had not been measured and staged properly every week for the Sacral wound, left lateral knee, left calf, left heel, left ankle and left buttock. This failure further resulted in an identification of an Immediate Jeopardy (IJ) 4/29/15 . While the IJ was removed on 05/01/2015, the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures affected 4 residents and placed 9 additional residents that were identified at risk for pressure ulcers at risk for a decline in health and need for additional treatment. Findings Include: Resident # 57 Record review of the medical record face sheet revealed Resident # 57 was originally admitted on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. He was discharged on the evening of 4/28/2015 to another facility. Record review dated 4/13/15 of Resident 57's Hospital Physician Discharge Summary revealed Resident skin color, texture normal, no rashes or [MEDICAL CONDITION]. Record review of Resident # 57's Admission MDS assessment with 3/5/2015 ARD date revealed he was readmitted to the facility on [DATE]. His Cognitive Skills for Daily Decision Making was assessed as moderately impaired. He was totally dependent and required one person assistance with bed mobility, transfers, eating, and toilet use. He required two or more person assistance with ambulation, dressing, and personal hygiene. He was assessed as having a range of motion impairment on one side of his upper and lower extremities. He had an indwelling urinary catheter and was always incontinent of bowel. The skin condition section of the assessment revealed he did not have a pressure ulcer and was not at risk of developing a pressure ulcer. Record review of Resident 57 's Interim Plan of Care dated 4/13/2015 revealed no documentation in the pressure sore section of the document. In the pressure ulcer risk section, documentation read "inspect skin according to protocol". There were no specific interventions guidelines listed. Record review of Resident 57's Braden Scale - Predicting Pressure Score Risk revealed on 4/13/2015 his score was an 11 (high risk) and on 4/20/2015 his score was an 10 (high risk). Record review of Resident # 57's nurses notes, an "Admission Summary" dated 4/13/2015 and signed as written by LVN W read "....Skin inspection unremarkable at this time some sacral redness present no active pressure sore, will continue to monitor". There were no measurements or further description noted. There was no documentation indicating if the physician or responsible party was notified of the sacral redness. Record review of Resident # 57 's nurses notes, a "Health Status" note dated 4/18/2015 signed by LVN A read, "Skin breakdown to sacrum .... On coming nurse informed of skin breakdown". There were no measurements or further description noted. Further record review of a Daily Skilled Nurse's note signed by LVN A dated 4/18/2015 read in part, "...Skin breakdown noted to sacrum, covered with barrier cream wound care made aware". Record review of a Skin/Wound Note dated 4/19/2015 and signed by RN B describing the sacral pressure ulcer read, "SDTI (suspected deep tissue injury) dark purple and black color with skin that has opened without depth .... Right buttock measures 10.1 cm X 4.5 cm with central area of shearing measuring 5.0 cm X 4.0cm .... Left buttock measures 3.5 cm X 4.0 cm". Heel pressure ulcer: "Right heel exhibits SDTI measuring 2.5 cm X 3.0 cm and intact; prevalon boots intiated on 4/13/2015. Notes written on the report read, "spoke to the CNAs about repositioning Resident # 57 side to side only and that the resident was on a low air loss mattress". Record review Resident # 57 's Wound Treatment and Progress record (found in the Wound Care binder) and signed by RN B dated 4/19/2013 revealed she documented that the sacral and heels pressure ulcers were unstageable and notified Resident # 57's responsible party. Further record review of the Wound Care Nurses binder revealed no documentation by LVN W regarding the redness found on Resident # 57's sacrum on admission. Record review of Resident # 57's care plan revealed the following care plans were updated on 4/17/2015: Keep family/responsible party and MD informed of residents progress. Assist with turning/repositioning every two hours and prn. Use padding between pressure areas and positioning devices for proper body alignment. Provide pressure relieving device for bed and chair. Record review of Resident # 57's Daily Skilled Nurses notes, Progress Notes and Assessment notes from the time of admission on 4/13/2015 to 4/18/2015 revealed no documentation of the condition of Resident # 57's skin, the presence of a low air loss mattress, or interventions being done to prevent the worsening of the redness found on his sacrum. Record review of Resident # 57's physician's orders revealed the following orders: Low air-loss mattress dated 4/17/2015. Cleanse open area sacrum/buttocks with NS (normal saline) pat dry, apply silicone gel dressing change Q 3 days (every three days) and PRN (as needed) dated 4/19/2015. Cleanse right heel with NS, pat dry, apply [MEDICATION NAME] dressing Q 3 days and PRN. Turn side to side only; prevalon boots BLE (bilateral lower extremities) dated 4/19/2015. Record review of a Health Status note dated 4/18/2015 and timed 5:31 pm, read in part, "Open areas noted behind bilateral ears, dressing in place c/d/I (clean, dry, intact), red area to left mid abd (abdomen) noted .... Healing sacral wound noted". An observation on 4/28/2015 at 4:00 pm revealed that Resident # 57 was in bed on an air mattress and had prevalon boots on both feet. He was positioned on his back with the head raised slightly. He was wearing a nasal cannula with gauze wrapped around the tubing behind his ears. The resident had a feeding tube and a Foley catheter in place. He was awake, but was unable to verbalize. His wife was at the bedside. In an interview done on 4/28/2015 at 4:00 pm with Resident # 57 's RP, she said she was aware of the redness on the resident sacrum on admission. However, upon observing his sacrum while RN B performed wound care on 4/24/2015, she found his sacral pressure ulcer had progressed. She said she had not been notified that the pressure ulcer had worsened from admission. Resident # 57's RP also reported earlier that day she found the PE[DEVICE] was pressed against his chest causing the development of persistent reddened areas on his chest. She notified a nurse who padded the tube in gauze. When asked how long Resident # 57 had been positioned on his back, she reported it had been about two and a half hours. She further reported he had developed a new pressure ulcer on this right heel since his readmission and that he has had the prevalon boots on since his admission. An observation on 4/29/2015 at 9:00 am revealed Resident # 57's bed was empty. The air mattress was still present but all other personal items were removed. In an interview done on 4/30/2015 at 9:30 am with Resident # 57's physician, he reported he was made aware of Resident # 57's pressure ulcers "a few days after admission". In an interview with LVN A on 4/30/2015 at 9:45 am, he said on 4/18/2015 he noted the first layer of skin on Resident # 57's sacrum was broken and without bleeding or drainage. He further stated that he had not noted any skin breakdown on 4/16/2015 or 4/17/2015. When asked who he informed about the broken skin on the sacrum, he stated he called Resident # 57 's physician and notified the wound care nurse. In an interview with RN B, wound care nurse, conducted on 4/30/2015 at 11:30 am, she reported she became aware of Resident # 57's sacral pressure ulcer on 4/19/2015 upon reading other nurses notes in the computer. She then did her first assessment of Resident # 57's skin and recorded her findings in the computer and in the wound care binder. RN B stated she did not do skin assessments for new admissions and that it was the charge nurse's responsibility. She further said the charge nurse would notify her if any problems were found. During the interview RN B described Resident # 57's pressure ulcer as "really red, dark purple" with shearing to the superficial top layer of skin. She also stated there was no depth to measure. RN B also reported she found a small darkened area on his right heel with intact skin. She said she notified Resident # 57's responsible party and received treatment orders from Resident # 57's physician. RN B further stated she received her wound care training over three days from Wound Care Nurse C, who was a LVN. In an interview with LVN W on 4/30/2015 at 4:55pm, she said she assessed Resident # 57 on admission including a skin assessment. She described the area on Resident # 57's sacrum as very red with no skin breakdown. She further stated in order to communicate the redness to the wound care nurse, she wrote a note in the wound care nurses binder and also documented it in a nurses' note in the computer. LVN W said upon reading the notes, the wound care nurse would then assess for treatment and implement care plans. Record review of a Discharge Summary note dated 4/28/2015 revealed he was dicharged to a hospice facility. Resident # 34 Record review of Resident # 34's face sheet revealed an [AGE] year old male admitted to the facility on [DATE]. Among his [DIAGNOSES REDACTED]. Record review of Resident # 34's annual Minimum Data Set completed on 04/07/2015 indicated in Section M that Resident # 34 was not at risk of developing pressure ulcers. Resident # 34's initial Brief Interview for Mental Status (BIMS) score was 06 out of a possible high 15 for cognitive status (severe impairment). Resident # 34 was identified as requiring extensive assistance/two persons with transfers and extensive assistance/one person with bed mobility. Record review of Resident # 34's initial care plan dated 03/28/2015, revealed development of pressure sores was identified as an area of concern. Care plan dated 03/28/2015 did not have specific preventative measures to help prevent Resident # 34 from developing pressure sores. Initial care plan was not updated after Resident # 34 was identified with a large left heel unstageable pressure sore on 04/11/2015. Record review of Resident # 34's medical record, the initial skin assessment Braden Score dated 03/17/15 was detailed as a 12 (High Risk) for development of pressure sores. In an observation on 04/28/2015 at 03:45 PM Resident # 34 was lying quietly in bed. Resident #34's feet were lying directly on his mattress. In an observation on 04/29/2015 at 08:50 AM Resident # 34 was lying quietly in bed. Resident # 34's feet were lying directly on his mattress. Resident # 34 was observed during wound care performed by RN B to have a very large unstageable pressure sore to his left heel and a deep tissue injury to his left great toe. RN B cleaned the wound with normal saline and applied [MEDICATION NAME] with a gauze bandage. In an interview with RN B on 04/30/2015 at 01:30 PM, she stated that she has only been in the wound care nurse role for about two weeks. She further stated that she was trained for a few days by Wound Care Nurse C. She stated that she did not actually have a skills check off as she had just shadowed Wound Care Nurse C. RN B stated her wound care training in the facility was minimal. Stated that Resident # 34's large left heel unstageable pressure sore was identified during weekly skin assessment rounds on 04/11/2015. Stated preventative pressure sore development measures should have been identified and put in place when Resident # 34 admitted to the facility on [DATE]. Stated that she can not locate any weekly skin assessments sheets on Resident # 34 prior to 04/11/2015. Stated she is not sure if weekly skin assessments were being performed. In an observation on 04/30/2015 at 08:35 AM, Resident # 34 was sitting up in his wheelchair. Resident # 34's bed was made with only a regular mattress in place. In an observation on 05/01/2015 at 08:50 AM, Resident # 34 was observed to not be in his room. Resident # 34's bed was observed to have a heel lift lying on top of his mattress. In an observation on 05/01/2015 at 09:20 AM, Resident # 34 was observed to be lying quietly in his bed. Resident # 34's feet were noted to have heel protectors which were resting on top of a heel lift. Record review of Resident # 34's weekly skin assessments dated 4/11/15, 04/18/15 and 04/25/15 revealed that Resident # 34 had a large unstageable heel pressure sore and a deep tissue injuiry to his left great toe. Record review of Resident #34's physician's telephone order dated 4/12/15 read in part, "1. apply [MEDICATION NAME] to left great toe and leave open to air every day and PRN. 2. Clean left heel with normal saline, pat dry, apply [MEDICATION NAME] and cover with dry gauze every 3 days and PRN". In an interview with Wound Care Nurse C on 05/01/2015 at 11:38 AM, he stated the facility does not really have a system in place as far as wound care is concerned. He further stated that the system in the facility is a failed system. He stated that a recently hired wound care nurse (RN B) shadowed him for a few days. He stated that he did not actually have RN B do a skills checkoff. He stated that he was not allowed to stage a wound. He stated that some of this facility's physicians do not want their residents to be followed by a wound care physician. He stated that the last time state surveyors were in the facility would care was identified as a problem. Wound Care Nurse C stated that he had not recently received any training on wound care. He stated that he could not recall the last time he had training on wound care. In interview with ADON on 05/01/2015 at 02:55 PM, she stated that she was not sure exactly who does the training for the wound care nurses in the facility. She further stated that the wound care nurses in the past she believes were trained by wound care nurses from other buildings. She also stated that she did not realize an LVN had recently trained an RN on wound care in the facility. The ADON stated that wound care nurses report directly to the DON. The ADON stated that she has no wound care background. In an interview with the DON on 05/01/2015 at 3:05 PM, she stated that RN B was trained by Wound Care Nurse C for a week. Stated that Wound Care Nurse C had been trained by Wound Care Nurse A. DON stated that she provides in service training on wound care to the facility's nurses. DON further stated that she does not have a background in wound care and she also stated that neither Wound Care Nurse C or RN B had not been checked off on their wound care skills. DON stated that preventative measures such as heel lifts, heel protectors, special mattresses, fluids at bedside, weekly skin assessments, and if appropriate a referral to the in house wound care physician should be immediately put into place once a resident is identified as high risk for development of pressure sores. She stated that since Resident # 34 had a initial Braden Score of 12 on admission to the facility on [DATE] he should have had preventative pressure sore measures identified and put into place. She stated that preventative pressure sore measures should have been re-evaluated on 04/12/2015 when the large left heel unstageable pressure sore was identified on Resident 34. In an interview with Corporate Nurse A on 05/01/2015 at 05:15 PM, she stated that she does not have special training in wound care. She stated that a Certified Woundcare Specialist (CWS) had been contacted to come to the facility immediately in order to provide comprehensive training to staff on wound care. In an interview with CWS A on 05/01/2015 at 05:50 PM, she stated that she was a Certified Woundcare Specialist (CWS). She stated that she had speciality training in wound care with the designation of CWS. She stated that she had been called by the facility to provide in depth wound care training for the facility staff. In an interview on 04/29/2015 at 11:45 AM with Resident # 34's responsible party, he stated he had not been informed of the significant change in Resident # 34's physical condition related to the development of a large left heel unstageable pressure ulcer and a deep tissue injury to the great left toe. He further stated that today (04/29/2015) is the first time he has heard about Resident # 34 having an unstageable pressure ulcer to his left heel. Resident # 37 Record review of Resident # 37's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. Among his [DIAGNOSES REDACTED]. Record review of Resident # 37's admission MDS assessment with ARD of 4/17/15 revealed his cognitive skills for daily decision making was coded a "2 - moderately impaired" by staff assessment. He required extensive one person assistance for bed mobility, transfers, and all ADLS. He had one unstageable sacral pressure ulcer with slough.No measurement of the pressure ulcer was given in the assessment. Record review of Resident # 37's Care Plan dated 4/22/15 revealed a care plan for "potential for pressure ulcer development r/t immobility". The goals were "will have intact skin, free of redness, blisters or discoloration by/through review date." The Target Date was 7/12/15. The Interventions read, "Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning...Monitor nutritional status. Serve diet as ordered, monitor intake and record...Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated." Record review of a Braden Scale for Predicting Pressure Sore Risk dated 4/10/15 revealed he was a Low Risk with a score of 18.0. Record review of a Braden Scale for Predicting Pressure Sore Risk dated 4/24/15 revealed he was a Low Risk with a score of 15.0. Record review of Resident # 37's Weekly Skin Integrity Review dated 4/11/15 revealed that he admitted to the facility with an unstageable sacrum pressure ulcer measuring 5.0 x 2.5 cm. Old open area, bruises, and redness were checked in the pressure ulcer assessment. Record review of Resident # 37's Weekly Skin Integrity Review dated 4/18/15 revealed an unstageable sacrum pressure ulcer measuring 5.0 x 2.5 cm. Documentation read, "sacral unstageable, black/reddened, (missing word) below measuring 5.0 x 2.5 cm wound care ongoing". Record review of Resident # 37's Weekly Skin Integrity Review dated 4/25/15 revealed a Stage III sacrum pressure ulcer measuring 5.0 x 2.5 cm. Record review of Resident # 37's physician's orders revealed an order dated 4/16/15 for liquid protein supplement, 30 cc two times a day for 30 days. Review of his April and May 2015 MARS revealed he was receiving the protein supplement twice a day at 8:00 AM and 4:00 PM as ordered. Further review of the physician's orders revealed a low air loss mattress was ordered on [DATE]. Observation of Resident # 37 on 4/29/15 at 4:23 PM revealed he was lying flat on his back in bed on a low air loss mattress. The resident was sleeping soundly. Record review of Resident # 37's progress notes revealed a skin/wound note dated 4/29/15 at 6:13 PM read, "Overall skin evaluation, noted mushy right heel, blister to left knee, 3 small blisters to right shin, hydrogel dressing in place to sacrum with wound care ongoing. Left stump dressing clean/dry/intact. Spoke to (MD B) and received T.O.'s for [MEDICATION NAME] to blisters right shin & left knee with dressing QOD and [MEDICATION NAME] & leave OTA to right heel daily." Observation of Resident # 37 on 4/30/15 at 8:31 AM revealed he was lying flat on his back asleep on his bed. A water pitcher was sitting on the overbed table out of reach across the room beyond the foot of the bed. Observation of Resident # 37 on 4/30/15 at 2:11 PM revealed he was lying flat on his back on his bed awake. Resident # 37 was friendly and said hello. He was able to answer simple questions with mild confusion. He was observed to talk excessively, rambling about events in the past. In an observation of Resident # 37's wound care on 04/30/2015 at 09:15 AM, it was stated by RN B that Resident # 37 had a new wound to his right leg at the knee identified as an abrasion. The sacral wound was described by RN B as being a stage III with a very large newly developed excoriated area adjacent to the wound. In an interview with RN B on 04/30/2015 immediately afer performing wound care on Resident # 37 she stated that the large excoriated area next to the Stage III sacral wound was a change since April 28, 2015. She further stated that the reddened area with skin tear at the right knee was possibly a newly devloped pressure sore. Resident # 3 Record review of the Resident # 3's facility medical record revealed she had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident # 3's Quarterly MDS assessment dated [DATE] coded her cognition as 15 out of 15 possible correct answers on the BIMS. Continued record review of this same MDS dated 4/16/2015 coded Resident # 3 as having 6 pressure ulcers with the worst as a "Stage IV" (to the bone). Resident # 3's admission MDS dated [DATE] coded the pressure ulcer as 6 "unstageable" pressure ulcers. Record review of Resident # 3's weekly skin review sheets dated from 2/17/15 read as follows: -2/17/2015 "Right above knee amputation surgical site intact, multiple eschar (slough) to left lower extremity, sacral wound; -2/23/2015 Braden Scale skin assessment coded moderate risk of pressure ulcers; -2/24/2015, 3/03/2015, 3/10/2015,and 3/24/2015 all read "Right above knee amputation surgical site healed, multiple eschar to left lower extremity, and sacral wound; -3/02/2015 Braden Scale skin assessment coded as low risk for receiving pressure sores; Weekly skin assessments for Resident # 3 continued as: -3/31/2015 Sacral wound, left lateral knee, left calf, left heel, left ankle; -4/07/2015 Left knee, left lower extremity, left heel, left buttock, left ankle; -4/14/2015 Old open area; -4/21/2015 Left heel pressure ulcer, unstageable, left lateral foot, left buttock pressure ulcer 4.1cm X 4.9cm X 1 cm. Sacrum pressure ulcer 1.2cm X 0.6cm. X 0.4cm. unstageable. Left lateral calf pressure ulcer 5.3cm X 0.9cm X 0.1cm. Left lateral knee pressure ulcer 1.5cm X 1.6cm X 0.2cm; -4/28/2015 Old open area left lateral foot scab, right buttock largest 1 cm - 2.1cm, right buttock vascular 3.3cm X 4.9cm X 0.5cm, left heel unstageable, left lateral knee pressure ulcer." During an interview on 4/28/2015 at 12:14 PM with Resident # 3 in her room, she said that hardly anyone put on protective equipment. She said she was "really mad" about being in isolation. She said "It had been a week and no one seems to know why I am still in isolation. I've had infections all my life since I had the car wreck when I was 15 and made a paraplegic. I came in with a wound vac. That was done with. Not everyone who comes in here wears protective equipment. I do my own ostomy care. Sometimes the nurses do it. But I prefer to do it myself. I have been doing it a long time. I don't stay in my room like they want me to. I go all over. I just got back from the 300 hall where my friends are." In an interview and observation on 4/30/2015 at 1:45 PM with RN B providing wound care for Resident # 3, she stated she had been in the position for about 2 weeks. She said she felt "very comfortable" with doing wound care and had a long background in treating wounds. She said the wound specialist doctor does rounds on patients every Monday. She said that nearly all the wounds Resident # 3 had were unstageable because of the amount of eschar on them. She said the doctor was calling them "Unstageable" and was using collagen to pack the wounds. The wound on her was elongated and around the perimeter of the wound the skin was reddish pink color. RN B said the resident had "[MEDICAL CONDITION] in the whole leg, according to the doctor". RN B proceeded to Resident # 3's coccyx pressure ulcer. The old dressing was saturation with old blood. RN B removed the old wound dressing which was much larger than the other wounds and quite deep, going into the muscle underneath the skin. The wound bed was moist and beefy red. There was no odor. RN B said that the doctor had called this wound "unstageable" also. She cleaned the wound with normal saline, patted it dry with 4 X 4 gauze pads, and wearing the same gloves re-dressed the wound. Another smaller area just below the large wound was observed to be open and bleeding. RN B said it was "from taking the dressing on and off". She covered both areas with the same wound cover dressing. Record review of facility policy titled Prevention of Pressure Ulcers read in part "...6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family, and addressed." Record review of the facility policy titled Pressure Ulcer Risk Assessment read in part "... Steps in the Procedure ... 4. Once risk factors have been identified, proceed to the Resident Assessment Protocols, care planning and interventions individualized for the resident and their particular risk factors." The facility Administrator was notified on 04/29/2015 at 11:25 AM that an IJ situation had been identified due to above failures. The Plan of Removal was submitted by the Administrator on 04/29/2014. The final Plan of Removal was accepted by the survey team on 05/01/2015 at 6:15 PM. Plan of Removal The facility submits the following Plan of Removal for the alleged failure to have an effective system in place to implement interventions to prevent wounds from developing and/or worsening. 1. Head to toe skin assessments on 100% of residents initiated on 4/29/15. Any residents with an issue identified during these assessments had interventions ordered and implemented on 4/29/15. The resident's physician and responsible parties were notified of the changes in condition. Resident care plans were updated to reflect interventions. Any residents with skin issues were referred to the Registered Dietitian if warranted. A communication to Rehab was also initiated for evaluation for positioning as warranted. a. 3 residents were identified with new or worsened pressure ulcers by the surveyors prior to the initiation of the IJ. The following is what was identified and what interventions were implemented for those 3 residents: a. Resident # 57 identified with a reddened area on his coccyx on 4/17/15. DTI to right heel identified on 4/19/15. Resident discharged on [DATE] to an inpatient hospice unit. b. Resident # 34 identified with an unstageable pressure ulcer to left heel on 4/12/15 . A DTI to the left great toe on 4/12/15. c. Resident #37 identified with Stage II to sacrum. Stage II to left knee on 4/30/15. b. During the 100% audit of head to toe skin assessments the following residents were identified with pressure ulcers: a. Resident #3 - admitted to facility on 2/11/15 with the following: Unstageable to sacrum. Unstageable to right buttocks. Unstageable to left heel. Unstageable to LL foot. Unstageable to left calf. Unstageable to left outer knee. b. Resident # 12 - Unstageable pressure ulcer to Left Lower Foot identified on 4/16/15. c. Resident # 69 - Stage II to left heel identified on 4/29/15. d. Resident # 78 - DTI to Right great toe identified on 4/13/15. e. Resident # 90 - Stage II mid spine identified on 4/29/15. f. Resident 100 - Stage II to left heel identified on 4/20/15. g. Resident # 102 - Stage II to sacrum identified on 4/23/15. 2. Skin concerns were placed on the 24 hour report to communicate changes in condition to Licensed Nurses in relation to wounds on 4/29/15. The 24 hour report is reviewed daily by the DON/designee and the nursing management team Monday - Friday during the morning clinical meeting. 3. The C.N.A. 's received an in-service on 4/29/15, by RN J, on utilizing the Stop and Watch tool to report skin concerns. The Stop and Watch tool is a C.N.A. communication sheet used to identify changes in resident condition. The Stop and Watch tool will be turned into the Licensed Nurse at the time the change is noted and a copy of the tool will be given to the DON for follow up. 4. The Licensed Nurses were in-serviced, by RN J, on completing a head to toe skin assessment of residents upon admission on 4/30 and these assessments were initiated with all new admissions on 4/30/15. The treatment nurse/designee will perform a head to toe skin assessment after admission. The treatment nurse/designee will set the schedule for the weekly skin assessments beginning 4/30/15. The Director of Nurses and/or designee will monitor the treatment nurse and charge nurses to ensure system is followed. 5. The treatment nurse/designee will attend the morning clinical meeting held Monday through Friday, to report on findings of the skin assessments beginning on 4/30/15. The Nurse Management team will review for appropriate interventions. 6. The treatment nurse has been in-serviced by RN J and DON, on assessing pressure ulcers with each dressing change and notifying the physician of changes in the pressure ulcer, to include a deterioration of the pressure ulcer on 4/30/15. This in-service was repeated by the CWS on 5/1/15. The treatment nurse/designee will notify the physician and responsible party of the condition of pressure ulcers weekly beginning on 4/30/15. This in-servicing was completed on 4/30/15. 7. The Licensed Nurses and the C.N.A. 's were in-serviced by the nurse managers 4/30/15 on Pressure Ulcer Prevention. The Nurse Managers were in-serviced on 4/29/15 by the Vice President of Clinical Services. This in-service was repeated by the CWS on 5/1/15 with the DON. These measures included the following pressure ulcer prevention interventions: a. Turning and repositioning b. Pressure reducing devices in bed and/or chair such as cushions, pressure reducing mattresses, low air loss mattresses, heel floats, etc. c. Reducing friction and shear by lifting during repositioning d. Active and Passive Range of Motion e. Referral to rehab services for positioning f. Referral to Dietitian for nutritional support recommendations g. Encouraging nutritio

Based on interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to ensure that residents who entered the facility without pressure ulcers did not develop pressure ulcers and residents with pressure ulcers received treatment and services to promote healing for 3 of 13 residents reviewed for pressure sores. (Residents # 57, 34 and 37) The Administrator failed to: --ensure the DON had skills and/or knowledge in training, supervising, and evaluating the wound care staff. --supervise the DON to ensure that nursing staff completed accurate pressure sore assessments and nursing staff was monitored to ensure preventive care was provided to residents at risk for skin breakdown. The DON failed to: --ensure the nursing staff were trained on identifying, reporting and documenting skin issues. --monitor and supervise the nursing staff on accurate pressure sore assessment, use of pressure relieving devices, and that preventive care was provided to residents at risk of skin breakdown. --ensure training were provided to the staff to include the Wound Treatment Nurse to be able to identify, measure and stage pressure sore accurately. --monitor nurses and CNAs on application of pressure reliving devices and following physician's orders [REDACTED]. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 04/29/2015 at 11:25 AM. While the IJ was removed on 05/01/2015 at 7:05 PM, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice had the potential to place 13 residents at risk for developing new or worsening pressure sores, deterioration of existing ones, pain, infection and hospitalization . Findings Include: In an interview on 05/01/2015 at 4:50 PM the Admin stated he was not aware of the situation before it was brought up to him. He stated Resident #34's situation got worse and the facility identified it too late. When asked, what procedures are there to make sure the residents needs are being met, he stated the treatment nurse will report to the morning meeting and report on all the wounds. The charge nurses will report on the halls. All the reports will be placed on the 24 hour report. Also to ensure that the nursing has the skills to do what they need to do. When asked, how will you ensure the systems the DON and ADON monitor are being done sufficiently, he stated by being part of the daily nursing meeting. Understanding what the plan is and being involved in the process and if issues come up addressing them and being involved. Make resources available so that they can do the job they need to. When asked what resources they had available to them, he stated he explained the situation to the Medical Director. The Medical Director though the plan of removal was good. They facility has their sister facility's and the corporate staff and vendors to provide training as needed. In an interview with the DON on 05/01/2015 at 3:05 PM, she stated that she provides in service training on wound care to the facility's nurses. DON further stated that she does not have a background in wound care and she also stated that neither Wound Care Nurse B or RN B had not been checked off on their wound care skills. When asked how do you think the incident came about, she stated the resident has a pressures sores that developed in house. The facility did not take wound measurements, install preventative measures such as heel lifts, heel protectors, special mattresses or perform weekly skin assessments. In an interview with Corporate Nurse A on 05/01/2015 at 05:15 PM, she stated that she does not have special training in wound care. She stated that a Certified Woundcare Specialist (CWS) had been contacted to come to the facility immediately in order to provide comprehensive training to staff on wound care. In an interview with CWS A on 05/01/2015 at 05:50 PM, she stated that she was a Certified Woundcare Specialist (CWS). She stated that she had speciality training in wound care with the designation of CWS. She stated that she had been called by the facility to provide in depth wound care training for the facility staff. Resident # 57 admitted to the facility on [DATE]. His admission MDS assessment dated [DATE] indicated he did not have any pressure ulcers and was not at risk for developing pressure ulcers. He was identified on two Braden Scale assessments conducted by the facility as being a high risk for pressure ulcers and had sacral redness identified on admission. He developed multiple pressure ulcers including unstageable suspected deep tissue injuries to the sacrum and right heel, open areas bilaterally behind ears, and redness to the abdomen. Resident # 34 admitted to the facility on [DATE] with no pressure ulcers. The Admission MDS assessment dated [DATE] indicated he was not at risk for developing pressure ulcers. The Braden Scale initial assessment score was 12 - High Risk. Resident # 34 developed a large unstageable pressure sore to the left heel identified on 04/12/2015. Preventative pressure sore interventions including a heel lift and bilateral heel protectors were not put into place until 04/30/2015. Resident # 37 had one sacral pressure ulcer when admitted to the facility on [DATE], but was identified as low risk for pressure ulcers on two Braden Scale assessments conducted by the facility. Three skin assessments done by the facility did not identify any new areas. A skin assessment conducted on 4/29/15 after the IJ was called revealed a mushy right heal, a blister to the left knee, and three small blisters to the right shin. Observations of wound care on 4/30/15 revealed a new wound to Resident # 37 ' s right leg, below the knee. The facility Administrator was notified on 04/29/2015 at 11:25 AM that an IJ situation had been identified due to above failures. The following Plan of Removal was submitted by the Administrator on 04/29/2014. The final Plan of Removal was accepted by the survey team on 05/01/2015 at 6:15 PM. Plan of Removal The facility submits the following Plan of Removal for the alleged failure to have an effective system in place to implement interventions to prevent wounds from developing and/or worsening. 1. Head to toe skin assessments on 100% of residents initiated on 4/29/15. Any residents with an issue identified during these assessments had interventions ordered and implemented on 4/29/15. The resident's physician and responsible parties were notified of the changes in condition. Resident care plans were updated to reflect interventions. Any residents with skin issues were referred to the Registered Dietitian if warranted. A communication to Rehab was also initiated for evaluation for positioning as warranted. a. 3 residents were identified with new or worsened pressure ulcers by the surveyors prior to the initiation of the IJ. The following is what was identified and what interventions were implemented for those 3 residents: a. Resident # 57 identified with a reddened area on his coccyx on 4/17/15. DTI to right heel identified on 4/19/15. Resident discharged on [DATE] to an inpatient hospice unit. b. Resident # 34 identified with an unstageable pressure ulcer to left heel on 4/12/15 . A DTI to the left great toe on 4/12/15. c. Resident #37 identified with Stage II to sacrum. Stage II to left knee on 4/30/15. b. During the 100% audit of head to toe skin assessments the following residents were identified with pressure ulcers: a. Resident #3 - admitted to facility on 2/11/15 with the following: Unstageable to sacrum. Unstageable to right buttocks. Unstageable to left heel. Unstageable to LL foot. Unstageable to left calf. Unstageable to left outer knee. b. Resident # 12 - Unstageable pressure ulcer to Left Lower Foot identified on 4/16/15. c. Resident # 69 - Stage II to left heel identified on 4/29/15. d. Resident # 78 - DTI to Right great toe identified on 4/13/15. e. Resident # 90 - Stage II mid spine identified on 4/29/15. f. Resident 100 - Stage II to left heel identified on 4/20/15. g. Resident # 102 - Stage II to sacrum identified on 4/23/15. 2. Skin concerns were placed on the 24 hour report to communicate changes in condition to Licensed Nurses in relation to wounds on 4/29/15. The 24 hour report is reviewed daily by the DON/designee and the nursing management team Monday - Friday during the morning clinical meeting. 3. The C.N.A. 's received an in-service on 4/29/15, by RN J, on utilizing the Stop and Watch tool to report skin concerns. The Stop and Watch tool is a C.N.A. communication sheet used to identify changes in resident condition. The Stop and Watch tool will be turned into the Licensed Nurse at the time the change is noted and a copy of the tool will be given to the DON for follow up. 4. The Licensed Nurses were in-serviced, by RN J, on completing a head to toe skin assessment of residents upon admission on 4/30 and these assessments were initiated with all new admissions on 4/30/15. The treatment nurse/designee will perform a head to toe skin assessment after admission. The treatment nurse/designee will set the schedule for the weekly skin assessments beginning 4/30/15. The Director of Nurses and/or designee will monitor the treatment nurse and charge nurses to ensure system is followed. 5. The treatment nurse/designee will attend the morning clinical meeting held Monday through Friday, to report on findings of the skin assessments beginning on 4/30/15. The Nurse Management team will review for appropriate interventions. 6. The treatment nurse has been in-serviced by RN J and DON, on assessing pressure ulcers with each dressing change and notifying the physician of changes in the pressure ulcer, to include a deterioration of the pressure ulcer on 4/30/15. This in-service was repeated by the CWS on 5/1/15. The treatment nurse/designee will notify the physician and responsible party of the condition of pressure ulcers weekly beginning on 4/30/15. This in-servicing was completed on 4/30/15. 7. The Licensed Nurses and the C.N.A. 's were in-serviced by the nurse managers 4/30/15 on Pressure Ulcer Prevention. The Nurse Managers were in-serviced on 4/29/15 by the Vice President of Clinical Services. This in-service was repeated by the CWS on 5/1/15 with the DON. These measures included the following pressure ulcer prevention interventions: a. Turning and repositioning b. Pressure reducing devices in bed and/or chair such as cushions, pressure reducing mattresses, low air loss mattresses, heel floats, etc. c. Reducing friction and shear by lifting during repositioning d. Active and Passive Range of Motion e. Referral to rehab services for positioning f. Referral to Dietitian for nutritional support recommendations g. Encouraging nutritional and hydration intake h. Using moisture barriers for incontinent residents i. Avoiding skin to skin contact j. Protect bony prominence's as needed. 8. The Director of Nurses and/or designee will train all new hires (CNA 's and Licensed Nurses) upon employment at the facility. 9. The facility Medical Director was notified of the Immediate Jeopardy on 4/30/15 related to pressure ulcers and an impromptu QAPI meeting was held. The Medical Director has approved this plan. The survey team monitored the current plan of removal as follows: Reviewed interventions for Resident's # 34 as per stated in plan of removal. All interventions were initiated and carried out. Resident # 37 had a re-assessment of his wounds and new physician orders [REDACTED]. Resident # 57 transferred to a hospice facility. The facility conducted head to toe skin assessment on the residents currently residing in the facility. Skin concerns were addressed immediately. Completion date 4/30/15. Skin concerns were placed on the 24 hour report by hall to communicate to the charge nurses, residents with wounds when documenting daily skilled nurses notes. Completion date 4/29/15 and ongoing. The CNA's received in-service on 4/29/15 on utilizing the Stop and Watch tool to report skin concerns. Completion date 4/29/15. The licensed nurses and CNA's were in-serviced on pressure ulcer prevention for all shift. Completion date 4/30/15. The licensed Nurses were in-serviced on completing head to toe skin assessments. Completion date 4/30/15. The treatment nurse were in-serviced on assessing pressure ulcers, physician notification, deterioration of the pressure ulcer. Completion date 4/30/15. All in-service documentation was reviewed and attendance checked to ensure all licensed nurses were in-serviced. Completion date 4/30/15. Interviews conducted on 05/01/2015 with licensed nursing staff reflected the nurses knew how to appropriately identify, stage, treat and prevent pressure sores. Interviews conducted on 05/01/2015 with certified nursing aides reflected the CNA's knew how to report changes in resident skin, and how to monitor for changes in resident skin. On 05/01/2015 at 7:05 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 13 residents at risk for pressure sores. Refer to F314 for additional information.

Based on observation, interview and record review, the facility failed to ensure services provided or arranged by the facility met professional standards of quality for 2 of 6 residents (Residents CR#2, and #3) reviewed for skin assessments and treatments, as evidenced by: -CR #2 was never assessed for a necrotic toe and had to have an amputation; -Resident #3's records revealed she had no orders for an open pressure ulcer stage 2 on her sacrum and inappropriate orders for eschar on her heel. This failure affected 2 residents and placed the remaining 96 residents in the facility at risk of not receiving adequate skin assessments and interventions to prevent skin breakdown, pressure ulcers, venous ulcers and possible infections of wounds not assessed properly. Complaint # 8 Incident # 1 Findings include: CR #2 Record review of CR #2's closed facility medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of CR #2's Admission MDS assessment dated [DATE] revealed his BIMS score to be 5 of 15. He required extensive assistance from staff for ADLS, had complaints of pain on a scale of 0-10 as "5", received PT, OT, and ST, and was coded "0" for skin problems. Record review of CR #2's MDS assessment dated [DATE] revealed his BIMS score was 8 of 15. He was coded as having no skin problems. Record review of the incident investigation dated 7/14/14, relating to finding CR #2's necrotic toe revealed it was reported to the physician. Review of the written statements by staff caring for CR #2 during his stay in the facility revealed a hand written statement by CNA A which reflected that on July 3rd 2014 she was the shower tech and noticed "redness on his right big toe. I asked him has the nurse looked at it and he replied yes and stated it comes from his illness and I asked does it hurt he said no, after that I asked if someone treating it and he said yes, then I continued with his shower and charted him down in my Skin Inspection Record book." CNA A was unavailable to interview during the survey. Another written statement by the Administrator and DON dated 7/14/2014 revealed an interview conducted with LVN A, the treatment nurse, who said she had performed CR #2's skin assessment on Wednesday, 7/9/2014, and had found no wounds to the lower extremities. During a telephone interview on 7/15/2014 at 2:25 PM, CR #2's family member said that the resident was admitted to the facility because he had been falling at home and was becoming more confused. She stated he had no skin problems when he was admitted . She said another family member had checked CR #2 "Friday night and he was told his CR #2's toe was pink and a little puffy. He was usually up and around, because he was pretty much independent with walking and dressing himself. He could tell you what happened. He told us that he had told a nurse that his foot was hurting and they told him there was nothing that could be done because he was a diabetic. At the hospital his toe was necrotic and almost falling off. The doctors at the hospital said it might fall off before they could do surgery." During an interview on 7/15/2014 at 1:45 PM with the DON and Corporate Nurse they stated the weekend nurse just told them about CR #2's foot. The DON said that she had received a call Sunday night (7/14/2014) that a CNA had reported to the charge nurse when she was putting CR #2 to bed that CR#2's toe was "leaking and malodorous". The charge nurse and week-end supervisor called the doctor, the family, and the DON. The DON said that the resident went to the hospital as a direct admit per the physician. Further interview on 7/15/2014 at 1:45 PM, the DON and Corporate Nurse revealed they had started the investigation on 7/14/2014 and had called it into DADS on 7/14/2014 as a self-report. She said the Treatment Nurse had been suspended pending the outcome of the investigation. Both nurses said they were doing "Head to toe skin assessments on everyone in the building." The Corporate Nurse provided a 3 ring binder titled "Action Plan for Park Manor of the Woodlands/Skin System." This plan revealed that all nursing staff who had worked with CR #2 since 7/07/2014 were interviewed about his skin condition. The Action Plan contained a Care Plan on how the actions were going to take place and who would be responsible for different tasks/schedules. The Action Plan contained the following: " Initiate a 'Stop and Watch Tool Sheet' (triplicate document when any skin issues were noted); Head to Toe assessments initiated on all residents in facility with outcome pending completion and comprehensive reviews;1-1 in-servicing initiated with nursing staff on use of 'Stop and Watch Tool', when and what to report, who to report to, and a carbon copy will be turned in to the DON for follow up; in-services initiated to facility licensed nurses on how to properly conduct a head to toe assessment; in-services initiated to facility staff licensed nurses on 'Stop and Watch Tool' and use of SBAR (started 7/15/2014); DON or designee to conduct random head to toe skin assessments (approximately 5 residents a week) for high risk residents not currently on wound care case load; in-services started on 7/14/2014 for nursing staff related to correct skin assessments, to include: Upon injury residents must receive a complete skin assessment; Ensure you remove socks/ted hose/sandles, etc.; in-services initiated 7/14/2014 for Medication Aides and Licensed Nurses related to removal of daily medication patches...removal time for patches will be included on the MAR; remove old patch before applying new one; in-services initiated 7/14/2014 titled "Skin Assessments", ensure you are viewing all residents' skin, including feet and toes by removing shoes,socks, etc." During an interview on 7/15/2014 at 1:45 PM with LVN B he stated he had been doing wound care on weekends under the supervision of LVN A. He stated that he had been asked to take over temporarily the role of treatment nurse until the investigation was completed. During an interview on 7/15/2014 at 4:10 PM with the DON she said the charge nurse was responsible for performing the initial head to toe assessments for newly admitted residents and to document any findings. The DON said that the Treatment Nurse (LVN A) then followed up the next day and did another head to toe assessment. The DON further explained that the LVN A involved in the investigation had been with the facility "a few months " and was a certified wound care nurse. The DON said LVN A had been suspended until they completed the investigation, but they had been unhappy with some of the findings and would likely "fire her." The DON said the facility had a wound care physician who came in weekly to see residents with pressure ulcers or severe wounds. She said that she would sometimes do rounds with the doctor and the treatment nurse. Record review of CR #2's closed facility medical record revealed a History and Physical dated 5/29/2014 from a previous hospital stay that reflected he had an earlier stay in a nursing home due to his [MEDICAL CONDITION]. This H & P revealed his [DIAGNOSES REDACTED]. The Skin Exam portion of this document revealed "No [MEDICAL CONDITION] of significance." An interview on 7/15/2014 at 4:45 PM with the Corporate Nurse reflected that the facility was still undergoing investigation into skin issues with CR #2. She said that the DON, herself, and two Unit Managers were currently doing one on one in-services with all the nursing staff related to skin assessments, recognizing skin problems, preventing skin problems, how to properly use the "Stop and Watch" tool, who to report to, and when to report. She further stated that the DON would be responsible to do random head to toe skin assessments "about 5 residents a week" who were considered high risk for developing pressure sores and not currently on the skin care caseload. Record review of in-services currently having been initiated on 7/14/2014 documented that the following in-service subjects were provided to nursing staff: Correct skin assessment, correct skin assessments for injured residents, complete skin assessments, remove all clothing including shoes and socks, LVN and MA medication administration related to topical patch removal times, topical patch removal times put on MARS as reminders to remove the patches as ordered, skin assessment viewing on all residents on a routine schedule, and skin assessments to include feet and toes. During a telephone interview on 7/16/2014 at 2:30 PM, LVN C stated that CR #2 preferred to dress himself. She said he always wore socks and shoes. She said he was confused. She said that as soon as the aide found the foot sore we put a bandage on it but he kept taking it off and putting on his socks. She stated "I had no idea there was anything wrong with his foot. He had just moved to my floor. I did not notice any odor until I went to his room after the aide told me (7/14/2014). I was his charge nurse. As soon as I saw it I went to get the week-end supervisor and called the doctor and his family. He never complained of pain for me. He was constantly up and down in and out of his wheelchair and bed, so we were in there a lot because of the alarms. He would refuse to use the call light." An interview on 7/16/2014 at 3:30 PM with CM X at the hospital revealed she had seen CR #2's foot when he had originally come in. She stated he was having surgery at this time and his chart was unavailable because it was in surgery. Copies of his hospital record were obtained at this time. According to CM X CR #2's right fifth toe was "black and shriveled up like a raisin. It looked like it was about to fall off." A telephone interview on 7/16/2014 at 4:20 PM with RN A revealed she was the weekend supervisor. She said she was called to CR #2's room to look at his right toe on 7/14/2014. She said the charge nurse and CNA told her that CR #2's wound was leaking. "His right pinky toe was starting to get necrotic. I checked it and called the treatment nurse and the DON. I also called the doctor who gave us orders to treat it and get cultures and start antibiotics. There was nothing in his closed facility chart or TAR that indicated he had any wound." During an interview on 7/16/2014 at 4:35 PM with LVN A she said she was the treatment nurse. She said she had seen CR #2 when she had been in the facility, but was not treating him. She said "I am a wound care certified nurse now and I feel confident in taking care of patients. Typically, I get to order what I feel is right. I got permission to go ahead and treat with what I thought was needed from the doctors. I would write the orders. I could always call the wound care doctor for recommendations. He came out once a week, usually on a Monday or Thursday and we'd do rounds. Not on everyone. (CR #2) was not on our care. I never did a skin assessment on him. I do have a schedule to do skin assessments on residents. He could walk OK and used a wheelchair. He never complained of pain to me. The admitting nurse does the initial skin assessment and then I follow up. Me or the weekend treatment nurse. I do pull off socks and shoes or whatever. He had some bruising but nothing else. The CNAs and shower techs are very good about letting me know if anything is wrong with a resident's skin. He was already gone to the hospital when I came in Monday, so I didn't see it." When asked if she felt comfortable writing orders herself as an LVN, LVN A said "Yes, I do feel comfortable writing orders for treatments without a doctor's orders. I'll give the doctor's a heads up if I want to change something, being certified now I do write orders. I will go to the doctor's if I need to." An interview on 7/16/2014 at 5:25 PM with LVN B he said he would never write orders without a physician telling me what he or she wanted. During an interview on 7/16/2014 at 5:50 PM with the DON and Corporate Nurse, they both stated that nurses can take orders from physicians, but they never write or carry out an order without the doctor telling them what to do. During a telephone interview on 7/17/2014 at 10:30 AM with Dr. A, he stated that CR #2 had surgery to remove the toe and part of his foot, "this morning". He stated he had not been told about the toe prior to the evening of 7/13/2014 when he gave orders to start antibiotics and admit the resident to the hospital. Dr. A said he had not visualized the foot prior to the resident arriving at the hospital. He said "It didn't look good." When asked how long it usually took for a toe or foot to turn gangrenous, Dr. A stated "It could take days. It is hard to tell how long it would have taken to get that bad. Certainly not over-night." When asked if he had authorized an LVN certified wound nurse to write her own orders, Dr A said "No. The procedure is they call if they want to order something. It is our license." During a telephone interview on 7/17/2014 at 10:45 AM with Dr. B he stated he was the facility's wound care doctor and he had not been told about CR #2's wound. When asked how long he thought it would take for a wound to become necrotic, he said it would "depend on a lot of things, normally a week to three or four weeks, unless it was embolic which is very rare." When asked if he had given an LVN wound certified nurse the ability to write her own orders, Dr. B said "She calls me for orders and I tell her what I want." Further review of CR #2's closed facility medical records revealed he had been sent to the hospital by his physician on 7/14/2014 due to necrosis and pain of his right fifth toe. Record review of CR #2's hospital records dated 7/14/2014 revealed: "Direct admit from Nursing facility (Park Manor of the Woodlands) because of right fifth toe necrosis.....Integumentary: Right fifth toe is necrotic with foul smell with surrounding [DIAGNOSES REDACTED] on the right distal foot. Left fifth toe has a dry eschar as well..." Record review of CR #2's Progress note dated 7/14/2014 read in part "Resident found with open areas, discoloration to R pinky toe, R hallux, L pinky toe. Foul odor present. Dr. A and family notified with order to send to (hospital) direct admit ....." According to CR #2's facility medical record he had sustained 3 unwitnessed falls in his room without injuries, and had a bed and chair alarm in place. Record review of a hand written witness statement by CNA B, dated 7/13/2014, read in part "I observed some broken down spots on his left foot asked him what happen he stated it was from his diabetes. I told the nurse..." Record review of a hand written witness statement by CNA C, dated 7/13/2014, read in part "After dinner I started to put people to bed. I started with (CR#2). I took off his shoes and saw that his feet were leaking and smelled so I told my nurse." Resident #3 Record review of Resident #3's facility medical record revealed she was admitted to the facility on [DATE], and had a more recent readmission date of [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of the facility's CMS Form 802 did not document Resident #3 as having a pressure ulcer or worsening pressure ulcer. Record review of Resident #3's facility medical record revealed a document titled "Unavoidable Pressure Ulcer Risk Assessment Criteria" dated 7/09/2014 which was signed by a physician. This document read in part "History of healed decubitus? Yes, sacrum and left heel." Her Care Plan read in part "Right heel unstageable" and was dated as reviewed on 7/11/2014. This same Care Plan read in part "Stage 3 sacrum" dated as reviewed 7/04/2014. Record review of Resident #3's "Wound Treatment and Progress Report" dated 7/10/2014 read in part "Healed 7/10/2014 - upper back wound. Healed 7/07/2014 resolved Stage 3 sacrum." Observation on 7/15/2014 at 1:20 PM of Resident #3 revealed she was very thin, did not communicate, had her eyes open and was lying in a low air loss mattress bed, with the head of the bed up 40 degrees. She had a [DEVICE] infusing through a pump at 55 cc/hr. She was observed to have an indwelling urinary catheter hanging off the side of the bed to the collection bag. There was thick creamy looking sediment in the tubing going to the collection bag. Resident #3 was observed to have bilateral heel boots on her feet. Observation on 7/15/2014 at 2:00 PM of Resident #3's skin assessment with LVN B revealed several reddened areas over boney prominences on her feet. The right heel was completely covered with thick eschar with redness spreading to her right outer ankle. Her right big toe had discoloration (darkened area) next to the second toe. There was an observation of a reddened area under her right leg where the edge of the boot touches the leg. Resident #3's right hip was reddened over the boney prominence. Over the sacral area, Resident was observed to have open areas that were Stage 2 pressure ulcers. An observation on 7/16/2014 at 9:55 AM of wound care for Resident #3 was conducted by LVN B. There was no cross-contamination problems observed. The treatments were carried out as ordered by the physician. The areas of skin care treatments were the sacrum (Stage 2), right heel eschar, and right outer ankle. During an interview on 7/16/2014 at 5:50 PM with the DON and Corporate Nurse, they said they had just completed the skin assessments for Resident #3 and had staged her sacrum as a Stage 2 pressure ulcer. The DON said that they had looked at Resident #3's TAR and LVN A had apparently written "healed" by the Stage 3 sacral ulcer. The DON said it had likely re-opened and had not been reported. Record review of Resident #3's TAR revealed she had received treatment to a stage 2 pressure ulcer on her left heel which was discontinued on 6/23/2014. This same TAR read in part that she was also being treated for [REDACTED]." During a telephone interview on 7/17/2014 at 10:45 AM with Dr. B he stated he was the facility's wound care doctor. When asked if he thought that alcohol was an appropriate treatment for [REDACTED]. B said he never used alcohol for wounds. During an interview on 7/17/2014 at 1:30 PM with the DON she said the facility's skin care regime had been changed. She said that all the residents had been assessed from head to toe and a lot of changes had been put in place including orders for Doppler studies. "We have re-done the entire skin care and treatment process. We have a new plan and program to follow. Myself, the ADON and the two Unit Managers have routine residents to assess on a weekly and as needed basis." Record review of the facility's policy and procedure titled "Physician Medication Orders" dated 4/2010, read in part "Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state." Record review of the facility's policy and procedure titled "Pressure Ulcer Risk Assessment" dated 3/2005, read in part "General Guidelines; ....4) If pressure ulcers are not treated when discovered, they quickly get larger, become painful for the resident, and often times become infected ....6) Once a pressure ulcer develops, it can be extremely difficult to heal ....9) Pressure ulcers are a serious skin condition for the patient ....Assessment 1) Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes .....2) Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated ...3) Monitoring. A) Nurses are to be notified to inspect the skin if skin changes are identified ... B) Nurses will conduct skin assessments at least weekly to identify changes ....4) in addition, .....purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION] or induration)suggesting that deep tissue damage has already occurred ...." Record review of the Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 titled Standards of Nursing Pracitce revealed: "... (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: ... (iv) implementing appropriate aspects of care within the LVN's scope of practice; and ... ". According to the facility's CMS Form 672, there were 7 residents with pressure sores being treated in the facility. According to the census there were 98 residents residing in the facility.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with their comprehensive assessment and plan of care for 1 of 3 closed records (discharged ) residents (CR #s 2) and 1 of 4 [MEDICATION NAME] residents (Resident #3) assessed for wound care and skin assessments, as evidenced by: -CR #2 was never assessed for a necrotic toe and had to have an amputation; his Care Plan only assessed he was "at risk" for pressure ulcers. -Resident #3's records revealed she had no orders for an open pressure ulcer Stage 2 on her sacrum and inappropriate orders for eschar on her heel. This failure affected one discharged resident and 1 current resident, placing the remaining 97 residents in the facility at risk of not receiving adequate skin assessments and interventions to prevent skin breakdown, pressure ulcers, venous ulcers and possible infections of wounds not assessed properly. Complaint # 8 Incident # 1 Findings include: CR #2 Record review of CR #2's closed facility medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of CR #2's Admission MDS assessment dated [DATE] revealed his BIMS score to be 5 of 15. He required extensive assistance from staff for ADLS, had complaints of pain on a scale of 0-10 as "5", received PT, OT, and ST, and was coded "0" for skin problems. Record review of CR #2's MDS assessment dated [DATE] revealed his BIMS score was 8 of 15. He was coded as having no skin problems. Record review of the incident investigation dated 7/14/14, relating to finding CR #2's necrotic toe revealed it was reported to the physician. Review of the written statements by staff caring for CR #2 during his stay in the facility revealed a hand written statement by CNA A which reflected that on July 3rd 2014 she was the shower tech and noticed "redness on his right big toe. I asked him has the nurse looked at it and he replied yes and stated it comes from his illness and I asked does it hurt he said no, after that I asked if someone treating it and he said yes, then I continued with his shower and charted him down in my Skin Inspection Record book." CNA A was unavailable to interview during the survey. Another written statement by the Administrator and DON dated 7/14/2014 revealed an interview conducted with LVN A, the treatment nurse, who said she had performed CR #2's skin assessment on Wednesday, 7/9/2014, and had found no wounds to the lower extremities. During a telephone interview on 7/15/2014 at 2:25 PM, CR #2's family member said that the resident was admitted to the facility because he had been falling at home and was becoming more confused. She stated he had no skin problems when he was admitted . She said another family member had checked CR #2 "Friday night and he was told his CR #2's toe was pink and a little puffy. He was usually up and around, because he was pretty much independent with walking and dressing himself. He could tell you what happened. He told us that he had told a nurse that his foot was hurting and they told him there was nothing that could be done because he was a diabetic. At the hospital his toe was necrotic and almost falling off. The doctors at the hospital said it might fall off before they could do surgery." During an interview on 7/15/2014 at 1:45 PM with the DON and Corporate Nurse they stated the weekend nurse just told them about CR #2's foot. The DON said that she had received a call Sunday night (7/14/2014) that a CNA had reported to the charge nurse when she was putting CR #2 to bed that CR#2's toe was "leaking and malodorous". The charge nurse and week-end supervisor called the doctor, the family, and the DON. The DON said that the resident went to the hospital as a direct admit per the physician. Further interview on 7/15/2014 at 1:45 PM, the DON and Corporate Nurse revealed they had started the investigation on 7/14/2014 and had called it into DADS on 7/14/2014 as a self-report. She said the Treatment Nurse had been suspended pending the outcome of the investigation. Both nurses said they were doing "Head to toe skin assessments on everyone in the building." The Corporate Nurse provided a 3 ring binder titled "Action Plan for Park Manor of the Woodlands/Skin System." This plan revealed that all nursing staff who had worked with CR #2 since 7/07/2014 were interviewed about his skin condition. The Action Plan contained a Care Plan on how the actions were going to take place and who would be responsible for different tasks/schedules. The Action Plan contained the following: " Initiate a 'Stop and Watch Tool Sheet' (triplicate document when any skin issues were noted); Head to Toe assessments initiated on all residents in facility with outcome pending completion and comprehensive reviews;1-1 in-servicing initiated with nursing staff on use of 'Stop and Watch Tool', when and what to report, who to report to, and a carbon copy will be turned in to the DON for follow up; in-services initiated to facility licensed nurses on how to properly conduct a head to toe assessment; in-services initiated to facility staff licensed nurses on 'Stop and Watch Tool' and use of SBAR (started 7/15/2014); DON or designee to conduct random head to toe skin assessments (approximately 5 residents a week) for high risk residents not currently on wound care case load; in-services started on 7/14/2014 for nursing staff related to correct skin assessments, to include: Upon injury residents must receive a complete skin assessment; Ensure you remove socks/ted hose/sandles, etc.; in-services initiated 7/14/2014 for Medication Aides and Licensed Nurses related to removal of daily medication patches...removal time for patches will be included on the MAR; remove old patch before applying new one; in-services initiated 7/14/2014 titled "Skin Assessments", ensure you are viewing all residents' skin, including feet and toes by removing shoes,socks, etc." During an interview on 7/15/2014 at 1:45 PM with LVN B he stated he had been doing wound care on weekends under the supervision of LVN A. He stated that he had been asked to take over temporarily the role of treatment nurse until the investigation was completed. During an interview on 7/15/2014 at 4:10 PM with the DON she said the charge nurse was responsible for performing the initial head to toe assessments for newly admitted residents and to document any findings. The DON said that the Treatment Nurse (LVN A) then followed up the next day and did another head to toe assessment. The DON further explained that the LVN A involved in the investigation had been with the facility "a few months " and was a certified wound care nurse. The DON said LVN A had been suspended until they completed the investigation, but they had been unhappy with some of the findings and would likely "fire her." The DON said the facility had a wound care physician who came in weekly to see residents with pressure ulcers or severe wounds. She said that she would sometimes do rounds with the doctor and the treatment nurse. Record review of CR #2's closed facility medical record revealed a History and Physical dated 5/29/2014 from a previous hospital stay that reflected he had an earlier stay in a nursing home due to his [MEDICAL CONDITION]. This H & P revealed his [DIAGNOSES REDACTED]. The Skin Exam portion of this document revealed "No [MEDICAL CONDITION] of significance." An interview on 7/15/2014 at 4:45 PM with the Corporate Nurse reflected that the facility was still undergoing investigation into skin issues with CR #2. She said that the DON, herself, and two Unit Managers were currently doing one on one in-services with all the nursing staff related to skin assessments, recognizing skin problems, preventing skin problems, how to properly use the "Stop and Watch" tool, who to report to, and when to report. She further stated that the DON would be responsible to do random head to toe skin assessments "about 5 residents a week" who were considered high risk for developing pressure sores and not currently on the skin care caseload. Record review of in-services currently having been initiated on 7/14/2014 documented that the following in-service subjects were provided to nursing staff: Correct skin assessment, correct skin assessments for injured residents, complete skin assessments, remove all clothing including shoes and socks, LVN and MA medication administration related to topical patch removal times, topical patch removal times put on MARS as reminders to remove the patches as ordered, skin assessment viewing on all residents on a routine schedule, and skin assessments to include feet and toes. During a telephone interview on 7/16/2014 at 2:30 PM, LVN C stated that CR #2 preferred to dress himself. She said he always wore socks and shoes. She said he was confused. She said that as soon as the aide found the foot sore we put a bandage on it but he kept taking it off and putting on his socks. She stated "I had no idea there was anything wrong with his foot. He had just moved to my floor. I did not notice any odor until I went to his room after the aide told me (7/14/2014). I was his charge nurse. As soon as I saw it I went to get the week-end supervisor and called the doctor and his family. He never complained of pain for me. He was constantly up and down in and out of his wheelchair and bed, so we were in there a lot because of the alarms. He would refuse to use the call light." An interview on 7/16/2014 at 3:30 PM with CM X at the hospital revealed she had seen CR #2's foot when he had originally come in. She stated he was having surgery at this time and his chart was unavailable because it was in surgery. Copies of his hospital record were obtained at this time. According to CM X CR #2's right fifth toe was "black and shriveled up like a raisin. It looked like it was about to fall off." A telephone interview on 7/16/2014 at 4:20 PM with RN A revealed she was the weekend supervisor. She said she was called to CR #2's room to look at his right toe on 7/14/2014. She said the charge nurse and CNA told her that CR #2's wound was leaking. "His right pinky toe was starting to get necrotic. I checked it and called the treatment nurse and the DON. I also called the doctor who gave us orders to treat it and get cultures and start antibiotics. There was nothing in his closed facility chart or TAR that indicated he had any wound." During an interview on 7/16/2014 at 4:35 PM with LVN A she said she was the treatment nurse. She said she had seen CR #2 when she had been in the facility, but was not treating him. She said "I am a wound care certified nurse now and I feel confident in taking care of patients. Typically, I get to order what I feel is right. I got permission to go ahead and treat with what I thought was needed from the doctors. I would write the orders. I could always call the wound care doctor for recommendations. He came out once a week, usually on a Monday or Thursday and we'd do rounds. Not on everyone. (CR #2) was not on our care. I never did a skin assessment on him. I do have a schedule to do skin assessments on residents. He could walk OK and used a wheelchair. He never complained of pain to me. The admitting nurse does the initial skin assessment and then I follow up. Me or the weekend treatment nurse. I do pull off socks and shoes or whatever. He had some bruising but nothing else. The CNAs and shower techs are very good about letting me know if anything is wrong with a resident's skin. He was already gone to the hospital when I came in Monday, so I didn't see it." When asked if she felt comfortable writing orders herself as an LVN, LVN A said "Yes, I do feel comfortable writing orders for treatments without a doctor's orders. I'll give the doctor's a heads up if I want to change something, being certified now I do write orders. I will go to the doctor's if I need to." An interview on 7/16/2014 at 5:25 PM with LVN B he said he would never write orders without a physician telling me what he or she wanted. During an interview on 7/16/2014 at 5:50 PM with the DON and Corporate Nurse, they both stated that nurses can take orders from physicians, but they never write or carry out an order without the doctor telling them what to do. During a telephone interview on 7/17/2014 at 10:30 AM with Dr. A, he stated that CR #2 had surgery to remove the toe and part of his foot, "this morning". He stated he had not been told about the toe prior to the evening of 7/13/2014 when he gave orders to start antibiotics and admit the resident to the hospital. Dr. A said he had not visualized the foot prior to the resident arriving at the hospital. He said "It didn't look good." When asked how long it usually took for a toe or foot to turn gangrenous, Dr. A stated "It could take days. It is hard to tell how long it would have taken to get that bad. Certainly not over-night." When asked if he had authorized an LVN certified wound nurse to write her own orders, Dr A said "No. The procedure is they call if they want to order something. It is our license." During a telephone interview on 7/17/2014 at 10:45 AM with Dr. B he stated he was the facility's wound care doctor and he had not been told about CR #2's wound. When asked how long he thought it would take for a wound to become necrotic, he said it would "depend on a lot of things, normally a week to three or four weeks, unless it was embolic which is very rare." When asked if he had given an LVN wound certified nurse the ability to write her own orders, Dr. B said "She calls me for orders and I tell her what I want." Further review of CR #2's closed facility medical records revealed he had been sent to the hospital by his physician on 7/14/2014 due to necrosis and pain of his right fifth toe. Record review of CR #2's hospital records dated 7/14/2014 revealed: "Direct admit from Nursing facility (Park Manor of the Woodlands) because of right fifth toe necrosis.....Integumentary: Right fifth toe is necrotic with foul smell with surrounding [DIAGNOSES REDACTED] on the right distal foot. Left fifth toe has a dry eschar as well..." Record review of CR #2's Progress note dated 7/14/2014 read in part "Resident found with open areas, discoloration to R pinky toe, R hallux, L pinky toe. Foul odor present. Dr. A and family notified with order to send to (hospital) direct admit ....." According to CR #2's facility medical record he had sustained 3 unwitnessed falls in his room without injuries, and had a bed and chair alarm in place. Record review of a hand written witness statement by CNA B, dated 7/13/2014, read in part "I observed some broken down spots on his left foot asked him what happen he stated it was from his diabetes. I told the nurse..." Record review of a hand written witness statement by CNA C, dated 7/13/2014, read in part "After dinner I started to put people to bed. I started with (CR#2). I took off his shoes and saw that his feet were leaking and smelled so I told my nurse." Resident #3 Record review of Resident #3's facility medical record revealed she was admitted to the facility on [DATE], and had a more recent readmission date of [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of the facility's CMS Form 802 did not document Resident #3 as having a pressure ulcer or worsening pressure ulcer. Record review of Resident #3's facility medical record revealed a document titled "Unavoidable Pressure Ulcer Risk Assessment Criteria" dated 7/09/2014 which was signed by a physician. This document read in part "History of healed decubitus? Yes, sacrum and left heel." Her Care Plan read in part "Right heel unstageable" and was dated as reviewed on 7/11/2014. This same Care Plan read in part "Stage 3 sacrum" dated as reviewed 7/04/2014. Record review of Resident #3's "Wound Treatment and Progress Report" dated 7/10/2014 read in part "Healed 7/10/2014 - upper back wound. Healed 7/07/2014 resolved Stage 3 sacrum." Observation on 7/15/2014 at 1:20 PM of Resident #3 revealed she was very thin, did not communicate, had her eyes open and was lying in a low airloss mattress bed, with the head of the bed up 40 degrees. She had a [DEVICE] infusing through a pump at 55 cc/hr. She was observed to have an indwelling urinary catheter hanging off the side of the bed to the collection bag. There was thick creamy looking sediment in the tubing going to the collection bag. Resident #3 was observed to have bilateral heel boots on her feet. Observation on 7/15/2014 at 2:00 PM of a skin assessment for Resident #3 with LVN B revealed several reddened areas over boney prominences on her feet. The right heel was completely covered with thick eschar with redness spreading to her right outer ankle. Her right big toe had discoloration (darkened area) next to the second toe. There was an observation of a reddened area under her right leg where the edge of the boot touches the leg. Resident #3's right hip was reddened over the boney prominence. Over the sacral area, Resident was observed to have open areas that appeared to be Stage 2 pressure ulcers. An observation on 7/16/2014 at 9:55 AM of wound care for Resident #3 was conducted by LVN B. There was no cross-contamination problems observed. The treatments were carried out as ordered by the physician. The areas of skin care treatments were the sacrum (Stage 2), right heel eschar, and right outer ankle. During an interview on 7/16/2014 at 5:50 PM with the DON and Corporate Nurse, they said they had just completed the skin assessments for Resident #3 and had staged her sacrum as a Stage 2 pressure ulcer. The DON said that they had looked at Resident #3's TAR and LVN A had apparently written "healed" by the Stage 3 sacral ulcer. The DON said it had likely re-opened and had not been reported. Record review of Resident #3's TAR revealed she had received treatment to a stage 2 pressure ulcer on her left heel which was discontinued on 6/23/2014. This same TAR read in part that she was also being treated for [REDACTED]." During a telephone interview on 7/17/2014 at 10:45 AM with Dr. B he stated he was the facility's wound care doctor. When asked if he thought that alcohol was an appropriate treatment for [REDACTED]. B said he never used alcohol for wounds. During an interview on 7/17/2014 at 1:30 PM with the DON she said the facility's skin care regime had been changed. She said that all the residents had been assessed from head to toe and a lot of changes had been put in place including orders for Doppler studies. "We have re-done the entire skin care and treatment process. We have a new plan and program to follow. Myself, the ADON and the two Unit Managers have routine residents to assess on a weekly and as needed basis." Record review of the facility's policy and procedure titled "Physician Medication Orders" dated 4/2010, read in part "Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state." Record review of the facility's policy and procedure titled "Pressure Ulcer Risk Assessment" dated 3/2005, read in part "General Guidelines; ....4) If pressure ulcers are not treated when discovered, they quickly get larger, become painful for the resident, and often times become infected ....6) Once a pressure ulcer develops, it can be extremely difficult to heal ....9) Pressure ulcers are a serious skin condition for the patient ....Assessment 1) Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes .....2) Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated ...3) Monitoring. A) Nurses are to be notified to inspect the skin if skin changes are identified ... B) Nurses will conduct skin assessments at least weekly to identify changes ....4) in addition, .....purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION] or induration)suggesting that deep tissue damage has already occurred ...." According to the facility's CMS Form 672 there were 7 residents with pressure sores being treated in the facility. According to the census there were 98 residents residing in the facility.

Based on interview and record review, the Administrator and Director of Nurses failed to effectively and efficiently manage facility resources resulting in system failures which affected two of six residents (CR #2 and Resident#3) reviewed for pressure sores. Complaint # 8 Incident # 1 The Administrator failed to: Supervise and monitor the DON to ensure she carried out her responsibilities in the areas of assessments and monitoring of medical conditions. Ensure that staff was providing interventions to prevent and treat wounds or skin problems. The DON failed to: Ensure that staff was adequately monitoring residents for skin breakdown or skin conditions requiring intervention and monitoring. Treatment nurse, LVN A failed to: Provide all residents weekly skin assessments and monitor skin problems. These failures of the Administrator, DON and Treatment Nurse (LVN A), affected one resident and placed all 98 residents at risk for not receiving adequate skin assessments and interventions to prevent skin breakdown, pressure ulcers, venous ulcers and possible infections of wounds not assessed properly. Findings include: CR # 2 Record review of CR #2's closed facility medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of CR #2's Admission MDS assessment dated [DATE] revealed his BIMS score to be 5 of 15. He required extensive assistance from staff for ADLS, had complaints of pain on a scale of 0-10 as "5", received PT, OT, and ST, and was coded "0" for skin problems. Record review of CR #2's MDS assessment dated [DATE] revealed his BIMS score was 8 of 15. He was coded as having no skin problems. Record review of the incident investigation dated 7/14/14, relating to finding CR #2's necrotic toe revealed it was reported to the physician. Review of the written statements by staff caring for CR #2 during his stay in the facility revealed a hand written statement by CNA A which reflected that on July 3rd 2014 she was the shower tech and noticed "redness on his right big toe. I asked him has the nurse looked at it and he replied yes and stated it comes from his illness and I asked does it hurt he said no, after that I asked if someone treating it and he said yes, then I continued with his shower and charted him down in my Skin Inspection Record book." CNA A was unavailable to interview during the survey. Another written statement by the Administrator and DON dated 7/14/2014 revealed an interview conducted with LVN A, the treatment nurse, who said she had performed CR #2's skin assessment on Wednesday, 7/9/2014, and had found no wounds to the lower extremities. During a telephone interview on 7/15/2014 at 2:25 PM, CR #2's family member said that the resident was admitted to the facility because he had been falling at home and was becoming more confused. She stated he had no skin problems when he was admitted . She said another family member had checked CR #2 "Friday night and he was told his CR #2's toe was pink and a little puffy. He was usually up and around, because he was pretty much independent with walking and dressing himself. He could tell you what happened. He told us that he had told a nurse that his foot was hurting and they told him there was nothing that could be done because he was a diabetic. At the hospital his toe was necrotic and almost falling off. The doctors at the hospital said it might fall off before they could do surgery." During an interview on 7/15/2014 at 1:45 PM with the DON and Corporate Nurse they stated the weekend nurse just told them about CR #2's foot. The DON said that she had received a call Sunday night (7/14/2014) that a CNA had reported to the charge nurse when she was putting CR #2 to bed that CR#2's toe was "leaking and malodorous". The charge nurse and week-end supervisor called the doctor, the family, and the DON. The DON said that the resident went to the hospital as a direct admit per the physician. Further interview on 7/15/2014 at 1:45 PM, the DON and Corporate Nurse revealed they had started the investigation on 7/14/2014 and had called it into DADS on 7/14/2014 as a self-report. She said the Treatment Nurse had been suspended pending the outcome of the investigation. Both nurses said they were doing "Head to toe skin assessments on everyone in the building." The Corporate Nurse provided a 3 ring binder titled "Action Plan for Park Manor of the Woodlands/Skin System." This plan revealed that all nursing staff who had worked with CR #2 since 7/07/2014 were interviewed about his skin condition. The Action Plan contained a Care Plan on how the actions were going to take place and who would be responsible for different tasks/schedules. The Action Plan contained the following: " Initiate a 'Stop and Watch Tool Sheet' (triplicate document when any skin issues were noted); Head to Toe assessments initiated on all residents in facility with outcome pending completion and comprehensive reviews;1-1 in-servicing initiated with nursing staff on use of 'Stop and Watch Tool', when and what to report, who to report to, and a carbon copy will be turned in to the DON for follow up; in-services initiated to facility licensed nurses on how to properly conduct a head to toe assessment; in-services initiated to facility staff licensed nurses on 'Stop and Watch Tool' and use of SBAR (started 7/15/2014); DON or designee to conduct random head to toe skin assessments (approximately 5 residents a week) for high risk residents not currently on wound care case load; in-services started on 7/14/2014 for nursing staff related to correct skin assessments, to include: Upon injury residents must receive a complete skin assessment; Ensure you remove socks/ted hose/sandles, etc.; in-services initiated 7/14/2014 for Medication Aides and Licensed Nurses related to removal of daily medication patches...removal time for patches will be included on the MAR; remove old patch before applying new one; in-services initiated 7/14/2014 titled "Skin Assessments", ensure you are viewing all residents' skin, including feet and toes by removing shoes,socks, etc." During an interview on 7/15/2014 at 1:45 PM with LVN B he stated he had been doing wound care on weekends under the supervision of LVN A. He stated that he had been asked to take over temporarily the role of treatment nurse until the investigation was completed. During an interview on 7/15/2014 at 4:10 PM with the DON she said the charge nurse was responsible for performing the initial head to toe assessments for newly admitted residents and to document any findings. The DON said that the Treatment Nurse (LVN A) then followed up the next day and did another head to toe assessment. The DON further explained that the LVN A involved in the investigation had been with the facility "a few months " and was a certified wound care nurse. The DON said LVN A had been suspended until they completed the investigation, but they had been unhappy with some of the findings and would likely "fire her." The DON said the facility had a wound care physician who came in weekly to see residents with pressure ulcers or severe wounds. She said that she would sometimes do rounds with the doctor and the treatment nurse. Record review of CR #2's closed facility medical record revealed a History and Physical dated 5/29/2014 from a previous hospital stay that reflected he had an earlier stay in a nursing home due to his [MEDICAL CONDITION]. This H & P revealed his [DIAGNOSES REDACTED]. The Skin Exam portion of this document revealed "No [MEDICAL CONDITION] of significance." An interview on 7/15/2014 at 4:45 PM with the Corporate Nurse reflected that the facility was still undergoing investigation into skin issues with CR #2. She said that the DON, herself, and two Unit Managers were currently doing one on one in-services with all the nursing staff related to skin assessments, recognizing skin problems, preventing skin problems, how to properly use the "Stop and Watch" tool, who to report to, and when to report. She further stated that the DON would be responsible to do random head to toe skin assessments "about 5 residents a week" who were considered high risk for developing pressure sores and not currently on the skin care caseload. Record review of in-services currently having been initiated on 7/14/2014 documented that the following in-service subjects were provided to nursing staff: Correct skin assessment, correct skin assessments for injured residents, complete skin assessments, remove all clothing including shoes and socks, LVN and MA medication administration related to topical patch removal times, topical patch removal times put on MARS as reminders to remove the patches as ordered, skin assessment viewing on all residents on a routine schedule, and skin assessments to include feet and toes. During a telephone interview on 7/16/2014 at 2:30 PM, LVN C stated that CR #2 preferred to dress himself. She said he always wore socks and shoes. She said he was confused. She said that as soon as the aide found the foot sore we put a bandage on it but he kept taking it off and putting on his socks. She stated "I had no idea there was anything wrong with his foot. He had just moved to my floor. I did not notice any odor until I went to his room after the aide told me (7/14/2014). I was his charge nurse. As soon as I saw it I went to get the week-end supervisor and called the doctor and his family. He never complained of pain for me. He was constantly up and down in and out of his wheelchair and bed, so we were in there a lot because of the alarms. He would refuse to use the call light." An interview on 7/16/2014 at 3:30 PM with CM X at the hospital revealed she had seen CR #2's foot when he had originally come in. She stated he was having surgery at this time and his chart was unavailable because it was in surgery. Copies of his hospital record were obtained at this time. According to CM X CR #2's right fifth toe was "black and shriveled up like a raisin. It looked like it was about to fall off." A telephone interview on 7/16/2014 at 4:20 PM with RN A revealed she was the weekend supervisor. She said she was called to CR #2's room to look at his right toe on 7/14/2014. She said the charge nurse and CNA told her that CR #2's wound was leaking. "His right pinky toe was starting to get necrotic. I checked it and called the treatment nurse and the DON. I also called the doctor who gave us orders to treat it and get cultures and start antibiotics. There was nothing in his closed facility chart or TAR that indicated he had any wound." During an interview on 7/16/2014 at 4:35 PM with LVN A she said she was the treatment nurse. She said she had seen CR #2 when she had been in the facility, but was not treating him. She said "I am a wound care certified nurse now and I feel confident in taking care of patients. Typically, I get to order what I feel is right. I got permission to go ahead and treat with what I thought was needed from the doctors. I would write the orders. I could always call the wound care doctor for recommendations. He came out once a week, usually on a Monday or Thursday and we'd do rounds. Not on everyone. (CR #2) was not on our care. I never did a skin assessment on him. I do have a schedule to do skin assessments on residents. He could walk OK and used a wheelchair. He never complained of pain to me. The admitting nurse does the initial skin assessment and then I follow up. Me or the weekend treatment nurse. I do pull off socks and shoes or whatever. He had some bruising but nothing else. The CNAs and shower techs are very good about letting me know if anything is wrong with a resident's skin. He was already gone to the hospital when I came in Monday, so I didn't see it." When asked if she felt comfortable writing orders herself as an LVN, LVN A said "Yes, I do feel comfortable writing orders for treatments without a doctor's orders. I'll give the doctor's a heads up if I want to change something, being certified now I do write orders. I will go to the doctor's if I need to." An interview on 7/16/2014 at 5:25 PM with LVN B he said he would never write orders without a physician telling me what he or she wanted. During an interview on 7/16/2014 at 5:50 PM with the DON and Corporate Nurse, they both stated that nurses can take orders from physicians, but they never write or carry out an order without the doctor telling them what to do. During a telephone interview on 7/17/2014 at 10:30 AM with Dr. A, he stated that CR #2 had surgery to remove the toe and part of his foot, "this morning". He stated he had not been told about the toe prior to the evening of 7/13/2014 when he gave orders to start antibiotics and admit the resident to the hospital. Dr. A said he had not visualized the foot prior to the resident arriving at the hospital. He said "It didn't look good." When asked how long it usually took for a toe or foot to turn gangrenous, Dr. A stated "It could take days. It is hard to tell how long it would have taken to get that bad. Certainly not over-night." When asked if he had authorized an LVN certified wound nurse to write her own orders, Dr A said "No. The procedure is they call if they want to order something. It is our license." During a telephone interview on 7/17/2014 at 10:45 AM with Dr. B he stated he was the facility's wound care doctor and he had not been told about CR #2's wound. When asked how long he thought it would take for a wound to become necrotic, he said it would "depend on a lot of things, normally a week to three or four weeks, unless it was embolic which is very rare." When asked if he had given an LVN wound certified nurse the ability to write her own orders, Dr. B said "She calls me for orders and I tell her what I want." Further review of CR #2's closed facility medical records revealed he had been sent to the hospital by his physician on 7/14/2014 due to necrosis and pain of his right fifth toe. Record review of CR #2's hospital records dated 7/14/2014 revealed: "Direct admit from Nursing facility (Park Manor of the Woodlands) because of right fifth toe necrosis.....Integumentary: Right fifth toe is necrotic with foul smell with surrounding [DIAGNOSES REDACTED] on the right distal foot. Left fifth toe has a dry eschar as well..." Record review of CR #2's Progress note dated 7/14/2014 read in part "Resident found with open areas, discoloration to R pinky toe, R hallux, L pinky toe. Foul odor present. Dr. A and family notified with order to send to (hospital) direct admit ....." According to CR #2's facility medical record he had sustained 3 unwitnessed falls in his room without injuries, and had a bed and chair alarm in place. Record review of a hand written witness statement by CNA B, dated 7/13/2014, read in part "I observed some broken down spots on his left foot asked him what happen he stated it was from his diabetes. I told the nurse..." Record review of a hand written witness statement by CNA C, dated 7/13/2014, read in part "After dinner I started to put people to bed. I started with (CR#2). I took off his shoes and saw that his feet were leaking and smelled so I told my nurse." Resident #3 Record review of Resident #3's facility medical record revealed she was admitted to the facility on [DATE], and had a more recent readmission date of [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of the facility's CMS Form 802 did not document Resident #3 as having a pressure ulcer or worsening pressure ulcer. Record review of Resident #3's facility medical record revealed a document titled "Unavoidable Pressure Ulcer Risk Assessment Criteria" dated 7/09/2014 which was signed by a physician. This document read in part "History of healed decubitus? Yes, sacrum and left heel." Her Care Plan read in part "Right heel unstageable" and was dated as reviewed on 7/11/2014. This same Care Plan read in part "Stage 3 sacrum" dated as reviewed 7/04/2014. Record review of Resident #3's "Wound Treatment and Progress Report" dated 7/10/2014 read in part "Healed 7/10/2014 - upper back wound. Healed 7/07/2014 resolved Stage 3 sacrum." Observation on 7/15/2014 at 1:20 PM of Resident #3 revealed she was very thin, did not communicate, had her eyes open and was lying in a low air loss mattress bed, with the head of the bed up 40 degrees. She had a [DEVICE] infusing through a pump at 55 cc/hr. She was observed to have an indwelling urinary catheter hanging off the side of the bed to the collection bag. There was thick creamy looking sediment in the tubing going to the collection bag. Resident #3 was observed to have bilateral heel boots on her feet. Observation on 7/15/2014 at 2:00 PM of Resident #3's skin assessment with LVN B revealed several reddened areas over boney prominences on her feet. The right heel was completely covered with thick eschar with redness spreading to her right outer ankle. Her right big toe had discoloration (darkened area) next to the second toe. There was an observation of a reddened area under her right leg where the edge of the boot touches the leg. Resident #3's right hip was reddened over the boney prominence. Over the sacral area, Resident was observed to have open areas that were Stage 2 pressure ulcers. An observation on 7/16/2014 at 9:55 AM of wound care for Resident #3 was conducted by LVN B. There was no cross-contamination problems observed. The treatments were carried out as ordered by the physician. The areas of skin care treatments were the sacrum (Stage 2), right heel eschar, and right outer ankle. During an interview on 7/16/2014 at 5:50 PM with the DON and Corporate Nurse, they said they had just completed the skin assessments for Resident #3 and had staged her sacrum as a Stage 2 pressure ulcer. The DON said that they had looked at Resident #3's TAR and LVN A had apparently written "healed" by the Stage 3 sacral ulcer. The DON said it had likely re-opened and had not been reported. Record review of Resident #3's TAR revealed she had received treatment to a stage 2 pressure ulcer on her left heel which was discontinued on 6/23/2014. This same TAR read in part that she was also being treated for [REDACTED]." During a telephone interview on 7/17/2014 at 10:45 AM with Dr. B he stated he was the facility's wound care doctor. When asked if he thought that alcohol was an appropriate treatment for [REDACTED]. B said he never used alcohol for wounds. During an interview on 7/17/2014 at 1:30 PM with the DON she said the facility's skin care regime had been changed. She said that all the residents had been assessed from head to toe and a lot of changes had been put in place including orders for Doppler studies. "We have re-done the entire skin care and treatment process. We have a new plan and program to follow. Myself, the ADON and the two Unit Managers have routine residents to assess on a weekly and as needed basis." Record review of the facility's policy and procedure titled "Physician Medication Orders" dated 4/2010, read in part "Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state." Record review of the facility's policy and procedure titled "Pressure Ulcer Risk Assessment" dated 3/2005, read in part "General Guidelines; ....4) If pressure ulcers are not treated when discovered, they quickly get larger, become painful for the resident, and often times become infected ....6) Once a pressure ulcer develops, it can be extremely difficult to heal ....9) Pressure ulcers are a serious skin condition for the patient ....Assessment 1) Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes .....2) Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated ...3) Monitoring. A) Nurses are to be notified to inspect the skin if skin changes are identified ... B) Nurses will conduct skin assessments at least weekly to identify changes ....4) in addition, .....purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION] or induration)suggesting that deep tissue damage has already occurred ...." According to the facility's CMS Form 672 there were 7 residents with pressure sores being treated in the facility. According to the census there were 97 residents residing in the facility.

Based on interviews and record review, the facility failed to implement effective policies for Advance Directives for 1 of 15 residents reviewed for Advance Directives (CR#1). CR#1 was found in his room, non-responsive. The Resident was assessed, but life-saving measures were not initiated immediately due to LVN A misidentifying the resident as "DNR," (Do not Resuscitate). CR#1 expired at 1:45 AM on [DATE] at the facility. This failure placed the facility's 67 remaining residents with a "Full Code" status at risk of not receiving resuscitation, which could result in death. Findings included: Record review of CR#1's Admission Record Face Sheet dated [DATE] revealed the resident was a [AGE] year old male, who was admitted to the facility on [DATE]. The Face Sheet reflected the following [DIAGNOSES REDACTED]. Further review of CR#1's advance directive revealed he wanted CPR (Full Code) status, and there was no documentation showing that he was a hospice patient. Record review of CR#1 ' s Advance Directives Discussion Form dated [DATE] revealed his wishes to provide the following three types of life support systems: Cardiopulmonary Resuscitation, Artificial Respiration (including respirator), and Artificial means of providing nutrition or hydration. Record review of CR#1 ' s Physician Phone Orders dated [DATE] revealed status of " Full Code" signed by the Physician. Record review of CR#1's Record of Death dated [DATE] revealed the resident died on [DATE] at 1:45 AM. Record review of the facility ' s Provider Investigation Report dated [DATE] revealed that on [DATE] CNA C was in CR#1's room assisting his roommate to the bathroom and noticed that CR#1 was mumbling words but was not calling out for help. After assisting CR#1 ' s roommate to bathroom, she went over to CR#1 and he was unresponsive and without life. She reported it to LVN A. LVN A immediately went to his room to assess the resident. At that time, LVN A, misidentified CR#1 as a hospice resident. LVN A then went and notified the family and hospice of the death of the resident. LVN A noticed during that time that she had misidentified the resident. She then confirmed the Code Status of CR#1 and had another nurse start CPR as she called 911. No time frames were established in the report. In a statement from LVN A, she stated that she was very shaken up and her times could have been off due to her anxiety and emotional state. The report documented that LVN B and LVN C started CPR on CR#1 and continued CPR until EMS arrived. In a statement from LVN C, he stated that he was unable to recall what the time was due to him being busy and taking care of his patients. LVN B also stated that she could not remember the times. The report also revealed that the local county hospital district received information that unknown hospice nurse was advised CR#1 was deceased on [DATE] at 12:37 am, without clarification of the discrepancy. Attempts were made to contact LVN A by phone; however, attempts were unsuccessful. Interview with LVN C on [DATE] at 11:00 AM revealed he was working his hall when he was called by LVN B to assist with CR#1. He stated that he did not remember the exact time but remembers it was around 1:00 - 1:30 AM. LVN C stated that he did not know the whereabouts of LVN A. He stated that LVN B coordinated the initial CPR efforts and LVN A came in afterwards to assist with CPR. He stated that he performed CPR approximately 5 minutes until EMS arrived. In an interview with the Administrator on [DATE] at 12:00 PM, he stated the facility had a system in place for knowing the Code Status of the residents. He stated that the facility used a sticker placed on the side of the door to identify at a glance whether a resident was a DNR or a Full Code. He stated that the facility had the residents ' Advance Directives in their charts as well as their pictures to identify them. He stated that he did not know why LVN A had a lapse in her thinking and delayed CPR. He stated that with the sticker system in place it should have been effective in providing the resident ' s Advance Directives. In an interview with the DON on [DATE] at 12:25 PM, she stated the facility had a code system in place that makes it easy to identify a resident ' s Advance Directives status from a distance. She stated that someone else would bring the resident ' s chart to the resident ' s room to verify the code status. When asked if the system worked, she stated it didn't seem to in retrospect. She stated that initially it looked like it worked. She also stated that she does not know what happened in this situation. In an interview with LVN D on [DATE] at 2:00 PM, he stated that a green dot indicated a " Full Code " statue, and a red dot indicated a " DNR " status. He also stated that you cannot always go by the dots next to the residents ' doors. You have to verify code status with charts located at the nurses ' station. In an interview with Administrator on [DATE] at 4:00 PM, he stated that if anyone had questions regarding the facility ' s sticker dot system (resident ' s Code Status) or Advance Directives, they should be referred to the Administrator, DON, or Social Services Director for clarification. He identified and made reference to the statement listed as number 10 on the facility ' s Advance Directives Policy. Record Review of the Facility's policy titled "Chapter 2, Administrative Policies and Procedures-Advance Directives revealed the following: "Policy Statement: Advance Directives will be respected in accordance with state law and facility policy..." "Policy Interpretation: ... 4. Should the resident indicate that he or she has issued Advance Directives about his or her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident's medical record... 9. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such a directive when transfer from the facility via ambulance or other means is made. 10. Inquiries concerning Advance Directives should be referred to the Administrator, Director of Nursing Services, and/or to the Social Services Director. " According to the Daily Census Report, notated with resident's code status, provided by the Administrator on [DATE], 67 residents had a "full code" status.

Based on record review and interviews, the facility failed to develop and implement effective written policy and procedure that prohibits neglect for 1 of 15 residents (CR#1) reviewed for neglect. CR#1 was found in his room, non-responsive. Resident was assessed but life-saving measures were not initiated immediately due to LVN A misidentifying the resident as a "DNR." CR#1 was pronounced dead at 1:45 AM on [DATE] at the facility. This failure affected 1 resident and placed 66 remaining residents with "full code" status at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings included: Record review of CR#1's Admission Record Face Sheet dated [DATE] revealed the resident was a [AGE] year old male, who was admitted to the facility on [DATE]. The Face Sheet reflected the following [DIAGNOSES REDACTED]. CR#1 ' s advance directive was he wanted CPR (Full Code) status, and there was no documentation showing that he was a hospice patient. Record review of CR#1's facility Record of Death dated [DATE] revealed the resident died on [DATE] at 1:45 AM. CR#1 died at the facility and was not transported to a hospital. Record review of CR#1's Advance Directives Discussion Form dated [DATE] revealed his wishes to provide the following three types of life support systems: Cardiopulmonary Resuscitation, Artificial Respiration (including respirator), and Artificial means of providing nutrition or hydration. Record review of CR#1's Physician Phone Orders dated [DATE] revealed status of Full Code signed by the Attending Physician, Dr. Bharat Latthe. Record review of the facility ' s Provider Investigation Report dated [DATE] revealed that on [DATE] CNA C was in CR#1 ' s room assisting his roommate to the bathroom and noticed that CR#1 was mumbling words but was not calling out for help. After assisting CR#1 ' s roommate to bathroom, she went over to CR#1 and he was unresponsive and without life. She reported it to LVN A. LVN A immediately went to his room to assess the resident. At that time, LVN A, misidentified CR#1 as a hospice resident. LVN A then went and notified the family and hospice of the death of the resident. LVN A noticed during that time that she had misidentified the resident. She then confirmed the Code Status of CR#1 and had another nurse start CPR as she called 911. No time frames were established in the report. In a statement from LVN A, she stated that she was very shaken up and her times could have been off due to her anxiety and emotional state. The report documented that LVN B and LVN C started CPR on CR#1 and continued CPR until EMS arrived. In a statement from LVN C, he stated that he was unable to recall what the time was due to him being busy and taking care of his patients. LVN B also stated that she could not remember the times. The report also revealed that the local county hospital district received information that unknown hospice nurse was advised CR#1 was deceased on [DATE] at 12:37 am, without clarification of the discrepancy. Attempts were made to contact LVN A by phone; however, attempts were unsuccessful. Interview with LVN C on [DATE] at 11:00 AM revealed he was working his hall when he was called by LVN B to assist with CR#1. He stated that he did not remember the exact time but remembers it was around 1:00 - 1:30 AM. LVN C stated that he did not know the whereabouts of LVN A. He stated that LVN B coordinated the initial CPR efforts and LVN A came in afterwards to assist with CPR. He stated that he performed CPR approximately 5 minutes until EMS arrived. In an interview with the Administrator on [DATE] at 12:00 PM, he stated the facility had a system in place for knowing the Code Status of the residents. He stated that the facility used a sticker placed on the side of the door to identify at a glance whether a resident was a DNR or a Full Code. He stated that the facility had the residents ' Advance Directives in their charts as well as their pictures to identify them. He stated that he did not know why LVN A had a lapse in her thinking and delayed CPR. He stated that with the sticker system in place it should have been effective in providing the residents' Advance Directives. In an interview with the DON on [DATE] at 12:25 PM, she stated the facility had a code system in place that makes it easy to identify a resident's Advance Directives status from a distance. She stated that someone else would bring the resident's chart to verify the code status. When asked if the system worked, she stated it didn't seem to in retrospect. She stated that initially it looked like it worked. She also stated that she does not know what happed in this situation. When asked how much time may have passed between resident becoming non-responsive and initiating CPR, she stated, "Seemed to me anywhere from ,[DATE] minutes." In an interview with LVN D on [DATE] at 2:00 PM, he stated that a green dot indicated a " Full Code " statue, and a red dot indicated a " DNR " status. He also stated that you cannot always go by the dots next to the residents ' doors. You have to verify code status with charts located at the nurses ' station. In an interview with Administrator on [DATE] at 4:00 PM, he stated that if anyone had questions regarding the facility ' s sticker dot system (resident ' s Code Status) or Advance Directives, they should be referred to the Administrator, DON, or Social Services Director for clarification. He identified and made reference to the statement listed as number 10 on the facility ' s Advance Directives Policy. Record Review of the Facility's policy titled "Chapter 2, Administrative Policies and Procedures-Advance Directives revealed the following: "Policy Statement: Advance Directives will be respected in accordance with state law and facility policy..." "Policy Interpretation: ... 4. Should the resident indicate that he or she has issued Advance Directives about his or her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident's medical record... 9. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such a directive when transfer from the facility via ambulance or other means is made. 10. Inquiries concerning Advance Directives should be referred to the Administrator, Director of Nursing Services, and/or to the Social Services Director. " According to the Daily Census Report, notated with resident's code status, provided by the Administrator on [DATE], 67 residents had a "full code" status.

Based on record review and interviews, the facility failed to implement effective written policy and procedure that prohibits neglect for 1 of 15 residents (CR#1) reviewed for neglect: CR#1 was found in his room, non-responsive. Resident was assessed but life-saving measures were not initiated immediately due to LVN A misidentifying the resident as a "DNR." CR#1 was pronounced deceased at 1:45 AM on [DATE] at the facility. This failure affected 1 resident and placed 66 remaining residents with a "full code" status at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings included: Record Review of the Facility's policy titled "Chapter 2, Administrative Policies and Procedures-Advance Directives revealed the following: "Policy Statement: Advance Directives will be respected in accordance with state law and facility policy..." "Policy Interpretation: ... 4. Should the resident indicate that he or she has issued Advance Directives about his or her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident's medical record... 9. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such a directive when transfer from the facility via ambulance or other means is made. 10. Inquiries concerning Advance Directives should be referred to the Administrator, Director of Nursing Services, and/or to the Social Services Director. " Record review of CR#1's Admission Record Face Sheet dated [DATE] revealed the resident was a [AGE] year old male, who was admitted to the facility on [DATE]. The Face Sheet reflected the following [DIAGNOSES REDACTED]. CR#1 ' s advance directive was he wanted CPR (Full Code) status, and there was no documentation showing that he was a hospice patient. Record review of CR#1's facility Record of Death dated [DATE] revealed the resident died on [DATE] at 1:45 AM. CR#1 died at the facility and was not transported to a hospital. Record review of CR#1's Advance Directives Discussion Form dated [DATE] revealed his wishes to provide the following three types of life support systems: Cardiopulmonary Resuscitation, Artificial Respiration (including respirator), and Artificial means of providing nutrition or hydration. Record review of CR#1's Physician Phone Orders dated [DATE] revealed status of Full Code signed by the Attending Physician, Dr. Bharat Latthe. Record review of the facility ' s Provider Investigation Report dated [DATE] revealed that on [DATE] CNA C was in CR#1 ' s room assisting his roommate to the bathroom and noticed that CR#1 was mumbling words but was not calling out for help. After assisting CR#1 ' s roommate to bathroom, she went over to CR#1 and he was unresponsive and without life. She reported it to LVN A. LVN A immediately went to his room to assess the resident. At that time, LVN A, misidentified CR#1 as a hospice resident. LVN A then went and notified the family and hospice of the death of the resident. LVN A noticed during that time that she had misidentified the resident. She then confirmed the Code Status of CR#1 and had another nurse start CPR as she called 911. No time frames were established in the report. In a statement from LVN A, she stated that she was very shaken up and her times could have been off due to her anxiety and emotional state. The report documented that LVN B and LVN C started CPR on CR#1 and continued CPR until EMS arrived. In a statement from LVN C, he stated that he was unable to recall what the time was due to him being busy and taking care of his patients. LVN B also stated that she could not remember the times. The report also revealed that the local county hospital district received information that unknown hospice nurse was advised CR#1 was deceased on [DATE] at 12:37 am, without clarification of the discrepancy. Attempts were made to contact LVN A by phone; however, attempts were unsuccessful. Interview with LVN C on [DATE] at 11:00 AM revealed he was working his hall when he was called by LVN B to assist with CR#1. He stated that he did not remember the exact time but remembers it was around 1:00 - 1:30 AM. LVN C stated that he did not know the whereabouts of LVN A. He stated that LVN B coordinated the initial CPR efforts and LVN A came in afterwards to assist with CPR. He stated that he performed CPR approximately 5 minutes until EMS arrived. In an interview with the Administrator on [DATE] at 12:00 PM, he stated the facility had a system in place for knowing the Code Status of the residents. He stated that the facility used a sticker placed on the side of the door to identify at a glance whether a resident was a DNR or a Full Code. He stated that the facility had the residents ' Advance Directives in their charts as well as their pictures to identify them. He stated that he did not know why LVN A had a lapse in her thinking and delayed CPR. He stated that with the sticker system in place it should have been effective in providing the residents' Advance Directives. In an interview with the DON on [DATE] at 12:25 PM, she stated the facility had a code system in place that makes it easy to identify a resident's Advance Directives status from a distance. She stated that someone else would bring the resident's chart to verify the code status. When asked if the system worked, she stated it didn't seem to in retrospect. She stated that initially it looked like it worked. She also stated that she does not know what happed in this situation. When asked how much time may have passed between resident becoming non-responsive and initiating CPR, she stated, "Seemed to me anywhere from ,[DATE] minutes." In an interview with LVN D on [DATE] at 2:00 PM, he stated that a green dot indicated a " Full Code " statue, and a red dot indicated a " DNR " status. He also stated that you cannot always go by the dots next to the residents ' doors. You have to verify code status with charts located at the nurses ' station. In an interview with Administrator on [DATE] at 4:00 PM, he stated that if anyone had questions regarding the facility ' s sticker dot system (resident ' s Code Status) or Advance Directives, they should be referred to the Administrator, DON, or Social Services Director for clarification. He identified and made reference to the statement listed as number 10 on the facility ' s Advance Directives Policy. According to the Daily Census Report, notated with resident's code status, provided by the Administrator on [DATE], 67 residents had a "full code" status.

Based on interview and record review, the facility failed to provide services that met professional standards of quality for 1 of 15 residents (CR#1) whose care was reviewed. CR#1 was found in his room, non-responsive. Resident was assessed but life-saving measures were not initiated immediately due to LVN A misidentifying the resident as a "DNR." CR#1 was pronounced dead at 1:45 AM on [DATE] at the facility. This failure resulted in neglect to provide timely CPR and as a consequence may have resulted in death and could affect 67 other residents in the facilities that were a "Full Code" status. Findings included: According to the Texas Board of Nursing website, http://www.bon.texas.gov/nursinglaw/pdfs/bon-rr.pdf, Texas Administrative Code, Title 22, Part 11, Chapter 217: Rule ?217.11 Standards of Nursing Practice, (1), (M), Standards of Nursing Practice: "(1) Standards applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;" Rule ?217.12 Unprofessional Conduct, (1), (A), Unprofessional Conduct: "(4) Careless or repetitive conduct that may endanger a client ' s life, health, or safety. Actual injury to a client need not be established." Review of the facility ' s Report Abuse to Facility Management policy under Resident Rights and Dignity - Abuse Prevention (Revised [DATE]) revealed the definition: "Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Record review of CR#1's Admission Record Face Sheet dated [DATE] revealed the resident was a [AGE] year old male, who was admitted to the facility on [DATE]. The Face Sheet reflected the following [DIAGNOSES REDACTED]. CR#1 ' s advance directive was he wanted CPR (Full Code) status, and there was no documentation showing that he was a hospice patient. Record review of CR#1 ' s Advance Directives Discussion Form dated [DATE] revealed his wishes to provide the following three types of life support systems: Cardiopulmonary Resuscitation, Artificial Respiration (including respirator), and Artificial means of providing nutrition or hydration. Record review of CR#1 ' s Physician Phone Orders dated [DATE] revealed status of " Full Code " signed by the Physician. Record review of CR#1's Record of Death dated [DATE] revealed the resident died on [DATE] at 1:45 AM. Record review of the facility ' s Provider Investigation Report dated [DATE] revealed that on [DATE] CNA C was in CR#1 ' s room assisting his roommate to the bathroom and noticed that CR#1 was mumbling words but was not calling out for help. After assisting CR#1 ' s roommate to bathroom, she went over to CR#1 and he was unresponsive and without life. She reported it to LVN A. LVN A immediately went to his room to assess the resident. At that time, LVN A, misidentified CR#1 as a hospice resident. LVN A then went and notified the family and hospice of the death of the resident. LVN A noticed during that time that she had misidentified the resident. She then confirmed the Code Status of CR#1 and had another nurse start CPR as she called 911. No time frames were established in the report. In a statement from LVN A, she stated that she was very shaken up and her times could have been off due to her anxiety and emotional state. The report documented that LVN B and LVN C started CPR on CR#1 and continued CPR until EMS arrived. In a statement from LVN C, he stated that he was unable to recall what the time was due to him being busy and taking care of his patients. LVN B also stated that she could not remember the times. The report also revealed that the local county hospital district received information that unknown hospice nurse was advised CR#1 was deceased on [DATE] at 12:37 am, without clarification of the discrepancy. Attempts were made to contact LVN A by phone; however, attempts were unsuccessful. Interview with LVN C on [DATE] at 11:00 AM revealed he was working his hall when he was called by LVN B to assist with CR#1. He stated that he did not remember the exact time but remembers it was around 1:00 - 1:30 AM. LVN C stated that he did not know the whereabouts of LVN A. He stated that LVN B coordinated the initial CPR efforts and LVN A came in afterwards to assist with CPR. He stated that he performed CPR approximately 5 minutes until EMS arrived. In an interview with the Administrator on [DATE] at 12:00 PM, he stated the facility had a system in place for knowing the Code Status of the residents. He stated that the facility used a sticker placed on the side of the door to identify at a glance whether a resident was a DNR or a Full Code. He stated that the facility had the residents ' Advance Directives in their charts as well as their pictures to identify them. He stated that he did not know why LVN A had a lapse in her thinking and delayed CPR. He stated that with the sticker system in place it should have been effective in providing the resident ' s Advance Directives. In an interview with the DON on [DATE] at 12:25 PM, she stated the facility had a code system in place that makes it easy to identify a resident ' s Advance Directives status from a distance. She stated that someone else would bring the resident ' s chart to the resident ' s room to verify the code status. When asked if the system worked, she stated it didn't seem to in retrospect. She stated that initially it looked like it worked. She also stated that she does not know what happened in this situation. In an interview with LVN D on [DATE] at 2:00 PM, he stated that a green dot indicated a " Full Code " statue, and a red dot indicated a " DNR " status. He also stated that you cannot always go by the dots next to the residents ' doors. You have to verify code status with charts located at the nurses ' station. In an interview with Administrator on [DATE] at 4:00 PM, he stated that if anyone had questions regarding the facility ' s sticker dot system (resident ' s Code Status) or Advance Directives, they should be referred to the Administrator, DON, or Social Services Director for clarification. He identified and made reference to the statement listed as number 10 on the facility ' s Advance Directives Policy. According to the Daily Census Report, notated with resident's code status, provided by the Administrator on [DATE], 67 residents had a "full code" status.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care for 10 of 16 Residents (CR # 10, Resident #'s 2, 3, 6, 12, 13, and 15, and CR #'s 1, 8, and 9) as evidenced by the failure to assess and document the care provided. -CR # 10 admitted to the facility on [DATE] with a urinary tract infection, fracture and acute [MEDICAL CONDITION]. CR # 10 discharged to the hospital on [DATE] with a panic level potassium of 6.9 and a panic blood sugar level of 40. There was no nursing assessment including vital signs documented on 1/11/14 and 1/12/14. Labs were ordered for 1/12/14 and not done until 1/13/14 at 7:55 PM when they were ordered STAT. EMS and Hospital documentation reflected CR # 10's heart rate was in the 30's and required emergent [MEDICAL TREATMENT] and pacemaker. -Resident # 2 admitted on [DATE]. On 1/10/14 there was a physician's orders [REDACTED]. The IV medication did not start until 1/14/14 at 9:30 PM even though it was available in the facility's bulk drawer (emergency kit). -Resident # 3 admitted on [DATE] with pneumonia and on IV antibiotic therapy. There were no temperatures documented on 1/11/14, 1/12/14, 1/17/14, 1/18/14 and 1/19/14. Resident # 3 complained of severe itching, burning and cramping from head to toe on 1/17/14 and 1/18/14, was administered [MEDICATION NAME], but there was no further assessment documented. On 1/21/14 Resident # 3 had a temperature of 100.2 with no further follow up, intervention or assessment on that day. -Resident # 6 admitted on [DATE]. There were no documented vital signs on 11/28/13 and he was sent to the hospital on [DATE] due to slurred speech. Resident # 6 readmitted on [DATE] and there were no documented temperatures on 12/3/13, 12/14/13, 12/15/13, 12/17/13, 12/18/13, 12/21/13, 12/24/13 12/25/13, 12/27/13, 12/28/13 and 12/29/13. Resident # 6 was sent to the hospital on [DATE] with altered mental status, elevated temperature and nausea/vomiting. Resident # 6 readmitted on [DATE] with a PICC line and on IV antibiotic. There were no documented vital signs on 1/5/14. Resident # 6 was sent to the emergency roiagnom on [DATE] due to lethargy and [MEDICAL CONDITION] of 30. There were no documented assessments on 1/11/14 and 1/12/14. On 1/14/14 Resident # 6's PICC line dressing was observed to be dated 1/3/14 (11 days old). -Resident # 12 admitted on [DATE] with [MEDICAL CONDITION] and an abscess. There was no documented assessment on 11/22/2014, 11/25/2014, 12/3/2014, 12/20/2014, 1/1/14, 1/5/14, 1/11/14, 1/12/14, 1/18/14 and 1/19/14. On 1/9/14 an antibiotic was ordered for an upper respiratory infection with no documentation of symptoms. On 1/9/14-1/11/14 there was a physician's orders [REDACTED]. On 12/24/13 there was a physician's orders [REDACTED]. -Resident # 13 admitted on [DATE] with urinary tract infection, [MEDICAL CONDITION] with fever and was on IV antibiotic. There were no documented temperatures on 1/17/14 and 1/19/14. Resident # 13's PICC line came out on 1/18/14 with no documented assessment of the removal or care of the site. -Resident # 15 admitted on [DATE] with fractures. There were no documented assessments on 12/29/13, 1/4/14, 1/5/14, 1/11/14, 1/12/14, 1/18/14 and 1/19/14. Resident # 15 fell on [DATE] and suffered a laceration and a hematoma to the head. Resident # 15 was on [MEDICATION NAME] (a medication used to thin the blood). -CR # 1 admitted on [DATE] on IV antibiotic for an [MEDICATION NAME] abscess. The IV antibiotic did not start until 11/28/13 and and on 12/2/13 at 5:00 AM did not receive her scheduled dose due to "awaiting from pharmacy" even though the medication was available in the facility's emergency kit. There were no documented assessments or temperatures on 11/30/13, 12/1/13, 12/2/13 or 12/3/13. CR # 1 discharged to the hospital on [DATE] due to low labs (hematocrit and hemoglobin). CR # 1 readmitted on [DATE] on IV antibiotic, diagnosed with [REDACTED]. On 12/13/13 the scheduled times to administer the IV antibiotic were changed, resulting in the Resident not receiving 2 doses, even though it was available in the facility's emergency kit. There were no documented temperatures on 12/14/13, 12/15/13, 12/17/13, 12/18/13, 12/21/13, 12/22/13 and 12/24/13. CR # 1 was discharged to the hospital on [DATE] with loose stool, nausea/vomiting, and wheezing. -CR # 8 admitted on [DATE] with pneumonia, urinary tract infection, [MEDICAL CONDITION] and was on IV antibiotic. On 12/30/13 CR # 8 had a temperature of 99.2, the central line was red and there was an order to discontinue the central line. There was no documentation of the central line being discontinued, but a peripheral line was started. There was no documented assessment on 1/1/14 and 1/5/14. On 1/6/14 at 5:30 AM CR # 8 was unresponsive and was sent to the emergency room . -CR # 9 was readmitted to the facility on [DATE] with urinary tract infection, mitral valve and [DIAGNOSES REDACTED], [MEDICAL CONDITION], and [MEDICAL CONDITION]. There was no documentation of assessment on 12/15/2014, 12/17/2014, 12/20/2014, 12/24/2014 through 12/26/2014, 12/29 through 12/31/2014, and 1/5/2014 through 1/6/2014. The assessments in the medical record by nursing did not identify [MEDICAL CONDITION] but the NP/physician progress notes [REDACTED]. The resident was sent to the hospital with trouble breathing on 1/7/2014. These failures affected 6 residents and 4 discharged residents, and had the potential to affected the additional 106 residents for a decline in health status and delay in treatment. Failure to assess and intervene could result in a delay of treatment, decline in health status and a need for additional treatment and hospitalization . Intake # 0 and # 8. Findings include: Record review of the facility's undated "Follow Up Charting Guidelines" read in part, "...Antibiotic therapy... chart until 72 hours after last dose. Chart complete vital signs, signs and symptoms of condition, interventions and effects of ABT. New Admissions/Readmissions: Chart every shift with full vital signs for 7 days. Chart how resident is assimilating into facility... Incidents... Chart for 72 hours every shift, include in documentation, vital signs appearance of injury/resident, how incident occurred, ROM, neuro's (if indicated), mental status, interventions for prevention of further occurances... Change in Condition/Acute Episode... Chart until stable at least 72 hours after symptoms of condition, interventions and response..." CR # 10 Record review of CR # 10's face sheet revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years old. She discharged to the hospital on [DATE]. Record review of CR # 10's Admit/Readmit Screener dated 1/6/2014 at 8:12 PM revealed the following: -Admitting Diagnoses: [REDACTED]. The reason for admission per client or family was fractured left femur. -Most recent weight 1/6/2014 at 8:16 PM weight 390 per mechanical lift scale. -Most recent vital signs on 1/6/2014 at 8:18 and 8:19 PM, B/P 128/71, Temperature 97.9, Pulse 88, and respirations 20. The ADL section revealed the resident needed extensive assistance with bed mobility, transfer, self-performance, dressing self-performance. She was independent with eating. She needed limited assistance with toileting, supervision with ADLs and total dependence with bathing. The screener revealed the resident was alert to person, place, time, and situation and was verbally appropriate. It further revealed the resident had a catheter. It also revealed she had moderate pain of 5 on scale of 1 to 10 in her left femur. This assessment was signed by LVN H. Record review of CR # 10's Admit/Readmit Screener dated 1/7/2014 at 8:54 PM revealed the following: -Admitting Diagnoses: [REDACTED]. The reason for admission per client or family was unable to care for self, weakness. -Most recent weight 1/9/2014 at 2:10 PM weight 334. There was no type of scale listed. -Most recent vital signs on 1/10/2014 at 7:22 AM B/P 110/20, Temperature 97.9 on 1/6/2014 at 8:19 PM, Pulse 66 on 1/10/2014 at 7:22 AM, and respirations 20 on 1/6/2014 at 8:19 PM. The ADL section revealed the resident was had total dependence with transfer, self-performance. She needed extensive assistance with bed mobility, dressing self-performance, toilet use and ADLs. She was independent with eating. She needed limited assistance with eating, self-performance. The screener revealed the resident was alert to person, place, time, and situation and was verbally appropriate. She had generalized [MEDICAL CONDITION] and two plus in the lower extremities. It further revealed the resident had a catheter. It also revealed she no pain on a scale of 0 to 10. This assessment was signed by LVN A. Record review of CR # 10's pain assessment dated [DATE] at 8:54 PM revealed "no" had been checked for pain presence in the last 5 days and "rarely" had been checked for frequency. For pain intensity on scale of 0 to 10, 0 had been documented on the assessment. Record review of CR # 10's 1/7/2014 Order Summary Report revealed the following physician orders: -Bactrim DS 800-160 mg, one tablet by mouth twice a day for urinary tract infection for 10 days. The start date was 1/7/2014 and the end date was 1/17/2014. -Bumetamide 1 mg, one tablet by mouth every day for [MEDICAL CONDITION]. -[MEDICATION NAME] 0.125 mg, one tablet by mouth every day for [MEDICAL CONDITION]. -[MEDICATION NAME] HCL 30 mg, one table by mouth every day for hypertension. There were no parameters for blood pressure when to hold this medication. -[MEDICATION NAME]- [MEDICATION NAME] 10-325 mg, give one tablet by mouth every 4 hours as needed for pain for 5 days with a start date of 1/6/2014 and end date of 11/11/2014. -[MEDICATION NAME]- [MEDICATION NAME] 10-325 mg, give 2 tablet by mouth every 6 hours as needed for pain for 5 days with a start date of 1/7/2014 and end date of 11/12/2014. -[MEDICATION NAME] Insulin, inject 15 units subcutaneously at bedtime for diabetes. -[MEDICATION NAME] 25 mg, give one tablet by mouth two times a day for hypertension. There were no parameters for blood pressure or pulse when to hold this medication. Record review of CR # 10's Physician Telephone orders revealed the following orders: -1/6/2014 CBC, BMP, PT/INR -1/8/2014 Blood sugar checks every morning times 7 days. -1/11/2014 CBC on Monday or with next blood draw. Check INR in am. Check Urinalysis with culture and sensitivity 2 days after antibiotic completed, check BMP. Please order air mattress/bariatric bed. -1/13/2014 at 3:45 PM STAT CBC, BMP, [MEDICATION NAME] level. Hold [MEDICATION NAME] and [MEDICATION NAME] time 24 hours. Notify physician if HR less than 50 beats per minute. -Send to ER for evaluation and treatment. Record review of CR # 10's 1/2014 MAR indicated [REDACTED] -Bactrim DS 800-160 mg, one tablet by mouth twice a day for urinary tract infection for 10 days. The start date was 1/7/2014 and the end date was 1/17/2014. This medication was scheduled for 8:00 AM and 4:00 PM and therewas documentation that this was administered through 1/13/2014 4:00 PM dose. -[MEDICATION NAME] HCL 30 mg, one table by mouth every day for hypertension. There were no parameters for blood pressure when to hold this medication. There was documentation that this was administered from 1/7/2014 through 1/13/2014. There were no blood pressures listed with this medication. -[MEDICATION NAME]- [MEDICATION NAME] 10-325 mg, give one tablet by mouth every 4 hours as needed for pain for 5 days with a start date of 1/6/2014 and end date of 1/11/2014. There was documentation this was administered on 1/11/2014 at 2:30 PM. -[MEDICATION NAME]- [MEDICATION NAME] 10-325 mg, give 2 tablet by mouth every 6 hours as needed for pain for 5 days with a start date of 1/7/2014 and end date of 1/12/2014. There was documentation that this was administered on 1/8/2014 at 12:02 PM, 1/10/2014 at 6:10 PM, and 1/12/2014 at 5:15 PM. -[MEDICATION NAME] Insulin, inject 15 units subcutaneously at bedtime for diabetes. This medication was scheduled for 8:00 PM. There was documentation this was administered from 1/7/2014 through 1/13/2014. -[MEDICATION NAME] 25 mg, give one tablet by mouth two times a day for hypertension. There were no parameters for blood pressure or pulse when to hold this medication. This medication was scheduled for 8:00 AM and 4:00 PM. There was documentation that this was administered from 1/7/2014 through 1/13/2014 at 8:00 AM. For the 1/13/2014 4:00 PM dose the code 5 had been documented in the space which means: Hold/see nurses notes. Record review of CR # 10's electronic Daily Skilled Nurse's Notes revealed the following: -1/7/2014 at 5:26 PM revealed she was alert without behaviors. It further revealed she was incontinent of bowel and urine. There was no mention of the catheter. Her B/P 145/66 stable, P 70 stable, Temp 98.7 stable, and RR 18 stable. The services provided included observation/assessment of Resident ' s condition, Diabetic Care, Monitor fluid intake to prevent dehydration, and therapy. The summary revealed she was on day 2 of 7 of admission and day 1 of 10 on antibiotic for urinary tract infection. -1/8/2014 at 3:20 PM the electronic daily skilled nurse's note revealed the resident was alert and exhibited no behaviors. She had a right abdominal [MEDICAL CONDITION] and an indwelling urinary catheter with clear, straw colored urine without odor. It further revealed she had no [MEDICAL CONDITION]. Her oxygen saturation/oximetry was 95 %. Her vital signs were as follows and marked as stable: Temp 98.3, B/P 1230/66 (sic), RR 18, and HR 65. She had no pain was documented. The services provided included observation/assessment of Resident ' s condition, Monitor fluid intake to prevent dehydration, and therapy. The summary revealed she was on day 2 of 7 of admission and day 2 of 10 on antibiotic for urinary tract infection. It further revealed the resident had a fungal rash to upper inside of legs and groin with fungal powder ordered. The incision to her left hip had staples with dressing dry and intact. This note was signed by LVN G. -1/9/2014 at 5:19 PM the electronic daily skilled nurse's note revealed the resident was alert and exhibited no behaviors. She had a surgical wound. She had a [MEDICAL CONDITION] and an indwelling urinary catheter with clear, straw colored urine without odor. It further revealed she had no [MEDICAL CONDITION]. Her oxygen saturation/oximetry was 95 %. Her vital signs were as follows and marked as stable: Temp 98.1, B/P 98/50, RR 18, and HR 60. She had no pain was documented. The services provided included observation/assessment of Resident ' s condition, Diabetic Care, Monitor fluid intake to prevent dehydration, and therapy. The summary revealed she was able to voice her needs and denied pain or discomfort or shortness of breath. This note was signed by LVN G. -1/10/2014 at 4:56 PM the electronic daily skilled nurse's note revealed the resident was alert and exhibited no behaviors. She had a surgical wound. She had a [MEDICAL CONDITION] and an indwelling urinary catheter with clear, straw colored urine without odor. It further revealed she had no [MEDICAL CONDITION]. Her oxygen saturation/oximetry was 97 %. Her vital signs were as follows and marked as stable: Temp 97.2, B/P 108/56, RR 18, and HR 95. She had no pain was documented. The services provided included observation/assessment of Resident's condition, Monitor fluid intake to prevent dehydration, and therapy. The summary revealed she was on day 4 of 7 of admission. There was no mention of urinary tract infection. This note was signed by LVN G. -1/11/2014 there was no Daily Skilled Nurse's Note or Assessment documented. -1/12/2014 there was no Daily Skilled Nurse's Note or Assessment documented. -1/13/2014 at 4:29 PM the electronic daily skilled nurse's note revealed the resident was alert and exhibited no behaviors. She had a surgical wound. She had a [MEDICAL CONDITION] and an indwelling urinary catheter with clear, straw colored urine without odor. It further revealed she had no [MEDICAL CONDITION]. Her oxygen saturation/oximetry was 95 %. Her vital signs were as follows and marked as stable: Temp 98.2, B/P 99/54, RR 18, and HR 56. She had no pain was documented. The services provided included observation/assessment of Resident ' s condition, Monitor fluid intake to prevent dehydration, and therapy. The summary revealed she was on day 7 of 7 of admission. There was no mention of urinary tract infection. This note was signed by LVN G. Record review of CR # 10's electronic progress notes revealed the following: -1/8/2014 progress note at 12:02 PM read; "2." There was no other information in the note. The note was an eMAR - Medication Administration Note. -1/8/2014 progress note at 1:44 PM read: "PRN Administration was Effective." There was no explanation what PRN medication was administered or for what symptoms. The note was an eMAR - Medication Administration Note. -1/9/2014 progress note at 8:58 AM read: "bp low." This note was written by a medication aide. There was no blood pressure documented on the note or a note written by the nurse regarding the low blood pressure. The note was an eMAR - Medication Administration Note. -1/9/2014 at 11:47 AM electronic progress note revealed the note was an orders note. It read: "[MEDICAL CONDITION]: Document consistency of feces Q shift; L - Loose B-blood tinged stool W-watery N-Normal." -1/10/2014 at 6:10 PM revealed a medication administration electronic progress note that the resident had received 2 [MEDICATION NAME] tablets as needed for pain. There was no documentation of level or location of the pain. -1/10/2014 at 9:49 PM revealed a medication administration electronic progress note that read: "PRN Administration was Effective." -1/11/2014 at 2:30 PM revealed a medication administration electronic progress note that the resident had received 1 [MEDICATION NAME] tablet as needed for pain. There was no documentation of level or location of the pain. -1/11/2014 at 5:44 PM revealed a medication administration electronic progress note that read in part: "PRN Administration was Effective." -1/12/2014 at 5:15 PM revealed a medication administration electronic progress note that the resident had received 2 [MEDICATION NAME] tablets as needed for pain. There was no documentation of level or location of the pain. -1/12/2014 at 9:33 PM revealed a medication administration electronic progress note that read in part: "PRN Administration was Effective." 1/13/2014 at 4:20 and 4:21 PM the electronic progress note revealed two medications Solatol HCL Tablet 80 mg and [MEDICATION NAME] Tablet 25 mg and the statement "per c.n. (charge nurse) bp 109/51 p. 52." The only other progress note was for 1/14/2014 at 8:30 AM that read "hospital." Record review of CR # 10's January 2014 Amount Eaten Summary revealed she normally ate 76 to 100 % but on 1/13/2014 for breakfast and lunch she only ate 26 to 50 %. Record review of CR # 10's 1/11/2014 physician progress notes [REDACTED]. It further revealed pain was controlled with [MEDICATION NAME] and resident request an air mattress due to discomfort will order. It also revealed the resident had [MEDICAL CONDITION] and MD would check CBC. The resident had [MEDICAL CONDITION] and was on [MEDICATION NAME] and the MD would have an INR in morning and to continue [MEDICATION NAME] and [MEDICATION NAME]. It also listed that the resident had a urinary tract infection and was taking Bactrim DS and the physician would check a urinalysis, culture and sensitivity 2 days after antibiotic completed. The progress note revealed her hypertension and diabetes was controlled with medication. Record review of CR # 10's 1/13/2014 Physician /Nurse Practitioner Progress Note revealed that the visit type was new problem. It further revealed the resident had [MEDICAL CONDITION] (low pulse rate) with [MEDICAL CONDITION] (low blood pressure) now. The physical exam revealed that vital signs were as follows: B/P 111/48, P 56, RR 20. It further revealed her heart rate was irregular and apical pulse ranged from 40 to 56. The assessment/plan revealed resident was hypotensive with [MEDICAL CONDITION] both possible side effect of medication. Will hold [MEDICATION NAME] and [MEDICATION NAME] times 24 hours. [MEDICATION NAME] level, BMP, CBC stat. MD notified of above plan and he agrees. This note was written by the nurse practitioner. Record review of CR # 10's Weights and Vitals Summary that was in the clinical record revealed her weight was 390 by mechanical lift. Record review of CR # 10's Weights and Vitals Summary Report printed by the facility on 1/23/2014 revealed the following: Blood Pressure Summary -1/6/2014 at 8:18 PM B/P 128/71 -1/7/2014 at 7:56 AM B/P 125/64 -1/8/2014 at 8:16 AM B/P 120/50 -1/9/2014 at 8:57 AM B/P 99/50 -1/10/2014 at 7:22 AM B/P 111/50 -1/13/2014 at 8:02 AM B/P 110/61 There were no other blood pressures documented on the report. Temperature Summary -1/6/2014 at 8:19 PM Temperature 97.9 There were no other temperatures listed on the report. Pulse Summary -1/6/2014 at 8:19 PM Pulse 88 and regular -1/7/2014 at 7:56 AM Pulse 87 and regular -1/8/2014 at 8:16 AM Pulse 65 and regular -1/9/2014 at 8:57 AM Pulse 60 and regular -1/10/2014 at 7:22 AM Pulse 66 and regular -1/11/2014 at 8:39 AM Pulse 66 and regular -1/12/2014 at 8:28 AM Pulse 68 and regular -1/13/2014 at 8:02 AM Pulse 60 and regular There were no other pulses listed on the report. Respiration Summary -1/6/2014 at 8:19 PM respiration 20 per minute There were no other respirations listed on the report. Blood Sugar Summary -1/7/2014 at 9:13 PM BS 101 -1/8/2014 at 9:42 PM BS 130 -1/9/2014 at 7:49 AM BS 88 -1/9/2014 at 9:22 PM BS 131 -1/10/2014 at 7:36 AM BS 113 -1/10/2014 at 9:51 PM BS 114 -1/11/2014 at 7:48 AM BS 117 -1/11/2014 at 9:00 PM BS 84 -1/12/2014 at 9:13 AM BS 132 -1/12/2014 at 9:32 PM BS 111 -1/13/2014 at 8:52 AM BS 109 -1/13/2014 at 9:03 PM BS 92 There were no other blood sugars documented. Record review of CR # 10's Pain Assessment Medication Sheet for January 2014 revealed that 0 or 0 with a line through it (meaning no pain) was documented for every day and shift from 1/8/2014 through 1/16/ . Written over 1/14/2013 through 1/18/2014 was the word ERROR. On the day and evening shift for all the days for level of consciousness 1 was documented meaning alert and oriented. For the night shift 4 were documented which meant sleeping. Record review of the 24 hour report for the January revealed the following entries related to CR # 10: 1/14/2014 for 10 to 6 AM shift [MEDICAL CONDITION], Bactrim DS stop 1/17 urinary tract infection, urinalysis Record review of CR # 10 Physician Telephone orders revealed the following orders: -1/6/2014 CBC, BMP, PT/INR -1/8/2014 Blood sugar checks every morning time 7 days. -1/11/2014 CBC on Monday or with next blood draw. Check INR in am. Check Urinalysis with culture and sensitivity 2 days after antibiotic completed, check BMP. Please order air mattress/bariatric bed. -1/13/2014 at 3:45 PM STAT CBC, BMP, [MEDICATION NAME] level. Hold [MEDICATION NAME] and [MEDICATION NAME] time 24 hours. Notify physician if HR less than 50 beats per minute. -Send to ER for evaluation and treatment. Record review of CR # 10's Basic Metabolic Panel revealed it was collected on 1/13/2014 at 7:55 PM and resulted on 1/14/2014 at 1:22 AM. Listed on the lab report were lab results from 1/7/2014 to compare with current results from 1/14/2014. It revealed the following results for 1/7/2014 at 4:30 AM: -Potassium 5.9 with reference range of 3.5 - 5.1. -Glucose 88 with reference range of 70 - 105. -Urea Nitrogen 41 with reference range of 7 - 25. -Creatinine 1.7 with reference range of 0.8 - 1.2 -Calcium 8.0 with reference range of 8.6 - 10.3 Above the lab results the report read: "REPORT CONTAINS PANIC VALUE." for 1/14/2014 lab results. The report revealed the following results for 1/14/2014: -Potassium 6.9 with reference range of 3.5 - 5.1. Below the result "PANIC VALUE" was typed. -Glucose 40 with reference range of 70 - 105. Below the result "PANIC VALUE" was typed. -Urea Nitrogen 65 with reference range of 7 - 25. -Creatinine 4.0 with reference range of 0.8 - 1.2 -Calcium 7.7 with reference range of 8.6 - 10.3 There was a hand written note on the bottom of the lab report that revealed the lab had been called to the NP on 1/14/14 at 4:40 AM and there was an order to send the resident to the ER. There was an additional copy of the 1/14/2014 lab results in the medical record that had a hand written note on the bottom of the lab slip that revealed the resident was sent to the hospital in the morning and the NP was aware. It further revealed it was faxed at 4:30 PM with LVN B's signature. Record review of CR # 10's medical record revealed there was not an original lab report for the 1/7/2014 lab result. There was no documentation that the physician had been notified of the 1/7/2014 labs results. Record review of CR # 10's 1/14/2014 SBAR revealed that the change in condition, symptoms or signs the nurse called about were abnormal labs. The thing that make the condition or symptom worse or better both had unknown documented next to the statement. No was checked next to the condition, symptom or signs had occurred before. Under the background section of the form the following vital signs were documented B/P 141/76, P 60, RR 16 and temp 97.6. Her oximetry was 93 % on room air. Under the mental status of this section the following items were checked: -Increased confusion, decreased consciousness (sleepy, lethargic), other symptoms or signs of [MEDICAL CONDITION]. The description of symptoms or signs was blank. -Needs mores assistance with ADLs. The description of symptoms or signs was blank. -Decreased urine output. The description of symptoms or signs read: " 50 cc in 6 hrs. -Recent Lab results -K 6.9, urea nitrogen 65, Creatinine 4.0. Under the assessment (RN) or appearance (LPN), under For LPN it read more confused and lethargic. Under the request section: Transfer to the hospital was checked. The nursing note section this read in part: "Abnormal labs called to NP . . . order to send to ER . . . Notified family (and) DON." The SBAR revealed that the NP was notified on 1/14/2014 at 4:45 AM and the family member was notified on 1/14/2014 at 5:15 AM. Record review of CR # 10's 1/14/2014 Patient Transfer Form revealed the [DIAGNOSES REDACTED]. It further revealed her blood pressure at the time of transfer was 141/76, her heart rate was 60 and her respirations were 16 per minute. Record review of CR # 10's Emergency Department Physician T-sheet revealed she was registered at the hospital on [DATE] at 6:08 AM. It further revealed she arrived by ambulance and the patient and the EMS personnel were the historians. The history of present illness read: "ABNORMAL LAB. 9(EMS were called to park manor for abnormal lab. Upon arrival, told her k was elevated. They tested her BS, it was low at 40 so they gave her D50 ([MEDICATION NAME] 50 %, IV used to raise blood sugar). Her HR was also low in the 30's, and her BP was low in the 90's so they gave her [MEDICATION NAME] 0.5 mg x 2 without change. Pt was awake and alert and without complaints. Has CRI (chronic [MEDICAL CONDITION]), but her doctor has never spoken about [MEDICAL TREATMENT]." The report revealed her EKG # 1. showed [MEDICAL CONDITION] and [MEDICAL CONDITION]. Wide ORS and non-specific ST segment/T wave abnormalities. It further revealed EKG # 2 showed [MEDICAL CONDITION] and [MEDICAL CONDITION]. Normal ORS and non-specific ST segment/T wave abnormalities. The following lab and x-ray results were listed: -Potassium Level 7.7 collected at 6:30 AM on 1/14/2014 and called to at 6:56 AM. 7.4 collected at 7:07 AM and resulted at 7:37 AM. Critical result. Phosphorus level 6.5 collected at 6:30 AM on 1/14/2014 with reference range of 2.5 - 4.5 CO2 19 collected at 6:30 AM on 1/14/2014 reference range 24 - 32. Glucose 69 collected at 6:30 AM on 1/14/2014 reference range 70 - 99. -Creatinine level 4.4 collected at 6:30 AM on 1/14/2014 reference range 0.5 - 1.4 Blood Urea Nitrogen 66 collected at 6:30 AM on 1/14/2014 reference range 7 -22. -[MEDICATION NAME] Level 2.3 collected at 6:30 AM on 1/14/2014 reference range 3.5 - 5.0 -Calcium level 7.4 collected at 6:30 AM on 1/14/2014 reference range 8.5 - 10.5 -Chest x-ray Impression: Mild [MEDICAL CONDITION] vascular congestion. -Urinalysis with microscopic. Urinalysis color red. The process and Procedures section of the report read in part: "Upon arrival, labs drawn from yesterday noted to have K of 6.9. While waiting on labs, immediately started to treat her [MEDICAL CONDITION] (elevated potassium). After tx, the QRS narrowed, but pt still bradycardic in the 30 - 40's, still hypotensive. Have spoken with her cardiologist who will place a temporary pacemaker to stabilize pt so she can get a Quinton cath (access used for [MEDICAL TREATMENT] treatments) . . . for emergent HD . . . 7:15 AM dr . . . discussed case with pt, will come in and place temporary pace maker to stabilize pt while waiting for Quinton cath and emergent HD . . ." It further revealed resident was sent to cath lab for Quinton catheter at 7:45 AM. It further revealed her disposition was admitted to critical care with clinical impression of acute [MEDICAL CONDITIONS] with EKG changes, and symptomatic [MEDICAL CONDITION]. Record review of CR # 10's 1/14/2014 at 7:54 AM History and Physical revealed the resident was found to be generally lethargic over at Park Manor and labs were ordered. Her blood pressure was 80/58, pulse 50. It further revealed the patient looked lethargic. Record review of CR # 10's 1/15/2014 at 7:42 AM hospital consult revealed the reason for the consultation was critical care management. It further revealed the resident was admitted with altered mental status, shock, [MEDICAL CONDITION], found to have acute kidney injury with [MEDICAL CONDITION]. It further revealed she underwent emergent pacemaker placement as well as [MEDICAL TREATMENT]. She was placed on medication for both her heart rate and blood pressure control. It also revealed her speech was somewhat garbled and she complained of chronic lower extremity pain. The laboratories revealed her potassium was currently 5.7 and highest potassium was level 7.7 (1/14/2014, collected at 6:30 AM). Creatinine was 2.8 and glucose 152. The plan was for antibiotics for probable urinary tract infection [MEDICAL CONDITION] pain control and potassium and Creatinine per renal. Record review of CR # 10's 1/21/2014 Social Work referral revealed the resident was to be set up for outpatient [MEDICAL TREATMENT]. It further revealed the resident said transportation would be difficult and the family wanted to consider patient having home hemo [MEDICAL TREATMENT] (blood). Record review of CR # 10's 1/22/2014 renal progress note revealed the resident was still bothered by need to continue [MEDICAL TREATMENT]. It further revealed she only had 100 cc urine output the day before. Record review of CR # 10's 1/22/2014 Medicine progress note revealed end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT] being arranged, urinary tract infection bein