Every finding on record at Ryder Memorial Hospital Inc

Based on dining observations, review of policies procedures and facility staff interview performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that each resident (R), receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. This deficiency affects 1 out of 12 residents admitted receiving services (R #268). Findings include: 1. Resident interview #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis. -During the initial pool process on 03/24/2025 at 8:21 AM resident #268 indicated that when food is brought in sometimes there are foods that are not to his liking, when this happens the staff does not offer him some substitute food to ensure he has adequate food intake. -Record reviewed conducted on 03/24/2025 at 1:44 PM noted that the dietician made an estimate of the resident's tastes and needs, and these went to the kitchen for preparation.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 03/24/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to comply with the required sink compartment sanitations. This deficient practice could affect 24 out of 24 residents admitted receiving care at the facility. Findings include: Review of facility's policy and procedure [NAME], Enjuage y Saneamiento, Cleaning and Disinfection of three compartment Sinks regarding the process of cleaning and sanitization of kitchen equipment was reviewed on 03/24/2025 at 11:30 AM and it says that compartment one (1) must have a temperature of 110 F, on compartment two (2) and on compartment three (3) utensils should be for 30 seconds with a sanitizing solution concentration of 200 ppm.Test strip container was verified and stated that concentration testing should be taken with a temperature of 75 degrees Fahrenheit. 1.During the visual inspection and staff interview it was noticed that 3 compartment sinks were not prepared as stated in the facility policies and procedures. It was observed that the staff working the sink did not have knowledge of the temperatures required in the sanitization compartments. It was requested that the concentration of sanitizer be taken on the third compartment, and the concentration measurement was found to be higher than the requirement of 200 ppm. Overuse of the sanitizing agent could be harmful. 2.During observation of the dry storage area, loose rice and beans were observed underneath the storage racks. A tuna can was observed left on the floor. 3.Lettuce was observed cut and wrapped in plastic wrapping with no date. 4.Prepared cereal (farina) was observed on container with no date of preparation. 5.Mandarin oranges were observed on container, apple juice wrapping, and plastic was inside container with oranges.

Based on observation during medication pass performance on 03/25/2025 from 8:22 AM till 9:30 AM, it was determined that the facility failed to ensure establish and maintain an infection prevention and control program relate to hand washing during the drug pass and failed to ensure establish and maintain an infection prevention and control program related to changing gloves in bed baths in 1 out of 1 resident observed (RR #215) 51829 Findings include: 1. During the drug past performance on 03/25/2024 from 8:22 AM till 9:30 AM, it was observed two register nurses in the process medication administration, and it was found the following. a. On 03/25/2025 at 8:55 AM RN #10 failed to follow appropriate hand washing process during the medication administration and failed to hand wash 1 out to 7 opportunities for hand wash 14.28%. b. On 03/25/2025 at 8:22 AM RN #11 failed to follow appropriate hand washing process during the medication administration and failed to hand wash 9 out to 11 opportunities for hand wash 81.81%. 47632 2. R.R #215 is a [AGE] year-old male admitted [DATE] with Infected Sacral Ulcer. During the bed bathing procedure by Licensed Practical Nurse (LPN) employee #15, she performed 3 water changes and did not perform 3 glove changes.

Based on observations performed on 03/24/2025 from 8:30 AM through 3:30 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficient practice affects 24 out of 24 residents admitted receiving treatment at the facility. Findings include: 1. During a visual inspection of the equipment in the physical therapy area, it was observed that of 7 wheelchairs observed, 3 of these had peeling paint and signs of rust, and clinical tape on the arm rests. 2. It was also observed that of 15 walkers available, 5 of them showed signs of rust and wear and tear. 3. Two (2) out of two (2) of pedal floor exerciser were observed with signs of rust.

Based on observation and eighteen records reviewed (RR) on 03/24/2025 through 03/26/2025 from 9:00 AM to 3:00 PM, it was determined that the facility did not ensure providing in making decisions regarding medical care and treatment with the resident or representative in advance directives 2 out of 18 records reviewed. (R.R #106 and #108). Findings include: 1. During the evaluation of the records review on 03/25/2025, the following was found: a. R.R #215 is a [AGE] year-old male admitted [DATE] with Infected Sacral Ulcer. Noted in the record review on 03/26/2025 at 10:13 AM, the advance directive was observed without the signature of the resident or representative. b. R.R #217 is a [AGE] year-old male admitted on [DATE] with Amputation of the First Toe of the Right Foot. Noted in the record review on 03/25/2025 at 2:10 PM, that the resident was on Family Department Service and that the advance directive was not signed by a proxy. It was verified that the resident had signed an X on the advance directive document. A request was made on 03/25/2025 at 8:43 AM to employee administrator #1 for a policy indicating when the resident was unable to sign and was unavailable. Social Work employee #8 was interviewed on 3/25/2025 at 11:44 AM and stated that when a resident is in the Family Services Department, staff is responsible for signing all the resident's paperwork.

Based on observations and interviews with residents, facility administrator and physical environment personnel during the survey for the physical environment, it was determined that the facility failed to ensure that resident's sleeping rooms have comfortable and safe temperature levels and room environment is not homelike. This deficient practice was identified in 5 out of 20 residents' rooms. Findings include: 1. During the tour of physical environment with a nurse, performed on 03/25/2025 at 10:30 AM all residents' sleeping rooms were visited. Residents located in room [ROOM NUMBER], 106 and 114 referred that room temperature was very cold. Those residents were observed covered with blankets and complained about low temperatures. 2. Resident located in rooms # 105,# 106 and # 114 stated during individual interviews on 03/25/2025 from 10:30 AM through 11:00 AM they would prefer warmer temperatures. It was identified that those rooms did not have a thermostat to be used to regulate the temperature of the room. 3. Physical environment personnel (employee #3) stated during interview on 03/25/2025 at 11:40 AM that resident rooms #105,# 106 and # 114 did not have a thermostat to be used to regulate the temperature of the room. He explains that room air condition temperature is set between 71 degrees and 81 degrees. That every resident room air condition system had a thermostat that continuously monitors the temperature in the room and sends signals to the control board to adjust the cooling output of the air conditioner as needed , however it is impossible to read or identify what the room temperature is. 4.The facility administrator (employee #1) was asked on 03/25/2025 at 1:20 PM if facility had a system or mechanism to monitor resident rooms temperature in order to adjust this temperature based on each resident preference. She stated that the facility did not have a mechanism or procedure to monitor resident rooms temperature in order to adjust this temperature based on each resident preference. 17959 5. During the tour for physical environment with an LPN Nurse ( employee #17) on 03/24/2025 from 8:45 AM till 10:45 AM on patients' rooms 116 A, 116C and 117C the following was observed: a. On resident room [ROOM NUMBER] the bathtub curtain has one of the holes on the right side broken and lacks one of the hooks which makes the curtain touch the floor. b. On resident room [ROOM NUMBER]C wall behind the patient's bed, paint detachment was observed. The arm of the TV, wheelchair and the air conditioning grill were observed with mold. 47384 6. Based on observations of the physical environment, review of policies procedures on 03/24/2024 from 8:30 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable and homelike environment. This deficient practice could affect 24 out of 24 residents admitted receiving care at the facility. 1. Black mold spots were observed on ceiling tile of cubicle #5 on the Physical Treatment area. 2. Lifted paint was observed on back wall of cubicle #3 on the Physical Treatment area. 3. Black mold spots were observed on ceiling tile of open area on the Physical Treatment area. 4. Excessive dust was observed on filter grills of two AC units on the Physical Treatment area. 5. Excessive vegetative material was found on the bottom part of the emergency exit door next to station #4. 6. Exterior wall of treatment station #5 (orange wall) was observed with broken gypsum board on the bottom part of the wall. 7. Several residents were interviewed, and they reported that the rooms were very cold. Room temperatures were taken, and the following was found: a. room [ROOM NUMBER]- 71 degrees b. room [ROOM NUMBER] -73 degrees c. room [ROOM NUMBER] - 68 degrees d. room [ROOM NUMBER] - 69 degrees e. room [ROOM NUMBER] - 67 degrees f. room [ROOM NUMBER] - 68 degrees g. room [ROOM NUMBER] - 69 degrees h. room [ROOM NUMBER] - 72 degrees i. room [ROOM NUMBER] - 73 degrees The facility does not have a specific policy for room temperature, but they adjust to the temperature policy for the medication room [NAME] de Temperatura de Cuarto de Medicamento which states parameters between 71- and 81-degrees Fahrenheit. 8.Extractor grill on room [ROOM NUMBER] on wall of rooms were observed with rust and excessive dust.

Based on review of twelve medical records, resident interview and interview with the Administrator (employee #1) performed from 03/24/2025 thru 03/26/2025, from 8:00 AM thru 3:30 PM, it was determined that the facility failed to develop and implement baseline care plan within 48 hours of a resident's admission in order to promote the continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. This deficient practice was identified in 2 out of 12 cases reviewed. (RR #265, #266) and fail to update information based on the comprehensive care plan identified on 5 out of 6 records reviews. (Residents #6, # 7, #10, #13 and #108 ). Findings include: 1.Record Review #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. -The resident was admitted for rehabilitation and therapy services. Record review conducted on 03/24/2025 at 2:25 PM, it was identified that the resident's plan of care was identified with another patient's label. -The facility removed the label with the other patient's name and proceeded to place the correct label without signing or evaluating other options. -A policy stating the process to follow when this occurs was requested and the facility did not provide one. 2. File review #266 is an [AGE] year-old female admitted on [DATE] with a diagnosis of L+ femur fracture. -The resident was interviewed during the initial pool on 03/24/2025 at 8:55 AM and stated that she suffers from urinary incontinence. She also stated that she is kept in a diaper in the SNF and when she calls the nurse call system, she is diapered after approximately 30 minutes. -During the care plan review conducted on 03/24/2025 at 1:18 PM it was noted that the incontinent care plan was not opened by nursing. The facility failed to implement a care plan that provided follow-up to the residents' current problems. 17959 3. Resident #6 is an 83-year male admitted on [DATE] at 10:20 PM with diagnosis of Left hip fracture status post-op. admitted for rehabilitation with Physical Therapy and Occupational therapy. a. During the record review performed on 03/24/2025 at 1:18 PM, it was found that the MDS was performed and signed for MD on 1/18/2025, LDN signed on 1/20/2025, PT on 1/22/2025, OT on 1/23/2025, Pharmacy on 1/25/2025 and Social Worker on 1/20/2025. However, LND and Phycology signed on 3/20/2025 sixty-two days later than the admission. The MDS lacks the intervention of the Recreative therapist since admission to 66 days later. b. The consultation report to Speech Pathology performed on 3/20/2025 at 9:30 AM lacks reason to request the Speech Pathology evaluation, no date, time and signature of Attending Physician signature. c. The PMR consultation report lacks who notified the consultant, date, time and to whom. 4. Resident #7 is a 73 -year female admitted on [DATE] at 2:57 PM with diagnosis of Right Total Hip Replacement status post-op. admitted for rehabilitation with Physical Therapy daily. a. During the record review performed on 03/24/2025 at 2:03 PM the standardized admission orders miss the signature of the register nurse, title, license number, date and time. b. The physician admission evaluation was maintained in blank. c. The physician's orders performed on 3/24/2025 at 2:03 PM lack the physician signature. d. On 3/24/2025 at 2:03 PM no evidence of the physical therapy evaluation in patient record. e. The discharge planning performed on 3/22/2025 per Interdisciplinary Equipment did not have the physician and the physical therapist participation. 5. Resident #10 is a 61-year male admitted on [DATE] with primary diagnosis of Amputation of right finger of left toe, Osteomyelitis and Acute Renal Failure, Metabolic Acidosis, HBP, CVD, HTN Decondition, Peripheral Vascular Disease, Hyperlipidemia. On 01/03/2025 at 6:40 PM the resident was transferred to [NAME] Hospital at Telemetry because the laboratory results were altered. The record was reviewed on 03/25/2025 at 9:54 AM and the following was identified: a. The Interdisciplinary Discharge Planning was performed on 12/17/2024 and there is no evidence of the Physical Therapy participation. b. The infection history, allergy history and vaccination history it's in blank. 6. Resident #13 is a 45-year male admitted on [DATE] and discharge on 12/27/2024 with diagnosis of Stroke, Debility, Gota, Dermatitis, Hight Blood Pressure and Raynaud's Syndrome. The record was reviewed on 03/25/2025 at 11:12 AM and the following was identified: a. The physician progress note did not have the hour and date when the physician documented. b. The PMR, Physical Therapy and Occupational Therapy consult lacks information. Physician signature and license number. c. Discharge orders did not have the date when the physician wrote the order. d. The Interdisciplinary Discharge plan lacks disposition of case. e. The protocol for Pulmonary prevention was maintained in blank, only have the physician signature, lacks the nurse's signature, date and time. f. Vaccination history was maintained in blank. g. Photography consent form lacks resident name 47632 7. R.R #108 is a [AGE] year-old male admitted on [DATE] with Amputation of the First Toe of the Right Foot. Noted in the record review on 03/25/2025 at 2:10 PM, lack of signatures of the resident or representative in the following documents: a. Permission to take photo. b. Consent to Admission. c. Commitment to pay. d. Certification of patient and/or family orientation. e. Interdisciplinary Care Plan. f. Advance directives. g. Baseline Care Planning. h. Guidance received on care plans. i. Use of bedside rails. j. Estimated administration of Influenza, Pneumococcal and Covid -19 vaccines. k. Validation of education offered to patient or family members. l. Guidance on Minimum Data Set (MDS). Social Work Employee #8 was interviewed on 03/25/2025 at 11:44 AM regarding the documents with an X signed by the resident, she stated that the X is valid as a signature, she was asked for a policy that she would have to verify if the administrator had the policy which she did not have created. The social worker also stated that the resident is in a mental state of disorientation period and is in the service of the Family Department at the Yabucoa location, they are responsible for signing those documents that are pending in the medical record.

Based on observations on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (employee #16), it was identified that facility failed to evidence the participation of Interdisciplinary Team (IDT) professionals in the development, implementation and review of the comprehensive person-centered care plan for a resident who is identified with non- compliance with the drug regimen. This deficient practice affects 3 out of 12 residents included in the sample selection. (Resident, #4, #67, #217). Findings include: 1. The following information was identified while reviewing the medical record of resident #67 with the Nursing personnel (employee #16), on 03/26/2025 at 9:00 AM: a. RR #67 is a 45 male resident admitted on [DATE] with a diagnosis of Right Knee Replacement. According with information documented in the medical record this resident had history of Anxiety Disorder and Depression (other than bipolar ). b. When the resident was admitted to the facility on [DATE] nursing personnel perform medication reconciliation. During medication reconciliation resident notifies that he refuses to take Zoloft Elavil and Klonopin since he was receiving services at the hospital before being admitted to the SNF. c. Zoloft PO is a prescription medication that can help treat depression and other mental health conditions, Elavil PO, that is a tricyclic antidepressant used to treat depression and mood disorders and Klonopin PO is used to prevent and treat anxiety disorders. d. Comprehensive plan of care for this resident was prepared by the interdisciplinary team on 03/20/2025. Pharmacy and medications areas of this plan include the medications that the resident is refusing and not using. No information was documented as notified to the physician or pharmacist in relation to resident refusal of those prescribed medications used to treat depression and other mental health conditions. So, using this type of medications can create a chemical imbalance and result side effects. 47632 2. Resident #4 is a [AGE] year-old female admitted [DATE] with osteomyelitis sacral ulcer stage 4, according to the information collected in the medical record. a. On 3/24/2025 at 1:20 PM, it was noted in the medical record that the interdisciplinary care plan was not completed by recreational therapy, nutrition and pharmacy staff. The interdisciplinary care plan in the expected outcomes on the evaluation date there was no continuity or outcomes according to the care plan. On 03/25/2025 at 9:03 AM, medication pass nurse #11, referred that they discuss the interdisciplinary care plan every Tuesday with the nursing staff. On 03/25/2025 at 10:05 AM, employee #12, MDS coordinator, was interviewed and stated that cases are evaluated individually in the first seven days when they are completing the MDS, but officially the interdisciplinary group has not met since the pandemic. 3. Resident #217 is a [AGE] year-old male admitted with amputation of the first toe of the right foot according to the information collected in the medical record. a. Minimum Data Set (MDS) resident Assessment and Car Screening noted incomplete participation in the assessment and setting (identify all active participants in the assessment process) the part of another legally authorized representative and Cognitive Skill for Daily Decision Making (decision making related to daily living tasks) blank. b. During the evaluation of the medical record on 03/26/2025 at 2:40 PM, it was noted that the resident was not oriented to his care plan or given the opportunity to participate in the care .

Based on observations performed on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (employee #16), and Administrator (employee #1) it was identified that facility failed to develop and implement comprehensive person-centered care plan for a resident who is identified with social service's needs and failed to guarantee participation of the interdisciplinary group in the comprehensive care plan meetings This deficient practice affects 1 out of 12 residents included in the sample selection. (Resident #3). Findings include: 1. The following information was identified while reviewing the medical record of resident #3 with the Nursing personnel (employee #16), on 03/25/2025 at 9:15 AM: a.RR #3 is an 80 male resident admitted on [DATE] with a diagnosis of Right Femur Fracture. Accordingly with information documented on the medical record Social Worker Initial Assessment resident lives alone in an independent elderly apartments complex. Apparently, the resident begins to experience disorientation episodes, felt down and fractured right hip. After surgery the resident was admitted receiving rehabilitation in the SNF and the social worker of the SNF communicate with resident daughter on 01/20/2025. Accordingly with information documented by the social worker in the medical record, resident daughter notifies the social worker that she and her sister were in charge to provide care to their mother who had Alzheimer, they notify that cannot take care of their father or have the economic resources to pay for housing and care for their father. On 01/31/2025 the case was referred to Puerto Rico State Social Family Department in order to request help to locate the resident when was discharged home from the SNF. b. The Social worker follow-up with the social services department of Puerto Rico state social family department on 02/03/2025, 02/04/2025, 02/05/2025,02/06/2025,02/10/2025,02/11/2025 and 02/18/2025. There is no evidence of any other social worker intervention for this case, after 02/18/2025. c. On 03/25/2025 facility administrator document that communicated with social services department of Puerto Rico state social family department in order to request information of status of resident location. The Social services department of Puerto Rico state social family department requests a certification of resident medical conditions. d. The comprehensive care plan of this resident was reviewed by IDT on 03/17/2025. Social services areas were not triggered or included in this comprehensive care plan. e. Facility administrator stated on interview on 03/25/2025 at 10:00 AM that facility social worker resigns from her position on 02/19/2025. She informs that this social worker who resign from her position was recruited by contract as part-time position on 03/27/2025 while facility recruit another social worker. She also informs that another part-time social worker was recruited on 03/21/2025 while the facility recruit a full time social worker. f. The surveyor asked the facility administrator (employee #1) on 03/25/2025 at 10:30 AM if there is the possibility that those part-time social worker employees failed to participate and document the development and implementation of case #3 social services comprehensive plan. The administrator (employee #1) stated that there is the possibility that they did not document interventions carried out to follow-up with the State social services department of Puerto Rico Social family department the status of resident location. 47632 2. The MDS coordinator employee #12 was interviewed on 03/25/2025 at 10:05 AM about the meetings held by the interdisciplinary group. She said that they used to meet once a week, but since the pandemic they no longer meet. The meetings that are held individually with part of the interdisciplinary group are the first seven days when staff come in to fill out the MDS and then they take the opportunity to discuss the relevance of a resident. Virtual meetings were not considered according to employee #12 MDS coordinator. The only interdisciplinary group meetings that were held were the weekly nursing staff meetings every Tuesday according to nursing employee #14. Administrator employee #1 was interviewed on 3/25/2025 at 10:25 AM, she stated that they had not met due to Covid-19, but now she knew she was going to meet with staff to start interdisciplinary group meetings. The facility did not ensure participation of the interdisciplinary group to work together to provide the greatest benefit to the residents. The facility did not develop an alternative method, i.e., face-to-face or virtual meetings, for the interdisciplinary group members to provide input into the development and review of the resident's plan of care.

Based on observations performed on 03/24/25 through 03/26/25 from 8:30 AM till 4:00 PM and interview with Nursing personnel (employee #16), it was identified that facility failed to evidence that identify irregularities in the medication review were documented, reported and if necessary to the attending physician and pharmacist. This deficient practice affects 3 out of 12 residents included in the sample selection. (Resident #67, #265 and #268). Findings include: 1.The following information was identified while reviewing the medical record of resident #67 with the Nursing personnel (employee #16), on 03/26/2025 at 9:00 AM: a.RR #67 is a 45 male resident admitted on [DATE] with a diagnosis of Right Knee Replacement. According to the information documented in the medical record this resident had history of Anxiety Disorder and Depression (other than bipolar ). b. When the resident was admitted to the facility on [DATE] nursing personnel perform medication reconciliation. During medication reconciliation resident notified that he refused to take Zoloft Elavil and Klonopin since he was receiving services at the hospital before being admitted to the SNF. c. Zoloft PO is a prescription medication that can help treat depression and other mental health conditions, Elavil PO, that is a tricyclic antidepressant used to treat depression and mood disorders and Klonopin PO is used to prevent and treat anxiety disorders. No evidence was found documented on the medical record or drug regimen review of the oversight by pharmacy or physician when was identified that this resident is refusing previously ordered for depression and other mental health conditions. This resident had history of anxiety disorder and Depression (other than bipolar ) accordingly with information documented in the medical record. d. The reason why residents refuse to take those medications was not found documented as part of the documentation of the drug regimen review. e. No evidence was found documented related to information provided to resident #67 in relation of the possible effects that he could experience when stopping antidepressants and other mental health medications or withdrawal symptoms. 51637 2. Record Review #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. -Record review conducted on 03/24/2025 at 2:25 PM, it was noted that medication reconciliation by pharmacy was incomplete. Although she had a signed medication reconciliation within the stipulated time, it lacked documentation indicating the reaction or interaction of each medication and suggestions or consultation with the medical director if necessary. 3. Record review #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis. -Record review conducted on 03/24/2025 at 1:44 PM noted that the medication reconciliation by pharmacy was incomplete. Although he had a signed medication reconciliation within the stipulated time frame, it lacked documentation indicating the reaction or interaction of each medication and suggestions or consultation with the medical director if necessary. In addition, the resident was prescribed opioids for pain after the initial medication reconciliation and there was no follow-up medication reconciliation. During the interview with pharmacy licensee employee #7 conducted on 03/25/2025 at 11:09 AM she indicated that medication reconciliations are initial only and are not provided follow-up unless there is a specific order for it. She also indicated that there was no documentation other than the signature on the stipulated document for medication reconciliation. 4. The facility failed to provide or promote a mechanism to ensure that the review of each resident's medication regimen is monitored to improve their condition, reduce risks or deterioration of their condition.

Based on the observations made through the initial pool process and the request for policies and procedures to the administrative staff conducted on 03/24/2025 through 03/26/2025 from 8:00 AM to 3:30 PM, it was determined that the facility failed to provide a respectable service where the residents' dignity was maintained. This deficiency was identified in 1 out of 24 cases reviewed during the initial pool process (Resident #265). 1. Resident #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. The resident was observed on 03/24/2025 at 10:11 AM leaving the scale with no pants or sheets covering her legs so she was exposed to view. On 03/25/2025 at 9:15 AM a policy was requested from the facility regarding the procedure for female wheelchair use and was not provided. The facility failed to treat each resident with respect and dignity and provide care and services in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on review of 12 medical records reviewed (RR) and interviews performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote mechanisms to identify the psychotropic drugs are not given unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice was identified in 2 out of 12 active records reviewed. (R.R. #265 and #268). Findings include: 1. Resident #265 is an [AGE] year-old female admitted on [DATE] with a diagnosis of decondition. Record review conducted on 03/24/2025 at 2:25 PM, it was noted that the resident has high risk medications orders: Eliquis 2.5 milligrams (mg) 1 tab orally (PO) two times per day (BID), Lasix 40mg PO Daily and Seroquel 25mg tab PO hour of sleep (HS). No evidence was found that the License Pharmacist performed a Medication Regimen requirement to identify the psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. 2. Resident #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis. Record review conducted on 03/24/2025 at 1:44 PM it was noted that the resident has high risk medication orders: Lovenox 40mg subcutaneous (SQ) Daily, Zoloft 50mg tab PO Daily, Xanax 1mg tab PO HS x 5 days, Tylenol #3 with codeine 2 tabs PO every 6 hours as needed (PRN) for pain. No evidence was found that the License Pharmacist performed a Medication Regimen requirement to identify the psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. 3. During the interview with pharmacy licensee employee # 7 conducted on 03/25/2025 at 11:09 AM she indicated that medication reconciliations are initial only and are not provided follow-up unless there is a specific order for it. She also indicated that there was no documentation other than the signature on the stipulated document for medication reconciliation. The facility failed to provide or promote a mechanism to ensure that the review of each resident's medication regimen is monitored to improve their condition, reduce risks or deterioration of their condition.

Based on dining observations, review of policies procedures and facility staff interview performed on 03/24/2025 through 03/26/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to ensure that each resident receives food that accommodates resident allergies, intolerances, and preferences. This deficiency was identified in 1 out of 12 residents of the sample selection (Resident #268). 1. Resident interview #268 is a [AGE] year-old male admitted on [DATE] with a diagnosis of lumbar discitis osteomyelitis. -During the initial pool process on 03/24/2025 at 8:21 AM resident #268 indicated that when food is brought in sometimes there are foods that are not to his liking, when this happens the staff does not offer him some substitute food to ensure he has adequate food intake. -Record reviewed conducted on 03/24/2025 at 1:44 PM noted that the dietician made an estimate of the resident's tastes and needs, and these went to the kitchen for preparation. The facility failed to ensure that resident preference was granted, and recommendation of the nutritionist was granted.

Based on observations and interview with the Dietitian (employee #2) performed from 05/13/2024 thru 05/15/2024, from 8:00 AM thru 5:00 PM, it was determined that the facility failed to provide sufficient support for personnel safely and effectively carry out the functions of the food and nutrition service. Findings include: During an interview with the Dietitian performed on 05/14/2024 she stated that the facility did not have all the necessary personnel in the kitchen. A kitchen personnel pattern was requested to the kitchen manager by the surveyor and it was noticed that the pattern revealed 5 more employees were needed for optimal operation.

Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that residents needs and preferences related with food services are met. This deficiency was identified in 3 out 13 sample cases reviewed (Resident #116, #120 and #121). Findings include: Facility policy Title: Food Services to Residents was reviewed on 05/13/2024 at 11:35 AM with Dietitian (employee #2) Policy clearly stated on the procedures that every resident's breakfast must be delivered between 7:00 AM-8:15 AM. 1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A stated that breakfast did not arrive at a time in the morning that best suits their needs. a. Resident sample # 116 stated in the interview on 05/13/24 at 8:40 AM that breakfast has arrived for the past four days after 8:30 AM. She stated that she was admitted on [DATE] due to status post right hip surgery for rehabilitation. She stated that breakfast came at the same time physical therapy escort personnel comes for us to take us to physical therapy in the morning. Because breakfast came at the same time physical therapy escort personnel is coming for us to take us to physical therapy in the morning this does not permit us to eat calmly and to go to the bathroom before going to the physical therapy treatment. She also stated that she prefers to have breakfast between 7:30 AM and 8:00 AM. b. Resident sample # 120 stated in an interview on 05/13/24 at 8:50 AM that breakfast has arrived for the past four days after 8:30 AM. She stated that she was admitted on [DATE] due to Left Knee Replacement for rehabilitation. She stated that breakfast came at the same time physical therapy escort personnel is coming for me to take me to physical therapy in the morning. Resident stated that she has diabetes, and she usually eats breakfast earlier in the morning. She also stated that she prefers to have breakfast between 7:30 AM and 8:00 AM. c. Resident sample # 121 stated in an interview on 05/13/24 at 9:10 AM that breakfast has arrived for the past four days after 8:30 AM. He stated that he was admitted on [DATE] due to Left Knee Replacement for rehabilitation. He stated that breakfast came at the same time physical therapy escort personnel is coming for me to take me to physical therapy in the morning. Resident stated that he has diabetes, and he usually eats breakfast earlier in the morning. He also stated that she prefers to have breakfast between 7:30 AM and 8:00 AM. d. Resident preferences related with time where breakfast came in the morning is discussed with facility administrator (employee #1) on 05/13/24 at 10:50 AM. Facility administrator stated on interview that she had knowledge of the situation and that referred the situation to the facility dietitian for her to meet with kitchen contracted manager to solve the situation. Facility administrator also stated in an interview that agreements had been reached with the kitchen contracted company to adjust food delivery in a way that adjusts to resident preferences and rehabilitation routine. 47384 e. During an interview with the Dietitian performed on 05/14/2024 she stated that the facility did not have all the necessary personnel in the kitchen. A kitchen personnel staffing pattern was requested to the kitchen manager by the surveyor, and it was noticed that the pattern revealed 5 more employees were needed for optimal operation. f. Facility dietitian (employee #2) stated in an interview on 05/13/24 at 11:10 AM that a new kitchen company began to offer services on March 1, 2024. She stated that since this company began to offer services; she met with kitchen manager on several occasions to explain to her the importance of adjust resident's food delivery in a way that adjust to their resident preferences and rehabilitation routine. She stated that kitchen manager agrees since the company began to offer services, that food delivery was going to be carried out in a way that adjusts to resident preferences and rehabilitation routine. She stated that those are the agreements that they made with the kitchen contractor manager, but she also explained that she had knowledge that the kitchen contracted company had experience staff turnover and this could affect services provided.

Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that input received from residents and preferences related with food services are met. This deficiency affects 4 out of 13 cases reviewed during initial pool process (Resident #108, #116, #120 and #121). Findings include: The facility policy Title: Nutritional Needs last updated in January 2024, was reviewed on 05/15/2024 at 3:05 PM with Dietitian. Policy clearly stated the procedures that for every resident admitted to the facility food will be provided considering each resident preference. 1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A stated that food brought by the kitchen personnel had items that they do not like in their breakfast, lunch, and dinner. a.Resident sample #116 stated in an interview on 05/13/24 at 8:40 AM that she receives in her breakfast eggs and coffee with milk and that she does not like those. She stated that she receives milk with lunch and dinner, and she does not drink milk. She also stated that she wants and request fresh fruit and receives canned fruits. Review of department of kitchen card with diet specifications of resident #116 on 05/15/24 at 11:00 AM evidence that card clearly specifies that resident prefer black coffee, that she does not want milk with foods, and that she prefers fresh fruits. Resident preferences of resident #116 was discussed with facility dietitian (employee #2) on 05/13/24 at 10:55 AM. Facility dietitian (employee #2) stated on interview on 05/13/24 at 11:00 AM that she performs the nutritional initial assessment to resident #116 on 05/04/24 when she was admitted and she specify in the diet order that no eggs or milk were liked by the resident, she also specifies that resident want to receive fresh fruits. On 05/14/24 at 8:00 AM it was observed that residents receive for breakfast scrambled eggs and coffee with milk. On 05/14/24 at 12:10 PM it was observed that residents receive canned mandarin orange. b. Resident sample #120 stated in an interview on 05/13/24 at 8:50 AM that she does not like to eat rice every day during lunch and dinner. She said that she prefers salad or potatoes, cassava or other starchy tuberous. She stated that she does not like carrots. She stated that she receives rice with lunch and dinner, and she does not want to eat rice on daily basis. Review of department of kitchen card with diet specifications of resident #120 on 05/15/24 at 11:30 AM evidence that card clearly specify that resident prefer starchy tuberous instead of rice. Resident #120 preferences were discussed with facility dietitian (employee #2) on 05/13/24 at 11:15 AM. Facility dietitian (employee #2) stated on interview on 05/13/24 at 11:25 AM that she performs the nutritional initial assessment to resident #120 on 05/10/24 when she was admitted , and she specify in the diet order that resident prefer starchy tuberous instead of rice. On 05/13/24 at 12:15 PM it was observed that residents received for lunch pasta and steamed carrots. c. Resident sample #121 stated in an interview on 05/13/24 at 9:10 AM that he does not eat hot cereal for breakfast. He stated that he prefers a sandwich in the morning. He also stated that if he receives eggs or hot cereal for breakfast, he does not like it and he does not eat those items. Review of department of kitchen card with diet specifications of resident #120 on 05/15/24 at 11:55 AM evidence that card clearly specify that resident prefer sandwich for breakfast and does not like hot cereal. Resident #121 preferences were discussed with facility dietitian (employee #2) on 05/13/24 at 11:35 AM. Facility dietitian (employee #2) stated on interview on 05/13/24 at 11:30 AM that she performs the nutritional initial assessment to resident #121 on 05/10/24 when he was admitted , and she specify in the diet order that resident prefer sandwich for breakfast. On 05/14/24 at 12:22 PM it was observed that residents receive scrambled eggs for breakfast. No explanation were provided by the facility dietitian (employee #2) of the reason why the kitchen personnel did not address the correct diet recommendations. 20423 d. Resident #108 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total knee Replacement. During the interview 05/13/2023 at 10:00 AM, she states that she likes some days with a sandwich for breakfast and Lactose Free milk, that she notified the nutritionist but continued with regular milk. During the record review performed on 05/14/24 at 3:27 PM the nutritionist evaluation was performed on 5/7/2024 and recommended 1500 kilocalories diet low sodium, low sugar, 25 gram of fiber, 60 gram of protein, 1500 milliliter of liquid, Lactose free milk, no sauce food, option of sandwich for breakfast to vary, 8 ounces of Glucerna for snack. The department of kitchen card with diet specifications of resident #108 reviewed on 05/14/24 12:00 PM, revealed that resident preference was some days sandwich for breakfast, No Lactose, no sauce, 2 snack and include fresh fruits on 5/7/24. During observation on 5/13/2024 at breakfast time the meals tray not observe Lactose free milk, during the lunch time the lunch was cold, and no fresh fruit was observed. On 5/14/2024 at 7:45 AM resident was asked about breakfast and stated that she does not drink milk because she do not know if it is lactose free milk. During an interview with the nutritionist related to resident observation she states that supposed to be labeled the milk as Lactose free. The facility failed to ensure that resident preference was granted, and recommendation of the nutritionist was granted, and the fruit was caned not palatable, attractive, and appetizing temperature. No explanation was provided by the facility dietitian (employee #2) of the reason why the kitchen personnel did not address the correct diet recommendations.

Based on dining observations, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that each resident receives, and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. This deficiency affects 5 out of 13 cases admitted receiving services (Resident #108, #111, #116, #120 and #121). Findings include: Facility policy Title: Nutritional Needs last updated in January 2024, was reviewed on 05/15/2024 at 3:05 PM with Dietitian. Policy clearly stated the procedures that for every resident admitted to the facility food will be provided considering each resident preference. 1. During initial pool process residents located in room [ROOM NUMBER]-A, #116-A and #117-A, stated that food brought by the kitchen personnel is not palatable, appetizing and at appetizing temperature. a. Resident sample # 116 stated in an interview on 05/13/24 at 8:40 AM that food that she receives for breakfast, lunch and dinner lack of flavor and is not agreeable to the palate or taste. She also stated that food brought by kitchen personnel does not have an appetizing temperature during breakfast, lunch, or dinner. She stated that cold food items are warm and hot food is brought cold. b. Resident sample # 120 stated in an interview on 05/13/24 at 8:50 AM that food items brought by the kitchen personnel for breakfast, lunch and dinner are not pleasant to taste. She also stated that food at the facility is not appetizing, savory, tasty or tempting. She stated that the fact that cold food is brought by kitchen personnel warm and hot food is brought by kitchen personnel cold it has its effect on the desire to eat those food items. c. Resident sample # 121 stated in an interview on 05/13/24 at 9:10 AM that food items brought by kitchen personnel for breakfast, lunch and dinner are not palatable or agreeable to the palate. He also stated that cold food items are brought by kitchen personnel warm and that hot food items are brought by kitchen personnel cold. He stated that he does not opt for asking personnel to heat hot food items because he thinks that it may make its taste worse, and he eats a little, but he remains hungry sometimes. Facility dietitian (employee #2) stated in an interview on 05/13/24 at 11:10 AM that a new kitchen company begin to offer services on March 1, 2024. She stated that since this company began to offer services, she met with kitchen manager on several occasions to explain to her the importance of adjusting residents' food preferences. She stated that kitchen manager agreed since the company began to offer services, that food delivery was going to be carried out in a way that adjusts to resident preferences. She stated that those are the agreements that they did with the kitchen contractor manager, but she also explained that she had knowledge that the kitchen contracted company had experience staff turnover and this could affect services provided. 20423 d. Resident #108 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total knee Replacement. During the interview 05/13/2023 at 10:00 AM, she states that she likes some days a sandwich for breakfast and Lactose Free milk, that she notified the nutritionist but continued with regular milk. During the record review performed on 05/14/24 at 3:27 PM the nutritionist evaluation was performed on 5/7/2024 and recommended 1500 kilocalories diet low sodium, low sugar, 25 gram of fiber, 60 gram of protein, 1500 milliliter of liquid, Lactose free milk, no sauce food, option of sandwich for breakfast to vary, 8 ounces of Glucerna for snack. The diet kitchen cart reviewed on 05/14/24 12:00 PM, revealed that resident preference was some days sandwich for breakfast, No Lactose, no sauce, 2 snack and include fresh fruits on 5/7/24. During observation on 5/13/2024 at breakfast time the meals tray no Lactose free milk observed, during the lunch time the lunch was cold, and no fresh fruit was observed. On 5/14/2024 at 7:45 AM resident was asked about breakfast and stated that she do not drink milk because she do not know if it is lactose free milk. During an interview with the nutritionist related to resident observation she states that supposed to be labeled as Lactose free milk. The facility failed to ensure that resident preference was granted, and recommendation of the nutritionist was granted, and the fruit was caned not palatable, attractive, and appetizing temperature. e. Resident #111 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Deconditioning. During the interview the resident stated that the food was cold. During observation on 5/13/2024 at 8:15 AM at breakfast time and at 12:00 PM lunch time the resident says that food was cold, and she likes it hot. The facility failed to ensure that resident preference was granted for appetizing temperature.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 05/13/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to comply with the required sink compartment sanitations. Findings include: Review of facility's policy and procedure [NAME], Enjuage y Saneamiento, Cleaning and Disinfection of three compartment Sinks regarding the process of cleaning and sanitization of kitchen equipment was reviewed on 05/13/2024 at 11:30 AM and it says that compartment one (1) must have a temperature of 110 F, on compartment two (2) and on compartment three (3) utensils should be for 30 seconds with a sanitizing solution concentration of 200 ppm. 1. During the visual inspection and staff interview it was noticed that 3 compartment sink was not prepared as stated in the facility policies and procedures. It was observed that the staff working the sink did not have knowledge of the temperatures required in the different sinks' compartments. It was requested that the concentration of sanitizer be taken on the third compartment and the concentration measurement higher than 600 ppm and the requirement is 200 ppm. Overuse of the sanitizing agent could be harmful.

Based on review of Quality Assessment Performance Improvement ( QAPI) activities and interview with facility administrator (employee #1) performed on 05/13/24 through 05/15/24 from 8:00 AM till 4:30 PM it was determined that facility failed to ensure the participation of all required members on the Quality Assessment Performance Improvement (QAPI) committee meetings. Findings include: 1. During review of facility committee meetings of QAPI during year 2023 and the months of January 2024 and April 2024 the following was identified: Upon review of facility rules and procedures related with QAPI program committee meeting activities last reviewed on July 15, 2016, it was identified that rule did not establish that the Infection Preventionist must participate in every QAPI committee meeting. a. There is no evidence of participation of facility Infection Preventionist on QAPI committee meetings performed on April 19, 2023, July 20, 2023, October 25, 2023, January 30, 2024, and April 17, 2024. b. During interview on 05/15/24 at 1:00 PM facility administrator (employee #1) stated that infection control officer gives her the infection control report and discuss with her relevant areas and is her as administrator who present the findings on the QAPI committee meetings.

Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 05/13/2024 through 05/15/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This deficient practice had the potential to affect 21 out of 21 residents. Findings include: During observational tour the following was observed related with equipment in the facility: 1. 10 out of 15 wheelchairs in the Physical Therapy area were observed with rust. 2. 1 out of 2 walking canes in the Physical Therapy area were observed with rust. 3. 5 out of 10 walkers in the Physical Therapy area were observed with rust. 4. The parallel bars and steps showed rust in some of their parts.

Based on a recertification extended survey, observations during medication pass with the Registered Nurse (RN) (Employee #1) performed from 5/2/17 thru 5/4/17, it was determine that the facility failed to ensure that residents are treated with respect and dignity during delivery of nursing care, for 2 out of 28 residents (Resident #9 and Suplemental Sample Resident #11). Findings include: 1. During de medication pass on 5/3/17 at 9:37 am with the RN (Employee #1) on room [ROOM NUMBER]A it was observed that the RN was administering medication and explaining the medications to the resident and the physician (MD) (Employee #2) entered to the residents room without knocking the door and requesting permission to enter, and immediately started talking to the RN (Employee #1) ignoring the presence of the resident. During Interview with Administrator (Employee #3) on 5/3/17 at 3:12 pm, she stated: I already talk to the physician about the incident on room [ROOM NUMBER]A and he told me that he did not mention the name of the resident just the room number and the medication. But we are going to keep working on that. 2. Resident # 9 is a [AGE] years old male patient with a diagnostic of left femur fracture. On 5/04/2017 at 2:48 pm during interview resident # 9 was observed with pants' down to his knee, he stated I have my pants' down to my knees because I called the nurse 25 minutes ago because my diaper is wet. At 3:00 pm resident # 9 continued with the pant down to his knees and the diaper wet. At 3:05 pm the surveyor notified the administrator (employee #3) about the situation and the nursing personnel proceed to change resident # 9 diaper. The facility failed to ensure that residents are treated with respect and dignity during delivery of nursing care

Based on a recertification extended survey, observations from 5/2/17 thru 5/4/17, interviews with nursing staff and record review (RR), it was determined that the facility failed to establish preventive measures to avoid the development of pressure ulcer for 1 out of 8 residents in the sample selection (R# 2) . Findings include: 1. Resident #2 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the SNF for antibiotic therapy and rehabilitation. He is bedridden since April 2017 due to the Pneumonia. 2. During RR performed on 5/2/17 from 1:30 p.m. thru 3:45 p.m. the following was found: a. The Protocol of prevention and Management of patients with alteration in skin integrity. Protocolo de Prevencion y Manejo de Pacientes con alteracion en integridad de piel that the Registered Nurse (RN) in charge of performing the admission of the resident on 4/29/17 identified on the section called as Estimado de Factores de Riesgo Estimating risk factors that the resident has Musculoskeletal limitations. On the Braden scale (risk for developing ulcers) the points obtained was 15, meaning that the patient is not at high risk of developing ulcers. b. The ulcer protocol was found in the record. The criteria that were indicated are: Make assessment of the skin and observe changes, evaluate: State (turgor, appearance), Location of pressure area, Pressure Area Size, Appearance (red, wet, dry), and Type of exudate (color and quantity). However, the only thing that was marked was to estimate the skin and observe changes, not specifying which skin issues the nurse is going to evaluate. The other interventions identified by the RN were to evaluate: Keep resident bed dry, clean and wrinkle free, Make use of pillows to position and provide comfort, Lifting heels out of bed with pillows or splints, Use of protectors in elbows and heels, Care for the back and osseous prominences by applying lubricating lotions, Minimize trauma to remove tape or tape in skin, Care according to medical order. c. The initial evaluation performed by nursing staff the section of the integumentary system subsection 1. Condition of the skin only marks dry skin. d. The initial medical evaluation indicates that the patient only has rash in the sacral area. e. The sheets of the Protocol of Prevention and handling of residents with alteration in the integrity of the skin of days 4/30/17, 5/1/17 and 5/2/17 indicate that multiple lacerations are observed and [MEDICATION NAME] is being applied and [MEDICATION NAME]. It is observed that [MEDICATION NAME] was only being applied once a day and not twice a day according to the medical order of 4/29/17. It was also found that in the medical order of 4/29/17 the doctor writes that the [MEDICATION NAME] Cream should be applied in the area of the sacrum and pubic areas at each diaper change. f. No documentation of the RN was found on the clinical record indicating what interventions she performed to decrease the red skin on the buttocks area. It was not determined the frequency in which the skin medications were administered. g. The progress notes of the registered nurses do not reflect the observations and care provided by the RN who is the professional that is performing the Braden Scale assessment, daily skin assessments, and the care provided to the [MEDICAL CONDITION]. h. No evidence was found on the registered nurses progress notes information related to the importance of doing changes position every 2 hours to avoid skin breakdown. This is part of skin prevention aspects that is recommended on the guidelines for Prevention and treatment of [REDACTED]. 3. On 5/3/17 at 11:00 am when the resident was visited, the sister told the surveyor that she is worried because her brother has a rash in his buttock and in the sacrum; when the nurse came to change the diaper she saw blood on the brief. Surveyor asked about what the nurse is applying on the rash and she said and ointment cream. The surveyor asks her how she found this. She stated that her brother told her that it hurts quite in the back. When she checked the resident's sacrum area it was redder than yesterday and with some blood. 4. The resident can perform by himself the changes of position. However, during the survey process, it was observed that the resident remained in the same position when observations were performed on different days and hours. 5. On 5/3/17 at 9:05 am the license practical nurse (LPN) in charge of the resident was asked by the surveyor about what is happening with resident #2. She indicates that she is applying an ointment that the resident has in the drawer and when she bath the resident she applied it on the laceration areas. She stated: The RN is in charge to apply the medication on the resident lacerations. The surveyor asked if she wants to access the resident skin and she said that the LPN do the assessment during the patient bed bath. The RN observed the area and indicates that the area is red and with some blood spots because of the friction of the brief due to the resident movements. She says that the skin it is not open. 6. On 5/3/17 at 11:20 am the surveyor accompanied by the infection control preventionist (employee #7) requested for a RN to look at the affected area of the resident. The RN indicated that she was going to care the lacerations in that moment. Employee #7 asked to the RN what she is applying to the resident; the RN answered that she has to check because she did not remember. 7. However, no documentation related to this new problem was found on the clinical record. The nursing staff failed to identify the new concern, to write their observations on the daily skin assessment form and to develop a plan of care according to the new findings observed. 8. The facility failed to ensure an accurate initial assessment to implement a protocol for risk of pressure ulcer development.

Based on a recertification extended survey, Records Reviewed (R.R.) with the Registered Nurse (RN) (Employee #1) performed from 5/2/17 thru 5/4/17, it was determine that the facility failed to ensure that the physician is notified of all laboratory results so that prompt, appropriate action may be taken if indicated for the resident's care, for 1 out of 28 (Resident (R) #1). Findings include: 1. During R.R.#1 on 5/2/17 at 1:00 pm it was found between the nurses notes a Urinalysis Report from 4/21/17 12:02 pm, that was not signed by the physician as evidence of evaluation of the results. 2. The laboratory result of 4/21/17 12:02 pm that was altered included: a. Clarity: Turbid (normal range: Clear) b. Leukocytes: Large (normal range: Negative) c. [MEDICATION NAME]: Positive (normal range: Negative) d. Glucose: 150 mg/dL (normal range: Negative) e. Blood: Small (normal range: Negative) f. RBC (Red Blood Cell): 8-30 (normal range: <4-8) g. WBC (White Blood Cell): Over 50 (normal range: <6-10) h. White Blood Cell Clump: Many (normal range: <Rare) i. Bacteria: Many (3+) (normal range: <Few) j. Budding Yeast: Few (normal range: <Rare) During interview with RN (Employee #1) on 5/3/17 at 11:00 am, she stated: If the laboratory results does not have the signature of the physician it probably because it has not been informed. Let me call the physician and confirm this information. 3. During R.R. R#1 on 5/3/17 at 11:15 am was found that there was no evidence of the altered urinalysis report being notified to the physician from 4/21/17 until 5/3/17. During interview with Nursing Supervisor (Employee #4) on 5/3/17 at 11:30 am, she stated: If the urinalysis was miss place and archive between the nursing notes that is probably the reason of why the physician did not see the results. Nursing staff should have identified that urinalysis report and notified the physician immediately. During interview with the Physician (Employee #5) on 5/3/17 at 1:15 pm, she stated: It is possible that I have not seen that urinalysis report because I always write my signature when I evaluate them. I ordered a new urinalysis and urine culture. The facility failed to assure that the physician is notified of all laboratory results so that prompt, appropriate action may be taken if indicated for the resident's care.

Based on observations, interviews and eight records reviewed with nursing personnel responsible for residents' care, it was determined that the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 out of 8 residents (R). (R #3). Findings include: 1. Resident #3 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 3/14/16 at 11:50 am and provided evidence the resident had history of High Blood Pressure, [MEDICAL CONDITION] disease and Diabetes Mellitus. Record review reveals that resident was surgically intervened twice to place a center line. The second intervention was because the first center line gets infected during the resident admission into the facility. a. The resident's record was reviewed on 3/14/16 thru 3/17/16 from 11:50 am until 4:00 pm of the 3/14/16 and provided evidence that she was admitted for five weeks of antibiotic treatment because of the infected knee. It was found that the resident central line was changed because the first one gets infected. The surgeon placed an order for [REDACTED]. Observation every hour by surveyor reveals that the resident never has been isolated. Interviewed with DON (employee #5) on 3/14/14 at 3:45 pm states that she gave the order to prepared a room to move the resident. Observation performed on 3/15/16 at 8:45am reveals that the resident is still in the same room and she never been moved to other room alone. Record review performed on 3/15/16 at 9:00 am reveals that the resident was visited by the infectologist and he discontinued the contact isolation order. Interviewed with DON (employee #5) on 3/15/16 at 9:15 am reveals that the resident spoke with the infectologist and indicated to him that she does not want to be alone in a room. Employee #5 stated that she knows that the resident needs to be apart for her well-being condition and to assure residents well-being. Interviewed with physician (employee #10) reveals that she does not know why the infectologist discontinue the resident isolation by contact. Employee #10 stated that she talked with the resident and explain to her that it was better been apart because the recovery is more promptly. Employee #10 stated that resident refuse to be moved to another room. b. During the Record review performed on 3/14/16 at 11:50 am it was found that the resident was admitted for antibiotic treatment. The admission order indicated [MEDICATION NAME] 1gm IV (intravenous) every 12 hrs per 5 weeks [MEDICATION NAME] mg IV every 12 hrs. per 5 weeks. An order from the infectologist from 2/12/16 was found [MEDICATION NAME] mg IV q (every) 12 hrs per 6 weeks and [MEDICATION NAME] 1gr q12hrs. per 6 weeks, an order from the infectologis on 3/14/16 at 4:30 pm of Polimixyn B 1,000,000 units dilute in 1000 DW 5% per 7 days and [MEDICATION NAME] 600mg IV q 12 hrs per 9 days and discontinue [MEDICATION NAME] and the [MEDICATION NAME]. No progress notes about changes on the antibiotic treatment and education about side effects of these new antibiotics. c. On the record review of 3/16/16 at 9:00 am it was found that the psychiatrist visited the resident and put an order on the consultation report sheet [MEDICATION NAME] PO at 9:00 pm and Klonopin 2 Mg at 8:00 am per 7 days. No physician order was found for these medications and no drug regimen review for these medications and no education about the side effects were found. Interviewed with DON (employee #5) that after the nurse gave [MEDICATION NAME] mg to the resident after few hours residents start to vomit and feel dizziness. Immediately RN calls the physician and she gave the order to transfer her to emergency room . d. The facility failed to provide evidence of the following: No evidence was found that the pharmacist gave an education about the side effects of the antibiotic. Interview with the pharmacist (employee #11) on 3/17/16 at 10:30 am reveals that both antibiotic are highly nephrotoxic and neurotoxic and the dose that the psychiatrist gave to the resident [MEDICATION NAME] it is too high to start and combine with the antibiotics.

Based on observations and record review, it was determined that the facility failed to review and establish surveillance in those residents where adverse consequences are potential due to resident ' s condition and the risks or adverse consequences related to current medication regimen for 1 out of 8 sample selection resident (R) (R # 7 ). Findings include: 1 A mechanism to ensure that licensed pharmacist's review resident's regimen of medications depending upon the resident's condition and the risks or adverse consequences related to current medication(s) taken was not promoted accordingly with the following findings identified during survey procedures on 3/14/16 through 3/17/16: a.Resident #3 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 3/17/16 for second time at 8:50 am and provided evidence that on 3/16/17 resident was evaluated by a psychiatrist and placed an order of Ambien 10mg PO at 9:00 pm and Klonopin 2 mg PO at 8:00 am for the next 7 days. This resident does not have history of mental illness. Accordingly with the psychiatrist consultation report the resident presents concern of anxiety and insomnia. Resident is receiving a treatment of [REDACTED]. Nurse progress note reveals that on 3/17/16 12;30 am resident needs to be transfer to the emergency room because she started to vomit and been disoriented. No drug regimen review was found for this resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with those medications.

Based on observation and interviews with personnel and residents made during the physical environment survey, it was determined that the facility failed to ensure to receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered affecting 1 out of 10 sample selection (R#9). Findings include: 1. On 7/2/15 at 10:00 am resident #9 a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident was observed sitting on a chair. The chair was observed with a blue cushion from the chairs located in the interior patio of the facility under the patients and the right leg elevated in the bed. During the group interview performed on 7/1/15 at 10:00 am the resident indicates that the chair available in the room is not comfortable for him. Resident refers The facility has to provide chairs higher. The chair is to low and it is difficult for me to sit . During interview performed on 7/2/15 at 10:00 am the resident refers I told my wife to go outside and bring me one of the cushion from the blue chairs located in the interior patio.

Based on observations, review of ten clinical sample records, medication administration records (MAR) and interviews, it was determined that the facility failed to ensure the quality of care and appropriateness management for 1 out of 10 resident (R) sample selection (R # 7). Findings include: 1. A mechanism to ensure that healthcare professionals follows the best practices during continuous glucose monitor procedures with finger stick blood samples was not performed according with these findings identified during survey procedures on 6/30/15 through 7/6/15: a. Resident #7 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 7/2/15 at 10:00 am and provided evidence that physician order [REDACTED]. This resident had ordered [MEDICATION NAME] 10 mgs PO daily and [MEDICATION NAME] 500 mgs PO twice a day since 6/26/15 at 3:00 pm. Review of finger stick blood glucose sample result registry Registro de Resultado de Prueba de Dxt y Administración de Insulina por Escala evidence that on 6/27/15, 6/28/15, 6/29/15 6/30/15, 7/1/15, 7/2/15 and 7/3/15 blood glucose Dtx results require regular insulin who was not administered by personnel in charge of the patient. During review of the Registro de Resultado de Prueba de Dxt y Administración de Insulina por Escala with register nurse (employee #7 ) on 7/3/15 at 9:55 am she stated on interview that on this facility Licensed Practical Nurses (LPN's ) and Register Nurses (RN's ) are both assigned to perform Dtx finger stick blood samples. She stated that some of the results documented on the blood glucose sample result registry from 6/27/15 through 7/3/15 are the ones performed by LPN's and maybe this personnel do not inform results to the Register nurse in charge of the resident care. She stated that other blood glucose samples are documented as taken by RN's in charge of the resident. However no subcutaneous regular insulin coverage were reported as administered as required by with facility Protocolo de Insulina Subcutánea . Review of nurses progress notes from 6/26/15 through 7/3/15 evidence that other (different from the ones documented on blood glucose sample result registry) dxt blood glucose sample results were documented as performed by the register nurse in charge of the resident. Some of this Dtx results documented on the nurses progress notes require regular insulin administration accordingly with Insulin protocol; however the was not administered. The Register nurse (employee #7 ) could not explained on 7/3/15 at 10:20 am the reason why Dtx finger stick blood samples documented on nurses progress notes are different from the ones documented on the finger stick blood glucose sample result registry taken in some shifts by LPN's and other RN's. b. Case of resident #7 was reviewed and discussed with Medical Director (employee #4 ) on 7/6/15 at 3:55 pm. He stated during interview that accordingly with Dxt finger stick blood sample results from 6/27/15 through 7/3/15 and considering that this resident was also receiving [MEDICATION NAME] 10 mgs PO daily and [MEDICATION NAME] 500 mgs PO twice a day maybe nursing personnel does not administer the regular insulin coverage to avoid a hypoglycemic episode on the resident. However the physician in charge of the resident was not informed that insulin coverage was not administered accordingly with facility Protocolo de Insulina Subcutánea in order to determine if the use of the Protocolo de Insulina Subcutánea are going to be re-evaluated. 2. The facility failed to implement consistently their protocols, perform re-evaluations and based on information from the assessment; re-evaluations and the results of their interventions, revises the interventions as necessary.

4. A mechanism to ensure that the facility evidence the care and services provided to residents admitted with breakdown on the skin that had high risk to develop ulcer was not promoted accordingly with the following findings: a. R.R. # 6 is an [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident was admitted to the facility to receive rehabilitative, restorative, and ongoing skilled nursing care. During review of the case on 08/26/14 at 11:00 am it was identified on the medical record that it was documented on 8/19/14 on the: " Protocolo de Prevencion y Manejo de Residentes con Alteracion en la Piel " Protocol for Prevention and Management of Resident with Skin Alteration, that resident was admitted with a laceration between buttocks. On the "Evaluacion Inicial de Enfermeria " Nursing Initial Evaluation dated 8/19/14 in the integumentary system review it only was documented that resident had dry skin. On the progress note documented by the nurse during admission on 8/19/14 at 8:00 pm it was indicated that resident had equimosis on both arms and a laceration between buttocks. In the Interdisciplinary plan of care " Potential/riesgo de lesiones en la piel " Potential/Risk of injury on Skin, are activated during admission and dated 8/19/14 indicate that personnel must follow standard order to prevent pressure ulcers and that resident and relatives must be oriented about measures to be followed to prevent skin breakdown. However documentation contained on the medical record does not reflect that relatives are oriented about this matter, and the resident could not be oriented or educated because resident present disorientation periods accordingly with neurologic/emotional assessment perform on a going basis from 8/19/14 through 8/26/14. On the nursing assessment and daily progress notes dated 8/25/14, on shift 6am-6 pm and on 8/24/14,8/23/14,8/22/14, 8/21/14 on shifts 6am-6pm-6pm-6am in the integumentary assessment it was document that resident skin remains intact. The facility failed to include a complete description and documentation (localization and measures) or the characteristics of the skin breakdown presented by the resident on the buttocks during admission. Provisions (incontinence management, prevent friction, rubbing and deterioration of the area) established on the interdisciplinary plan of care to be taken to prevent further deterioration of the laceration (perineal skin breakdown) with which the resident was admitted was not found documented on the medical record. Documentation found on the medical record does not support that best practices are performed to prevent that perineal skin breakdown that may progress to an ulcer was followed. Skin breakdown is identified early, during admission however there is no evidence that the cause of the breakdown are identified and eliminated or mitigated. b. Record sample selection # 10 ( closed record review ) is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident was admitted to the facility to receive rehabilitative, restorative, and ongoing skilled nursing care. During review of the case on 08/28/14 at 3:45pm it was identified in the " Evaluacion Inicial de Enfermeria " Nurses Initial Evaluation, dated 3/18/14 at 6:20 pm the integumentary system review was left in blank. On nurses progress notes dated 3/18/14 at 6:20 pm it was document that resident had equimosis on sacral area. On nurses progress notes dated 3/19/14 shift 6 am-6-pm and 6 pm-6 am it was document on the integumentary status assessment that resident had a altered skin status but no specify the area. On nurses progress notes dated 3/20/14 shift 6 am-6-pm and 6 pm-6 am it was document on the integumentary status assessment that resident had an intact skin. On nurses progress notes dated 3/21/14 shift 6 am-6-pm and 6 pm-6 am it was document on the integumentary status assessment that resident had an ulcer but not specify the area. At 10:00 am on 3/21/14 a telephone order was given to a nurse to apply Solosite gel on buttock on daily basis. Solosite is a hydrogel wound dressing with preservatives. It can donate moisture to rehydrate non-viable tissue. It absorbs exudates while retaining its structure in the wound. Solosite gel indications for use include that if the product is going to provided under the direction of healthcare professionals the indications for use are superficial lacerations, cuts and abrasions (partial thickness wounds) skin tears and pressure ulcers, the product creates a moist wound environment, which assists in autolytic debridement of wounds covered with necrotic tissues. (Smith & Nephew US Professional-website). On nurses progress notes dated 3/22/14 shift 6 am-6-pm and 6 pm-6 am it was document on the integumentary status assessment that resident had an ulcer but not specify the area. On nurses progress notes dated 3/23/14 shift 6 am-6-pm and 6 pm-6 am it was document on the integumentary status assessment that resident had a wound but not specify the area. On nurses progress notes dated 3/24/14 shift 6 am-6-pm and 6 pm-6 am it was document on the integumentary status assessment that resident had an ulcer but not specify the area. On nurses progress notes dated 3/25/14,3/26/14,3/27/14,3/30/14,3/31/14 and 4/1/14 shift 6 am-6-pm and 6 pm-6 am it was document on the integumentary status assessment that resident had an ulcer but not specify the area. On the " Protocolo de Prevencion y Manejo de Pacientes con Alteracion en Integridad de Piel " dated 3/18/14 it was document that resident had stage II ulcer on right buttock area. Facility failed to include a complete description and documentation (localization and measures) or the characteristics of the skin breakdown presented by the resident on the sacral area during admission. There is lot of discrepancy (ecchymosis versus wound, versus ulcer) on the documentation of the assessment, management and care provided of the sacral area of the resident. Medical record does not support that best practices are performed to prevent deterioration of skin of sacral area. Evidence that sacral area alteration of integumentary status was identified early, during admission in order to maintain appropriate management and care was not provided. Facility failed to evidence that services provided to residents identified with skin problems promote the prevention of pressure ulcer development; promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible). 5. A mechanism to ensure that facility is able to determine the extent to which each employee who participate on a pressure ulcer and wound management and care training using a self-learning module demonstrate understanding on the theme presented, was not performed accordingly with the following findings: The facility head nurse (employee # 3) stated on interview on 9/12/14 at 11:00 am that the facility offer the pressure ulcer and wound management and care training using a self-learning module. In order to assess learning, related with the theme every participant must have a baseline or pre-assessment of what participants know prior to instruction as well as an indication of what they know after instruction and culminate in a post test for participants to demonstrate understanding. This module accordingly with head nurse on 9/12/14 at 1:45 pm include pictures to create a meaningful context, accompanying the information with photographs that must used to evaluate the understanding of the wound and ulcer classification and categorization on the post-test. However no information was provided related with the post-test results for the activity performed on January, August and November 2013. 6. The facility failed to promote the use of assessment strategies which will help to determine the extent to which students met the learning objectives you developed. Based on observations from 8/25/14 thru 8/29/14, interviews to nursing staff and record review, it was determined that the facility failed to establish preventive measures to avoid the development of pressure ulcer for 3 out of 10 residents (R ) in the sample selection (R# 1) which constituted an Immediate Jeopardy and R#6 and closed record # 10. Findings include: 1. On 8/25/14 thru 8/29/14 from 8:30 am to 4:00 pm it was found that R#1, an [AGE] year old female was admitted on [DATE] with a diagnose of recent [MEDICAL CONDITIONS]. As secondary Diagnoses: [REDACTED]. The resident was admitted to the SNF for rehabilitation. 2. During RR performed on 8/28/14 from 9:00 a.m. thru 4:00 p.m. it was found that an initial comprehensive assessment for skin condition on section M on the Minimum Data Set (MDS) was not performed by the nursing staff nor the MDS Coordinator, employee # 5, between 8/22 thru 8/29/14. The lack of performing a comprehensive assessment can not allow developing an objective plan of care showing the real needs that the resident has. 3. During RR performed on 8/28/14 from 9:00 a.m. thru 4:00 p.m. it was found that on the Nursing Initial Assessment that the Registered Nurse (RN) in charge of performing the admission of the resident on 8/22/14 at 7:20 p.m., identified on the section called as "Sistema Intergumentario" (Integumentary System) that the resident has intact skin. On this nursing assessment, the RN did not identify on section called as "Orientacion a Paciente y/o Familia" (Orientation to Patient and/or Family) education related to pressure sores prevention. 4. On the same day, the RN initiated the Pressure Ulcer Protocol assessment where established on the Braden Scale a total punctuation of 16 points. If the punctuation is less than 9 points the resident is at risk of developing pressure ulcers. 4. This protocol has a standardized loose sheet that consists of two (2) parts: Part I is a table where the RN has to identify the type of ulcer, ulcer stage, treatment and lesion improvement. During RR performed on 8/28 and 8/29/14 from 9:00 a.m. to 4:00 p.m. it was found that the RN identified on days 8/22, 8/23,8/24, 8/25, 8/26 and 8/29/14 that the resident has intact skin. 5. The Part II of this formulary there is a blank space where the nursing staff has to write their observations including the administration of skin medicated lotions. During RR performed on 8/28 and 8/29/14 from 9:00 a.m. to 4:00 p.m. it was found that the RN identified on the part II of the Pressure Ulcer Protocol, the following observations: a. On 8/22/14 at 7:50 p.m incongruent information was found between the part I of the protocol where the RN stated that the resident has intact skin and in this Part II the nurse commented and quote: "small laceration between buttocks, both buttocks are reddish ". b. The nursing staff did not write observations related to the laceration and redness of the skin on both buttocks on days 8/23, 8/24, 8/25 and 8/26/14 on the Part II of this formulary. On 8/29/14 the Licensed Practical Nurse (LPN) wrote and quote: "Administration of [MEDICATION NAME] lotion plus Zinc Oxide in buttocks ". However, the LPN did not include more information related to the laceration and redness on both buttocks. 6. During observational tour performed on 8/25/14 at 1:30 p.m. with the LPN, employee # 13, the resident was visited and the sacral area where the laceration is located was observed. The area was observed with dark skin with some areas with loose skin. The resident stated the same day at 2:00 pm: "I have something in my back like a lesion that hurts me " . 7. On 8/26/14 when the resident was visited, she stated at 10:00 am: "I still have this laceration that hurts me and I even did not want to urinate because I feel discomfort on the area " . 8. On 8/27/14 at 1:30 p.m. the laceration was observed with dark skin and loose skin. The resident stated: "I feel with pain in the same area". A physician order [REDACTED]. The surveyor asks the resident if the nurse was applying the cream medication and she stated: "They apply it only in the morning after bath time ". 9. On 8/28/14 during observational tour performed at 10:00 am, the resident stated: " The laceration keeps hurting me. I want the diaper out ". During observation, the disposable diaper was dry and the nursing staff put the bed pan when the resident requested it. So the urine is not running up to the sacral area. (Cross reference TAG F241) 10. On 8/29/14 at 1:30 pm the resident stated: "I feel more pain on the area. Also, I saw blood in the urine ". The employee # 13 went to the room, requested by the surveyor, and it was observed that there was an ulcer stage II, with irregular borders and was observed redness in the middle of it. 11. During RR performed on 8/28 and 8/29/14 from 9:00 a.m. to 4:00 p.m., the nurse progress notes from 8/22/14 thru 8/28/14 showed according to their documentation, that there is integrity of the skin. This information is not congruent according to the observations made from 8/25/14 thru 8/29/14. The progress note of 8/29/14, at 2:00 p.m., was not available at the clinical record. 12. The nursing staff was not aware of the stage II ulcer. As observed, this ulcer shows characteristics that are similar to the descriptions of stage II ulcer definition written in the guidelines of Appendix PP on 483.25 for Pressure Sores and with cross reference to the guidelines written by the National Pressure Ulcer Advisory Panel. 13. There is not congruency between the documentation of the changes position and the observations made during 5 days (from 8/25/14 thru 8/29/14) on different hours. The nursing staff is writing on the formulary related to changes position that they are performing the changes every two hours from side to side and supine position but, as observed the resident remained on the same position, upright supine position which place on risk of the development of the stage II ulcer. 14. During RR performed on 8/29/14 at 1:30 p.m. it was observed on the laboratory results from 8/23/14 that [MEDICATION NAME] levels were 2.5 g/dl (normal parameters 3.5-4.8 g/dl) which were low and no evidence was found of a nutritional evaluation to address the pressure ulcer. The resident has been taking [MEDICATION NAME] 30 ml by mouth daily from 8/22 thru 8/25/14. On 8/25/14 the Nutritionist, employee #4, recommended to administer 2 scoops of protein powder by mouth three times a day due to low [MEDICATION NAME] levels. However, no improvement on tissue regeneration was observed over the [MEDICAL CONDITION] as observed on days 8/25, 8/27 and 8/29/14. 15. During RR performed on 8/28 and 8/29/14 from 9:00 a.m. thru 4:00 p.m. it was found that as part of the Pressure Ulcer Protocol there is an assessment where the RN identifies risk factors for the development of pressure ulcers and a section of nursing interventions. In this section, the RN that performed the admission process on 8/22/14 wrote a check mark besides the item that refers to put an air mattress. However, no air mattress or "G Mat" was placed on resident's bed to relieve the pressure on the sacral area of the resident. a. It was observed that the resident's right calf skin was turning red and with loose skin. The nursing staff did not notice this changes and no evidence was found on the Nursing Initial Assessment, Pressure Ulcer Protocol formularies or nurses ' notes. 16. During RR performed on 8/28 and 8/29/14 from 9:00 a.m. thru 4:00 p.m. it was found that the resident was admitted with moderate pain. According to the Nursing Initial assessment on section J. Estimado de Dolor (Pain Assessment), the RN wrote that resident's pain is located in her body. Did not specify in which part of her body is feeling pain. According to interviews to the resident, she was feeling pain in her sacral area since 8/25/14 thru 8/29/14. The nursing progress notes does not show pain assessment and interventions were not performed since 8/22/14 thru 8/29/14. 17. During RR performed on 8/28 and 8/29/14 from 9:00 a.m. thru 4:00 p.m. it was found that on the MDS section J. Health Conditions, items J0200, J0300, J0400, J0500, J0600, J0700, J0800 and J0850 related to pain assessment, were not written between 8/22 to 8/29/14 by employee #5 nor by the nursing staff. 18. On 8/29/14, at 2:00 p.m., the surveyor asks the Nursing Supervisor, employee #2, to evaluate the ulcer, and to take measurements of it. Also surveyor requested to call the physician to come to the facility to evaluate the ulcer and to determine the source of the bleeding that was observed on the disposable diaper. At 2:20 pm, employee #2 obtained the following measurements from the [MEDICAL CONDITION]: 1 cm long X 0.5 cm wide. 19. During interview to the physician, employee #17, at 4:50 p.m. she stated: "The resident has a laceration due to [MEDICAL CONDITION]. I don't think that is a stage II ulcer. It will improve applying Lotrisome cream. The [MEDICAL CONDITION] is not bleeding. I will order urine lab tests but her urine is clear". 20. An Immediate Jeopardy was notified on 8/29/14 at 2:00 p.m. to the Medical Director, employee # 15, and the Administrator employee #1. A plan of correction is requested. 21. The facility failed to protect resident from harm which constitute an Immediate Jeopardy. 22. The facility submitted a plan of correction on 8/29/14 at 6:30 pm which was evaluated by the surveyor and was not accepted. A revised POC was requested to the facility by the surveyor's while onsite. 23. A second POC was submitted by the facility on 8/29/14 at 8:10 pm and was received onsite by the surveyors, evaluated and accepted. The IJ was abated on 8/29/14 at 8:10 pm. 24. At the extended survey process performed on 9/11 and 9/12/14 from 8:30 a.m. thru 4:30 p.m. during the closed record review it was found the following measurements to work with the [MEDICAL CONDITION]: a. On 8/29/14 the Quality Coordinator, employee #3, obtained a signed inform consent from the resident for taking pictures on the area where is the skin breakdown. The employee #3 identified as ulcer the lesion that is going to be photograph. However, during interviews to some nurses and RR the nursing staff refer that the [MEDICAL CONDITION] is a laceration. b. On 8/29/14 at 6:00 pm the Head Physician ordered: "Solocite Cream to be applied to laceration (intragluteal) daily. According to the manufacturer, the indications for its use is on Stage I-IV ulcers, cuts, abrasions [MEDICAL CONDITION] a moist wound healing environment and assists in the debridement and removal of necrotic tissue. However, the lesion observed on days 8/25, 8/27 and 8/29/14 does not shows necrotic tissue. c. On 8/30/14 at 8:25 a.m. a consult to the Infectologist was ordered. The Infectologist wrote on his assessment performed on 8/30/14 at 10:00 a.m. and quote: " resident with open skin/[MEDICAL CONDITION] between gluteal folds with skin that appear to be a laceration wound. It is not a stage III ulcer ". He recommended Solocite Cream Gel, cover with Sterile Gauze and [MEDICATION NAME]. The nursing staff were providing care to the [MEDICAL CONDITION] with the hydrogel Solocite but on their documentation on the standardized part II of the Pressure Ulcer Protocol, it is incongruent because in Part I of the formulary they write that the lesion is not scarring and on the part II of the same formulary they write that the laceration is red and in scarring process. d. The Head Physician ordered on [DATE] at 11:15 a.m. [MEDICATION NAME] plus Solocite to be applied daily on laceration. According to the manufacturer, [MEDICATION NAME] dressing has alginate fibers that absorb wound fluid. It is designed to control minor bleedings and may be used for the management of external wounds such as: venous stasis ulcers, arterial ulcers, diabetic ulcers and pressure ulcers with partial and full thickness. Also, can be use on bleeding wounds such as: lacerations, abrasions, after surgical debridement. According to the Medication Administration Record [REDACTED]. It was administered on 9/2/14 at 9:00 a.m. The nurses' progress notes do not show the description of the lesion and its improvement after using the [MEDICATION NAME] dressing and the Solocite hydrogel. As observed on 8/25, 8/27 and 8/29/14 the [MEDICAL CONDITION] was not bleeding and was not observed fluids coming from the bed of the lesion nor in surrounding tissue. e. The use of [MEDICATION NAME] plus Solocite on the [MEDICAL CONDITION] was discontinued by the Head Physician the same day as ordered at 6:30 p.m. Then, ordered the application of [MEDICATION NAME] AG daily. The physician wrote on 9/1/14 at 9:00 p.m. on her progress notes and quote: "the [MEDICATION NAME] AG was ordered to intragluteal laceration due to humidity". According to the manufacturer, this [MEDICATION NAME] dressing promotes the autolytic debridement, moistening the wound and killing wound bacteria. The physician does not mention on her progress notes if suspect infection on the lesion or if recommends a wound culture to look for the presence of bacteria or yeast. f. According to the Discharge Home physician's progress notes performed on 9/4/14 at 6:00 a.m., says that resident continues with local care and changes position at home every two (2) hours but does not mention which wound product the resident or caregiver will use at home. On the same day, no evidence was found on nurses ' progress notes about wound care to be performed at home. On the part I of the Pressure Ulcer Protocol the RN wrote that the lesion has not improved because a scar was not develop. No other description was found. g. The picture taken by the nursing staff before the resident left the facility was observed and no improvement of the [MEDICAL CONDITION] was found. The ulcer remained with the same characteristics as observed on 8/29/14. No granulation tissue over the wound bed was observed and the surrounding tissue was more reddish and swollen than the first day that was identified. No measurements of the ulcer were found on nurses' progress notes to be compared with the first measurement that employee #2 obtained on 8/29/14. During interview on 8/29/14 at 2:20 pm with the Nursing supervisor (employee #2) and Head Nurse (employee #3), the surveyors ask what type of lesion the R#1 had, they did not answer what type of lesion the resident have.

Based on observations, review of records (RR) and policies/procedures (P&P) and interviews, it was determined that the facility failed to promote that resident (R) care and management follow best practices and standards of practice to prevent negligence in the management of residents who are receiving services at the facility for 2 out of 10 sample selection residents (R#1 and R#10 and random sample resident #8). Findings include: 1. During survey procedures throughout the first five days of survey from 8/25/14 to 8/29/14 the following was identified related with failure by the facility to care and provide medical care and attend properly cases admitted to the facility to receive rehabilitative, restorative, and ongoing skilled nursing care: Record sample selection # 10 ( closed record review ) is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the facility to provide rehabilitative, restorative, and ongoing skilled nursing care. During review of the case on 8/27/14 at 10:32 am it was identified a urine culture results of 3/21/14 that indicate microorganism isolated are [MEDICATION NAME] Faecalis and had the susceptibility panel for antibiotics. No evidence was found on the medical record of a physician orders [REDACTED]. During interview with the Infection control designated person (employee #3) stated on 8/28/14 at 1:00 pm that those cases must be informed to the hospital infection control officer to analyze, investigate and determine if resident had urinary tract infection. However evidence that this urine culture were reviewed was not provided. On 3/25/14 at 3:14 pm resident presents low blood pressure and weakness, nursing personnel call the physician in charge of the resident who orders to transfer to the emergency room ; in the emergency room they evaluate, treated and stabilize resident who was sent again to the SNF on 3/26/14 at 5:30 pm. No transfer physician orders [REDACTED]. The resident continue receiving care at the facility and on 3/27/14 at 10:45 am nurse call the physician due to high blood sugar results (higher than 500 mgs/dl-by fingerstick at 10:40 am). Physician gives the nurse by phone, instructions to administer Humalog insulin subcutaneous and repeat the [MEDICATION NAME] (Dtx) in two hours. At 12:40 md nurse repeat the Dtx fingerstick and call the physician again due to high blood sugar results (higher than 455 mgs/dl). The physician gives the nurse by phone, instructions to administer Humalog insulin subcutaneous and repeat the Dtx in two hours. At 3:00 pm nurse repeat the Dtx fingerstick and call the physician again due to high blood sugar results (433 mgs/dl). The physician gives the nurse by phone, instructions to repeat the Dtx in four hours and notify her to determine if resident need to be transfer to the emergency room . No further information was found documented on the medical record related with the reassessment of resident condition after those high blood sugar episodes. There are no progress notes or documentation by the physician for the evaluation of this case. The resident was discharge home on 4/1/14 at 7:00 am, resident remains in the facility until all discharge home arrangements were finished. On 4/1/14 at 11:45 am a telephone order was given to nurses to take a complete metabolic panel (CMP) blood sample, however there are no evidence found documented on the medical record of the reason to order the CMP. The CMP results came on 4/1/14 at 3:31 pm, sugar blood levels results revealed 309 mg/dl (normal values 70 mg/dl-99 mg/dl) , BUN results revealed 49.0 mg/dl (normal values 8.0 mg/dl-20.0 mg/dl ), Creatinine results 1.26 mg/dl (normal values 0.70 mg/dl-1.20 mg/dl) , Potassium results revealed 5.36 mmol/L (normal values 3.60 mmol/L-5.10 mmol/L) , SGPT results revealed 108 IU (normal values 14 IU-54 IU ) SGOT results revealed 100 IU (normal values 15 IU-41 IU ) and ALP results revealed 167 IU (normal values 38 IU-126 IU ). All of those comprehensive metabolic panel results were higher than the normal range, however, and there is no evidence that a physician review CMP results. The resident left the facility approximately at 6:00 pm discharge instructions regarding diet to be follow in the home was not documented as given to the resident. Facility failed to evaluate, follow-up, address/resolve medical and clinical concerns and issues that affect resident care and require constant medical care evaluation and management. 2. On 8/25/14 thru 8/29/14 from 8:30 am to 4:00 pm it was found that resident (R#1), an [AGE] year old female was admitted on [DATE] with a [DIAGNOSES REDACTED]. As secondary Diagnoses: [REDACTED]. The resident was admitted to the SNF for rehabilitation. (Cross reference TAG 0314) a. The R#1 was showing discomfort on her sacral area. During observational tour performed on 8/25/14 at 1:30 p.m. with the License Practical Nurse (LPN) employee # 13, visited the resident and was observed that on the sacral area and in between both buttocks a dark skin with some areas with loose skin. The resident stated the same day at 2:00 pm: "I have something on my back like a lesion that hurts me". b. On 8/29/14 at 2:00 p.m. it was identified that R#1 develop a grade II ulcer. During RR performed from 8/25/14 thru 8/29/14 during the standard survey and from 9/11/ 14 and 9/12/14 during extended survey, it was found lack of accuracy on the assessment of the [MEDICAL CONDITION]. The nursing staffs were identifying in the Pressure Ulcer Protocol the [MEDICAL CONDITION] as a laceration. Meanwhile, on their progress notes they were identifying that the resident had intact skin and at the Informed Consent for taking a picture of the lesion, they identified it as an ulcer. The lack of accuracy when performing an assessment and not classifying the [MEDICAL CONDITION] using the recommended guidelines do not allow to provided quality of care according to residents needs. c. The physician employee #18 did an assessment on 8/29/14 at 4:50 p.m. as requested by the survey team because the resident develop a stage II ulcer with irregular borders and was observed redness in the middle of it. On the same day, at 2:20 pm, the Nursing Supervisor, employee #2, obtained the following measurements from the [MEDICAL CONDITION]: 1 cm long X 0.5 cm wide. The physician referred that the resident has [MEDICAL CONDITION]. The physical history performed by the physician on 8/24/14 does not mention on section III, item A. Piel, cabello, u?as (Skin, Hair, Nails) that the resident has a [MEDICAL CONDITIONS] or discomfort on the sacral area. As observed on 8/29/14 at 2:00 pm, this ulcer shows characteristics that are similar to the descriptions of stage II ulcer definition written in the guidelines of Appendix PP on 483.25 for Pressure Sores and with cross reference to the guidelines written by the National Pressure Ulcer Advisory Panel. An Immediate Jeopardy (IJ) was notified to the facility due to the development of an ulcer and no preventive measures were performed. d. The Infectologist referred on consult that the resident has a laceration and ordered on [DATE] to apply Solocite hydrogel and cover it with [MEDICATION NAME]. The Head Physician ordered on [DATE] at 11:15 a.m. [MEDICATION NAME] plus Solocite to be applied daily on laceration. On the same day, at 6:30 p.m. discontinued the [MEDICATION NAME]/Solocite application and ordered to apply [MEDICATION NAME] AG daily. The physician did not follow the manufacturer ' s recommendations with each product. The Solocite and [MEDICATION NAME] help to absorb fluids, blood and to remove necrotic tissue. [MEDICATION NAME] AG promotes the autolytic debridement, moistening the wound and killing wound bacteria. According to manufacturer's indications of use, the effectiveness of each product has to be observed in 1 week or more. However, the physicians did not provided the recommended period of time to determine which product is better for the type of lesion that the resident has. As observed on 8/25, 8/27 and 8/29/14 the [MEDICAL CONDITION] was not bleeding and fluids, including blood, were not observed coming out from the bed of the lesion nor in surrounding tissue. This type of ulcer was developed by lack of changing positions adequately and by the accumulation of moisture for using a diaper. The resident stated at interviews on different days 8/25/14 thru 8/29/14 that she did not want the diaper. e. There is not congruency between the documentation of the changes positions and the observations made during 5 days (from 8/25/14 thru 8/29/14) on different hours. The nursing staff is writing on the formulary related to changes position that they are performing the changes every two hours from side to side and supine position but, as observed the resident remained on the same position, upright supine position which place on risk of the development of the stage II ulcer. f. During RR performed on 8/29/14 at 1:30 p.m. it was observed on the laboratory results from 8/23/14 that [MEDICATION NAME] levels were 2.5 g/dl (normal parameters 3.5-4.8 g/dl) which were low and no evidence was found of a nutritional evaluation to address the pressure ulcer. The resident has been taking [MEDICATION NAME] 30 ml by mouth daily from 8/22/14 thru 8/25/14. On 8/25/14 the Nutritionist, employee #4, recommended to administer 2 scoops of protein powder by mouth three times a day due to low [MEDICATION NAME] levels. However, no improvement on tissue regeneration was observed over the [MEDICAL CONDITION] as observed on days 8/25/14, 8/27/14 and 8/29/14. After the IJ notification a nutritional reevaluation was performed by the Nutritionist and she recommended to add Juven 1 package twice a day. However, as observed on the picture taken from the [MEDICAL CONDITION] before patient left the facility no granulation tissue was observed. Best results for the effectiveness of Juven will be seen two weeks after the first dose is taken by the resident. g. According to the Discharge Home physician's progress notes performed on 9/4/14 at 6:00 a.m., says that resident continues with local care and changes position at home every two (2) hours but does not mention which wound product the resident or caregiver will use at home. On the same day, no evidence was found on nurses ' progress notes about wound care to be performed at home. On the part I of the Pressure Ulcer Protocol the RN wrote that the lesion has not improved because a scar was not develop. No other description was found. h. The picture taken by the nursing staff before the resident left the facility was observed and no improvement of the [MEDICAL CONDITION] was found. The ulcer remained with the same characteristics as observed on 8/29/14. No granulation tissue over the wound bed was observed and the surrounding tissue was more reddish and swollen than the first day that was identified. No measurements of the ulcer were found on nurses' progress notes to be compared with the first measurement that employee #2 obtained on 8/29/14. 3. On 8/27/14 at 10:20 a.m. when the resident was in the bathroom, the Licensed Practical Nurse (LPN), employee #17, left the bathroom and the room looking for something, leaving the resident alone. After waiting for 2 minutes, it was observed the resident is sitting over the commode and was inclined to her left side. Employee #17 returned to the bathroom [ROOM NUMBER] minutes later leaving the resident at fall risk. 4. The facility failed to perform the interventions and service to avoid residents from neglect and physical harm.

Based on observations, review of records, policies/procedures (P&P) and interview, it was determined that the facility failed to ensure that the medical care of each resident is supervised by a physician. This deficient practice was identified on 1 out of 10 cases reviewed. (RR #10). Findings include: 1. During survey procedures throughout the five days of survey on 8/25/14 to 8/29/14 from 9:00am to 5:00 pm the following was identified related with failure by the facility to evidence that the medical supervision of the care of nursing home residents is performed by a physician. a. Record sample selection # 10 ( closed record review ) is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident was admitted to the facility to receive rehabilitative, restorative, and ongoing skilled nursing care. During review of the case it was identified a urine culture results of 3/21/14 that indicate microorganism isolated are [MEDICATION NAME] Faecalis and had the susceptibility panel for antibiotics. No evidence was found on the medical record of a physician orders [REDACTED]. On 3/25/14 at 3:14 pm resident present low blood pressure and weakness, nursing personnel call the physician in charge of the resident who orders to transfer to the emergency room ; in the emergency room they evaluate, treat and stabilize resident who was sent again to the SNF on 3/26/14 at 5:30 pm. No transfer physician orders [REDACTED]. The resident continue receiving care at the facility and on 3/27/14 at 10:45 am nurse call the physician due to high blood sugar results (higher than 500 mgs/dl-by fingerstick at 10:40 am). The physician gives the nurse by phone, instructions to administer Humalog insulin subcutaneous and repeat the [MEDICATION NAME] (Dtx) in two hours. At 12:40 md nurse repeat the Dtx fingerstick and call the physician again due to high blood sugar results (higher than 455 mgs/dl). The physician gives the nurse by phone, instructions to administer Humalog insulin subcutaneous and repeat the Dtx in two hours. At 3:00 pm nurse repeat the Dtx fingerstick and call the physician again due to high blood sugar results (433 mgs/dl). The physician gives the nurse by phone, instructions to repeat the Dtx in four hours and notify her to determine if resident need to be transfer to the emergency room . No further information was found documented on the medical record related with the reassessment of resident condition after those high blood sugar episodes. There are no progress notes or documentation by the physician for the evaluation of this case. The resident was discharge home on 4/1/14 at 7:00 am, resident remains in the facility until all discharge home arrangements were finished. On 4/1/14 at 11:45 am a telephone order was given to nurses to take a complete metabolic panel (CMP) blood sample, however there are no evidence found documented on the medical record of the reason to order the CMP. The CMP results came on 4/1/14 at 3:31 pm, sugar blood levels, BUN, Creatinine, Potassium, SGPT, SGOT and ALP were higher than the normal range however, and there is no evidence that a physician review CMP results. The resident left the facility approximately at 6:00 pm discharge instructions regarding diet to be follow in the home was not documented as given to the resident. Review of this case evidence eighteen telephone orders since resident admission through discharge .The case had three physician progress notes [REDACTED]. The facility failed to supervise the medical care of this resident participating in the resident assessment and care planning, when resident develop changes in health status that require treatment and continuous monitoring of changes in resident's medical status.

Based on observations, and review of records and policies/procedures (P&P) and interview, it was determined that the facility failed to take an active role in supervising the care of residents. This deficient practice was identified on 4 out of 10 cases reviewed. (RR #1, #3 and #10 and ramdom selection sample # 31). Findings include: 1. During survey procedures throughout the five days of the survey from 8/25/14 to 8/29/14 from 9:00 am to 5:00 pm the following was identified related with failure by the facility to evidence the evaluation and coordination of resident medical care in the facility and provide clinical guidance and oversight regarding the implementation of resident care policies: a. Record sample selection # 10 (closed record review ) is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident was admitted to the facility to receive rehabilitative, restorative, and ongoing skilled nursing care. During review of the case it was identified a urine culture results of 3/21/14 that indicated microorganism isolated are [MEDICATION NAME] Faecalis and had the susceptibility panel for antibiotics. No evidence was found on the medical record of a physician orders for the urine culture, urine culture results were not informed, or reviewed by the physician in order to determine if the resident require antibiotics. On 3/25/14 at 3:14 pm resident present low blood pressure and weakness, the nursing personnel call the physician in charge of the resident who orders to transfer to the emergency room ; in the emergency room they evaluate, treat and stabilize resident then was sent again to the SNF on 3/26/14 at 5:30 pm. No transfer physician orders or recommendations for the continuity of care after emergency room visit were found documented on the medical record. The resident continue receiving care at the facility and on 3/27/14 at 10:45 am nurse call the physician due to high blood sugar results (higher than 500 mgs/dl-by fingerstick at 10:40 am). The physician gives the nurse by phone, instructions to administer Humalog insulin subcutaneous and repeat the Destrostix (Dtx) in two hours. At 12:40 md nurse repeat the Dtx fingerstick and call the physician again due to high blood sugar results (higher than 455 mgs/dl). The physician gives the nurse by phone, instructions to administer Humalog insulin subcutaneous and repeat the Dtx in two hours. At 3:00 pm nurse repeat the Dtx fingerstick and call the physician again due to high blood sugar results (433 mgs/dl). The physician gives the nurse by phone, instructions to repeat the Dtx in four hours and notify her to determine if resident need to be transfer to the emergency room . No further information was found documented on the medical record related with the reassessment of resident condition after those high blood sugar episodes. There are no progress notes or documentation by the physician for the evaluation of this case. The resident was discharge home on 4/1/14 at 7:00 am; however resident remains in the facility until all discharge home arrangements were finished. On 4/1/14 at 11:45 am a telephone order was given to nurses to take a complete metabolic panel (CMP) blood sample, however there are no evidence found documented on the medical record of the reason to order the CMP. CMP results came on 4/1/14 at 3:31 pm, sugar blood levels results revealed 309 mg/dl (normal values 70 mg/dl-99 mg/dl) , BUN results revealed 49.0 mg/dl (normal values 8.0 mg/dl-20.0 mg/dl , Creatinine results 1.26 mg/dl (normal values 0.70 mg/dl-1.20 mg/dl , Potassium results revealed 5.36 mmmol/L (normal values 3.60 mmol/L-5.10 mmol/L) , SGPT results revealed 108 IU (normal values 14 IU-54 IU ) SGOT results revealed 100 IU (normal values 15 IU-41 IU ) and ALP results revealed 167 IU (normal values 38 IU-126 IU ). All of those comprehensive metabolic panel results were higher than the normal range, however, and there is no evidence that a physician review CMP results. The resident left the facility approximately at 6:00 pm; discharge instructions regarding diet to be follow in the home were not documented as given to the resident. Review of this case evidence eighteen telephone orders since resident admission through discharge .The case had three physician progress notes [REDACTED]. of Care/Notes/Orders " . The case was discussed with the medical director on 8/29/14 at 9:10 am to inform about the lack of medical supervision and physician follow-up of the case. 3. R#1 is an [AGE] years old female was admitted on [DATE] with a [DIAGNOSES REDACTED]. As secondary Diagnoses: [REDACTED]. The resident was admitted to the SNF for rehabilitation. a. During RR performed on 8/28 and 8/29/14 from 9:00 a.m. thru 4:00 p.m. it was found that the resident was admitted with moderate pain in her sacral area since 8/25/14 thru 8/29/14. (Cross Reference TAGS F241, F314) b. The physician ordered medications on 8/22/14 [MEDICATION NAME] 5/325 by mouth every 6 hours PRN for pain for 14 days. Eight days later, on 8/30/14 at 9:00 a.m. the physician ordered Tylenol 500 mg II tabs by mouth every 6 hours PRN for pain. The physician was not aware of discontinuing one of these medications due to drugs interactions (each medication has [MEDICATION NAME]) and side effects over resident's liver function. According to a comprehensive metabolic panel (CMP) performed on 8/23/14, the resident had increased levels on the hepatic enzymes: AST in 48 IU/L (normal parameters 15-41 IU/L), ALT in 80 IU/L (normal parameters in 14-54 IU/L). The physician did not considered these laboratory results before ordering pain medications. c. The physician ordered by phone on 8/22/14 at 7:40 p.m. [MEDICATION NAME] 40 mg by mouth daily. However, she was not aware of the abnormal results of the hepatic enzymes and did not reevaluate the [MEDICATION NAME] dose, considering that this medication can cause liver damage. On 8/28/14 this concern was discussed with the Pharmacist, employee 16, and decided to call the physician to recommend doses changes of [MEDICATION NAME], decreasing it to 20 mg daily. No evidence was found on the physician's progress notes evaluating the laboratory results from 8/23/14 showing the abnormal results of the hepatic enzymes. After discussing this concern with employee #16, the physician decided to change the [MEDICATION NAME] dose and ordered a CMP to be performed next day (8/29/14) and repeat it in 7 days. 4. During RR of random sample selection resident # 31 performed on 8/26/14 at 12:00 p.m., it was found that the resident is taking [MEDICATION NAME] and he brought the medication from home. The physician placed a telephone order on 8/20/14 at 9:00 p.m."[MEDICATION NAME] 450 mg PO 1 tab twice a day" and on standard order from 8/21/14 at 8:00 p.m. she ordered follow up laboratories: Comprehensive Metabolic Panel (CMP), Cells Blood Count (CBC) plus Differential every 8 days. However, no CMP results from 8/20 or 8/21/14 were found on the clinical record. According to RN progress notes from 8/20/14 at 5:00 a.m., she performed venipunction for CMP and CBC but the results were not found on the clinical record or computer data base coming from the Laboratory. The CMP has to be done due to [MEDICATION NAME] works over Sodium levels, decreasing them. No evidence was found of the physician requesting Sodium levels previous results to the resident to determine if the dose that was ordered was the one that the resident needed. This case was discussed with the Medical Director for follow up. 2. Resident #3 is an [AGE] years old female admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was observed on 8/26/14 at 9:30 am receiving a bed bath. However, during this procedure, the license practical nurse (employee # 12) finished the bed bath and did not ask the resident if she wants her hair washed. Also the nurse did not make any sign or movement to brush her hair. During interview on 8/26 at 10: 45 am the resident revealed that the resident has not received a hair wash since Monday 8/18/14 the day she went to the emergency room and they took some stitches on her head. The resident indicated that her knotted hair is because the dried blood of the wound. The resident states that the physician do not knows anything about the stitches because she does not know who the physician is. " Since I am here I have not have the opportunity to talk with my doctor " . During the record review performed on 8/26/14 at 11:00 am no evidence was found on the initial physician assessment or any progress notes about the resident head injured or the stitches. No physician order was found to cure the wound. There are no progress notes or documentation by the physician for the evaluation of this case. Also all the physician orders found on the medical record are telephone orders including the admission order. The case was discussed with the medical director (employee #15) on 8/29/14 at 9:10 am to inform about the lack of medical supervision and physician follow-up of the case.

Based on observations, review of records (RR), policies/procedures (P&P) and interviews, it was determined that the facility failed to provide the necessary care and monitoring and the medical director failed to show responsibility for the coordination of medical care in the facility to ensure that resident's (R) reach their highest practicable well-being for 3 out of 10 sample selection residents ( R #2, # 8 and #10). Findings include: 1. During survey procedures throughout the five days of survey on 8/25/14 to 8/29/14 from 9:00 am to 5:00 pm the following was identified related with failure by the facility to coordinate medical care in the facility and provide clinical guidance and oversight regarding the implementation of resident care policies: a. Record sample selection # 10 ( closed record review ) is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident was admitted to the facility to receive rehabilitative, restorative, and ongoing skilled nursing care. During review of the case on 8/28/14 11:09 am it was identified a urine culture results of 3/21/14 that indicate microorganism isolated are [MEDICATION NAME] Faecalis and had the susceptibility panel for antibiotics. No evidence was found on the medical record of a physician orders [REDACTED]. The Infection control designated person (employee #3 ) stated on interview on 8/28/14 at 1:00 pm that those cases must be informed to the hospital infection control officer to analyze, investigate and determine if resident had urinary tract infection. However evidence that this urine culture was reviewed was not provided. On 3/25/14 at 3:14 pm resident present low blood pressure and weakness, nursing personnel call the physician in charge of the resident who orders to transfer to the emergency room ; in the emergency room they evaluate, treat and stabilize resident who was sent again to the SNF on 3/26/14 at 5:30 pm. No transfer physician orders [REDACTED]. The resident continue receiving care at the facility and on 3/27/14 at 10:45 am nurse call the physician due to high blood sugar results (higher than 500 mgs/dl-by fingerstick at 10:40 am). Physician gives the nurse by phone, instructions to administer Humalog insulin subcutaneous and repeat the Destrostix (Dtx) in two hours. At 12:40 md nurse repeat the Dtx fingerstick and call the physician again due to high blood sugar results (higher than 455 mgs/dl). The physician gives the nurse by phone, instructions to administer Humalog insulin subcutaneous and repeat the Dtx in two hours. At 3:00 pm nurse repeat the Dtx fingerstick and call the physician again due to high blood sugar results (433 mgs/dl) Physician give the nurse by phone, instructions to repeat the Dtx in four hours and notify her to determine if resident need to be transfer to the emergency room . No further information was found documented on the medical record related with the reassessment of resident condition after those high blood sugar episodes. There no progress notes or documentation by the physician for the evaluation of this case. The resident was discharge home on 4/1/14 at 7:00 am, resident remains in the facility until all discharge home arrangements were finished. On 4/1/14 at 10:30 am accordingly with documentation found on the clinical dietitian progress note, resident was evaluated and the clinical dietitian review the Complete Metabolic Panel (CMP) results of 3/27/14 that indicate BUN, Creatinine and Potassium levels higher than normal levels. The clinical dietitian document that resident was dehydrated and discuss the case with a physician to consider repeat CMP before resident left the facility. On 4/1/14 at 11:45 am a telephone order was given to nurses to take a complete metabolic panel (CMP) blood sample, however there are no evidence found documented on the medical record of the reason to order the CMP. CMP results came on 4/1/14 at 3:31 pm, sugar blood levels results revealed 309 mg/dl (normal values 70 mg/dl-99 mg/dl) , BUN results revealed 49.0 mg/dl (normal values 8.0 mg/dl-20.0 mg/dl , Creatinine results 1.26 mg/dl (normal values 0.70 mg/dl-1.20 mg/dl , Potassium results revealed 5.36 mmmol/L (normal values 3.60 mmol/L-5.10 mmol/L) , SGPT results revealed 108 IU (normal values 14 IU-54 IU ) SGOT results revealed 100 IU (normal values 15 IU-41 IU ) and ALP results revealed 167 IU (normal values 38 IU-126 IU ). All of those comprehensive metabolic panel results were higher than the normal range, however, and there is no evidence that a physician review CMP results. The resident left the facility approximately at 6:00 pm discharge instructions regarding diet to be follow in the home were not documented as given to the resident. The Medical director failed to identify, evaluate, and address/resolve medical and clinical concerns and issues that affect resident care, medical care or quality of life, and are related to the provision of services. The case was discussed with the medical director on 8/29/14 at 9:10 am to inform about the lack of medical supervision and physician follow-up of the case. 2. The document "Funciones y Deberes del Director Medico Institucional " Funtions and Duties of the Institutional Medical Director and " Relacion con la Directora de Casa de Salud " Relationship with the Director of the Skilled Nursing dated 03-01-2010 reviewed on 8/28/14 at 3:55 pm evidence that medical Director is responsible to coordinate and implement standards of practice on the SNF, collaborating with the director of the SNF on all aspects related with the resident care and management and evaluating the performance of the physicians assigned to provide resident care. Facility failed to ensure that physician's responsibilities are followed accordingly with resident medical care policies, procedures and standards of practice that guide their profession. 3. Residents #2 is a [AGE] years old male. admitted on [DATE] with diagnostics of Left diabetic foot, Diabetes type II (DM type II), Hypertension (HTN), [MEDICAL CONDITION] (CKD) and [MEDICAL CONDITION]. On 8/25/14 at 2:35pm patient was interview and state: " I am not clear about my diagnostic. In this facility they said that I have [DIAGNOSES REDACTED] but in the hospital an orthopedist and a podiatrist said that I have arthritis. I have a pending consult with the rheumatologist since last week but the consult it is not answer yet " . On record review 8/26/2014 at 10:45 am consultations were found without answer. Rheumatology consult dated on 8/24/2014 at 11:00 am, Podiatric consult dated on 8/15/2014 at 7:50 am and orthopedic consult dated on 8/25/2014 with no hours. The facility policy for consult said that consultant physician have 72 hours for answer the consult. Podiatric consult do not comply with facility policy 3. Resident #8 Is a [AGE] years old female. admitted on [DATE] with a diagnostic of left [MEDICAL CONDITION]. During an interview with patient family member on 8/27/2014 at 10:00 am the family member state: " I do not know why my mother has a Foley. She always urine without problems. She supposed to go home today but they stop the discharge process because I did not have the necessary equipment yet." No documentation was found in the resident records related to the resident or her daughter orientation regarding resident condition and treatments.

Based on observational tours performed on 8/25/14 thru 8/29/14 (standard survey) and 9/11 /14 and 9/12/14 (extended survey) from 8:30 a.m. through 5:00 p.m., record reviewed (RR) and interviews to resident (R), nursing staff and rehabilitative program staff it was determined that the facility failed to do an accurate comprehensive assessment to address resident's needs and to implement the interventions established in the plan of care. The facility failed to have an ongoing pain assessment to allow planning an accurate care to the resident which can affect 1 out of 10 resident on the sample selection (R#1). Findings include: 1. On 8/25/14 thru 8/29/14 from 8:30 am to 4:00 pm it was found that R #1, an [AGE] year old female was admitted on [DATE] with a [DIAGNOSES REDACTED]. As secondary Diagnoses: [REDACTED]. The resident was admitted to the SNF for rehabilitation. 2. During RR performed from 8/25 to 8/29/14 from 8:30 a.m. thru 5:00 p.m. it was found that an initial comprehensive assessment for pain management on section J on the Minimum Data Set (MDS) was not performed by the nursing staff nor the MDS Coordinator, employee # 5. The lack of performing a pain comprehensive assessment can not allow developing an objective plan of care showing the real needs that the resident has. During the extended survey, it was found that Section J for Health Conditions, Section V for Care Area Assessment (CAAS) of the Minimum Data Set (MDS) and item #19 for Pain were not updated by the MDS Coordinator, employee #5 nor the nursing staff. (Cross Reference TAG F241) 3. During the RR performed on 8/28 and 8/29/14 from 9:00 a.m. thru 4:00 p.m. it was found that the resident was admitted with moderate pain. The Nursing Initial assessment on section J. " Estimado de Dolor " Pain Assessment and the nursing progress notes do not show accurate pain assessment and alternate interventions to keep resident in comfort zone, the assessment was not performed since 8/22/14 thru 8/29/14. According to interviews with the resident, she was feeling pain in her sacral area since 8/25/14 thru 8/29/14. (Cross Reference TAGS F241, F314) 4. The physician ordered medications on 8/22/14 [MEDICATION NAME] 5/325 by mouth every 6 hours PRN for pain for 14 days. Eight days later, on 8/30/14 at 9:00 a.m. the physician ordered Tylenol 500 mg II tabs by mouth every 6 hours PRN for pain. The physician was not aware of discontinuing one of these medications due to drugs interactions (each medication has [MEDICATION NAME]) and side effects over resident's liver function. According to a comprehensive metabolic panel (CMP) performed on 8/23/14, the resident had increased levels on the hepatic enzymes: AST in 48 IU/L (normal parameters 15-41 IU/L), ALT in 80 IU/L (normal parameters in 14-54 IU/L). The physician did not considered these laboratory results before ordering pain medications. 5. According to the RR the nursing staff, the Physical Therapist (PT), Occupational Therapist (OT) and Recreational Therapist (RT) did not performed accurate pain assessment during their daily interventions and the plan of care was not updated on an ongoing basis. During interview to the Physical Therapist Assistant (PTA), employee #19, on 8/26/14 at 9:00 a.m. she stated: "Before initiating the exercises I ask the resident if he/she took pain medications. After we finish the activities I ask how he/she feels related to pain. If the resident tells me that he/she has much pain before doing the exercises, I talk with the nurse. Then I plan with the resident if he/she wishes to do the exercises at that right moment or want to do it later". However, on the PT/PTA progress notes no documentation was found on the pain scale (Wong-Baker). The OT and RT initial assessments and progress notes do not show daily pain assessments and reevaluation of resident's response after participating on the scheduled activities. During interviews performed to the resident from 8/25 thru 8/29/14 at different hours, she stated: "I'm feeling pain in my back and on my buttocks". 6. After reviewing the Medication Administration Record [REDACTED]. 7. The facility failed to perform the interventions for pain management.

Based on observations, review of records and policies/procedures (P&P) and interview, it was determined that the facility failed to ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary for 1out of 10 sample selection residents (R) sample selection, (R # 7). Findings include: 1.During survey procedures throughout the five days of survey on 8/25/14to 8/29/14 from 9:00 am to 5:00 pm the following was identified related with failure by the facility to follow appropriate use and management of indwelling catheter and management of lower tract dysfunction according with standards of practice and evidence based guidelines: a. R # 7 is a [AGE] year old female admitted to the facility on [DATE] approximately at 2:30 pm with a [DIAGNOSES REDACTED]. Resident was admitted to the facility to provide rehabilitative, restorative, and ongoing skilled nursing care, she was admitted with a urinary catheter, according with information documented on the admission nurses progress notes urine was observed with hematuria. On 8/22/14 at 3:00 pm the physician order [REDACTED]. The nurses took urine laboratory samples, clamp the urinary catheter and then apparently discontinue the catheter because there is no evidence documented on the medical record of the hour where the urinary catheter was removed. The nursing progress notes dated 8/23/14 and 8/24/14 at 6 am evidence that resident had not experienced difficulties to eliminate urine. On 8/25/14 at 5:45 am nurse in charge of resident call the physician to inform that resident had pain and difficulty to eliminate urine. The physician order [REDACTED]. The nurses catheterize the resident but there is no evidence of the quantity of urine after the procedure. On 8/25/14 at 11:30 pm physician order [REDACTED]. The medical record evidence a urine culture results (taken 8/22/14) that indicate [MEDICATION NAME] Faecalis as the microorganism isolated on the culture. The resident presents temperature of 39.1 centigrade on 8/25/14 at 11:30 pm. Infection control designated person (employee #3) stated on interview on 8/28/14 at 1:00 pm that " those cases must be informed to the hospital infection control officer to analyze, investigate and determine if resident develop urinary tract infection as a result of the care provided at the facility " . However evidence that this urine culture was reviewed was not provided. On 8/27/14 at 9:00 am the resident was observed with urinary catheter. The physician in charge of the resident was interview on 8/27/14 at 11:58 am and she stated that she order to insert again the urinary catheter on 8/25/14 because the nurse inform her that the resident had discomfort and that during the catheterization procedure she eliminate 900 ml of urine. The facility ' s policy " Uso de Sonda Urinaria " Use of Urinary Catheter dated 06-13-2013 reviewed on 8/28/14 stated that residents admitted to the SNF must not use urinary catheters unless clinical condition demonstrate that the use is necessary and that evidence of medical factors considered for the use of urinary catheter must be documented on the medical record. The resident remains with the urinary catheter in place, there is no order to begin bladder training again, facility failed to ensure that each resident receives appropriate treatment & services to achieve or maintain as much normal urinary function as possible, there is no valid medical justification documented; for the use of an indwelling catheter on this case facility failed to promote that services are provided to restore or improve normal bladder function to the extent possible.

Based on the review of ten resident's records, policies/procedures (P&P), documents and interviews, it was determined that the facility failed to ensure that each resident with sufficient fluid intake to maintain proper hydration and health on 1 out of 10 cases review (R.R. # 10). Findings include: Record sample selection # 10 ( closed record review ) is a [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident was admitted to the facility to receive rehabilitative, restorative, and ongoing skilled nursing care. During review of the case on 08/28/14 at 3:45pm it was identified clinical dietitian (employee #4) evaluate the resident on 3/18/14 and recommends High fiber diet with 25 g scoop of protein powder tid, 4 ounces of ensure and assure 3 glasses of 7 ounces of water daily. Nurse's notes dated 8/10/14,8/15/14, 8/16/14,8/21/14 and 8/24/14 does not include information related with the quantity of fluids resident received on the shift 6am-6 pm. During interview on 8/27/14 at 2:39 pm the nursing supervisor (employee # 2) stated that facility had established a system to assure that residents received the recommended quantity of fluids to maintain hydrated. They implement a table that indicate the quantity of fluids that residents must received named " Ingesta de liquidos " Liquid Intake, where the exact amount of ounces of water recommended by the dietitian are established. " Ingesta de liquidos " format was complete on this case however the quantity of water indicated was not documented as provided by nursing personnel. The resident was discharge home on 4/1/14 at 7:00 am, but remains in the facility until all discharge home arrangements were finished. On 4/1/14 at 10:30 am according with documentation found on the clinical dietitian progress note, resident was evaluated and the clinical dietitian review the Complete Metabolic Panel (CMP) results of 3/27/14 that indicate sugar blood levels results revealed 477 mg/dl (normal values 70 mg/dl-99 mg/dl) , BUN results revealed 57.0 mg/dl (normal values 8.0 mg/dl-20.0 mg/dl , Creatinine results 1.22 mg/dl (normal values 0.70 mg/dl-1.20 mg/dl , Potassium results revealed 5.38 mmmol/L (normal values 3.60 mmol/L-5.10 mmol/L) , SGPT results revealed 106 IU (normal values 14 IU-54 IU ) SGOT results revealed 83 IU (normal values 15 IU-41 IU ) and ALP results revealed 167 IU (normal values 38 IU-126 IU ). All of those comprehensive metabolic panel results were higher than the normal range,. The clinical dietitian document that resident was dehydrated and discuss the case with a physician to consider repeat CMP before resident left the facility. On 4/1/14 at 11:45 am a telephone order was given to nurses to take a CMP blood sample, however there are no evidence found documented on the physician progress notes [REDACTED]. The CMP results came on 4/1/14 at 3:31 pm, sugar blood levels, BUN, Creatinine, Potassium, SGPT, SGOT and ALP were higher than the normal range however, and there is no evidence that a physician review CMP results. The resident left the facility approximately at 6:00 pm, discharge instructions regarding diet to be follow in the home was not documented as given to the resident. The facility failed to ensure that this resident who presents abnormal laboratory values may indicate dehydration is provided with appropriate management and care.

Based on observations, ten records reviewed and interviews, it was determined that the facility failed to provide the necessary care to monitor the resident for fluid intake, constipation and pain medications for one out of ten residents to reach her highest practicable well-being (resident #3). Findings include: 1. During the review of ten resident's records from 7/18/12 through 7/20/12 from 10:00 am through 3:00 pm, the following was determined for one out of ten clinical records reviewed: a.Resident #3 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. pain and using a scale of 1 through 10 she has a level 7 and the medication is not strong enough to deal with her pain. The clinical record was reviewed on 7/18/12 at 2:00 pm and provided evidence of the physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' s pain assessment in the MAR from 7/13/12 through 7/18/12. The resident also stated that she does not drink a lot of water because she does not want to urinate too much. The dietitian evaluates the resident for fluids on 6/7/12 for 1575 ml of free water, but from 7/11/12 through 7/19/12 nursing documentation for fluid intake provided evidence that the resident did not reach the minimum quantity. Laboratory results from 6/27/12 provided evidence that the [MEDICATION NAME] level was 2.8 g/dl and the dietitian recommends [MEDICATION NAME] but it was not given to the resident. The resident also states that she has not defecated for various days and on nursing documentation from 7/3/12 through 7/9/12 and from 7/13/12 through 7/17/12 no evidence was found that nursing personnel documented daily fecal elimination. The Quality Assurance officer (employee #2) stated during an interview on 7/20/12 at 10:45 am that the physician order [REDACTED]. The facility failed to ensure that this resident receives pain medications, sufficient fluids or treated for [REDACTED].

4. A mechanism to ensure that the facility estimates bedridden weigh gain or loss were not followed, nor promoted. The following findings were identified during the review of sample selection resident (#4) with the clinical dietitian (employee #4) on 7/20/12 at 1:42 pm: a. Resident #4 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. This resident was observed on 7/18/12 at 9:30 am bedridden, with a [MEDICAL CONDITION], gastrostomy and is totally dependent on activities of daily living. The clinical record was reviewed on 7/20/12 at 2:00 pm and provided evidence that the resident was not weighed when admitted to the facility. Information of the resident's weight was documented on the initial 5 days minimum data set instrument (MDS) date of reference 7/12/12. The MDS coordinator (employee #11) stated during an interview on 7/12/11 at 2:30 pm that the facility did not have a scale available to weight bedridden residents. When interviewed on 7/20/12 at 2:39 pm the clinical dietitian (employee #4) stated that the nutritional assessment on bedridden residents are performed using laboratory (chemical measures) and considering an estimated usual body weight of resident, but they did not have a mechanism in place to estimate weight changes, which includes anthropometric measures or an alternative way to determine weight gain or loss if they can not weigh the residents. 5. A mechanism to ensure that the facility is meeting professional standards of quality including accurate documentation of quantities of fluids given to residents, was not performed, nor followed. The following findings were identified during the review of sample selection residents (#2, #4 and #10) with the head nurse (employee #3) on 7/19/12 at 12:41 pm: a. Resident #4 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. This resident was observed bedridden, with a [MEDICAL CONDITION], gastrostomy and is totally dependent on activities of daily living. The clinical record was reviewed on 7/19/12 at 1:00 pm and provided evidence that the resident was evaluated by a dietitian on 7/12/12 and recommended [MEDICATION NAME] enteral feeding at 69 ml/hour for 18 hours and intake of fluids of 180 ml before and after each enteral feeding and 60 ml of water before and after giving medications every 24 hours, which is approximately 832 ml of free water. Nurse's notes from 7/12/12 through 7/18/12 include information that the resident received less quantity of free water than recommended on 7/12/12, 7/13/12, 7/15/12 and 7/17/12. Even though this resident appeared well hydrated, the facility failed to have a system in place to ensure that daily fluid intake, reaches the minimum calculated valve per day for this resident. b. Resident #2 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. status [REDACTED]. The clinical record was reviewed on 7/18/12 at 3:50 pm and provided evidence that the resident was evaluated by a dietitian on 7/16/12 who recommended 1,800 kcals diabetic diet, low fat, high fiber, 130 meq sodium plus 2 scoops of enterex protein powder three time/day, and fluid intake of 7 ounces of water daily, which is 840 ml of water daily. Nurse's notes from 7/16/12 through 7/18/12 include information that the resident received less quantity of free water than recommended. The facility failed to have a system in place to ensure that daily fluid intake, reaches the minimum calculated valve per day for this resident. c. Resident #10 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 7/20/12 at 1:50 pm and provided evidence that the resident was evaluated by a dietitian on 7/9/12 who recommended high fiber low sodium diet with 4 ounces of ensure three times/day and fluid intake of 7 ounces of water daily, which is 840 ml of water daily. Nurse's notes from 7/12/12 through 7/18/12 include information that the resident received less quantity of free water than recommended from 7/9/12 through 7/15/12. The facility failed to have a system in place to ensure that daily fluid intake, reaches the minimum calculated valve per day for this resident. 6. A mechanism to ensure that facility personnel document re-assessment performed to residents who are transferred to the emergency room to receive care due to an acute condition and return to the facility, was not performed nor followed. The following findings were identified during the review of sample selection resident (#5) with the head nurse (employee #3) on 7/20/12 at 2:25 pm: a. Resident #5 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 7/18/12 at 10:25 am the resident was transferred to the emergency room to receive an evaluation due to a cough, shortness of breath and chest pain. The resident was evaluated in the emergency room and received care and treatment and was transferred to the skilled nursing facility on 7/18/12 at 4:55 pm. No evidence was found documented the nursing progress notes of the status of resident when she returned to the skilled nursing facility or special provisions to be taken as a continuity of the care provided in the emergency room , in order to ensure that the resident remains stable. 7. A mechanism to ensure that nursing re-assessments are performed in cases where the nurse has interventions with the resident based on the initial assessment of needs according with standards of practice was not followed nor performed. a. Resident #4 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. This resident was observed bedridden, with a [MEDICAL CONDITION], gastrostomy and is totally dependent on activities of daily living. On 7/17/12 at 3:20 pm due to resident's constipation, the shift nurse (employee #13) called the physician who evaluated the resident and ordered a fleet enema and 30 ml of milk of magnesia stat. No information was found documented on the nursing progress notes, nor in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No evidence was found of nursing progress notes from the 7/17/12 from the 6 am-6 pm shift which describes the evaluation of the status of the resident after the administration of the medication and treatment. 8. A mechanism to ensure that the facility's personnel monitor and act upon treatment provided to residents with constipation was not performed, nor followed. The following findings were identified during the review of sample selection resident (#2) with the head nurse (employee #3) on 7/19/12 at 11:00 am: a. Resident #2 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. status [REDACTED]. During the initial observational tour the resident stated on 7/18/12 at 9:00 am that she was constipated and did not have a bowel movement since 7/9/12. The clinical record was reviewed on 7/18/12 at 3:50 pm and provided evidence that the resident was ordered [MEDICATION NAME] 200 mgs PO at bed time since 7/15/12 due to constipation. The resident stated on interview on 7/18/12 at 11:00 am that she was receiving [MEDICATION NAME] PO at bedtime but the medication had no results related to her constipation and she had already told the nurses that [MEDICATION NAME] did not work and no results were found of her constipation status. On 7/18/12 at 11:30 am after interventions, the head nurse (employee #3) called the physician who ordered 30 ml of milk of magnesia, 30 ml of mineral oil and 30 ml of [MEDICATION NAME] stat. Even though the facility identified the constipation issue that the resident had on 7/15/12 and prescribed medications, they failed to verify the effectiveness of the treatment prescribed and failed to take a more aggressive approach to correct this situation until it was brought to their attention. Based on observations, review of records and policies/procedures (P&P) and interviews, it was determined that the facility failed to provide the necessary care and monitoring and the medical director failed to show responsibility for the coordination of medical care in the facility to ensure that resident's reach their highest practicable well-being for six out of ten sample selection residents (sample selection resident #1, #2, #3, #4, #5, #6, #8 and #10 and random sample resident #18). Findings include: 1. During the review of ten resident's records from 7/18/12 through 7/20/12 from 10:00 am through 3:00 pm, the following was determined for one out of ten clinical records reviewed: a. Resident #3 is a [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. the pain and using a scale of 1 through 10 she has a level 7 and the medication is not strong enough to deal with her pain. The clinical record was reviewed on 7/18/12 at 2:00 pm and provided evidence of the physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident also stated that she does not drink a lot of water because she does not want to urinate too much. The dietitian evaluates the resident for fluids on 6/7/12 for 1575 ml of free water, but from 7/11/12 through 7/19/12 nursing documentation for fluid intake provided evidence that the resident did not reach the minimum quantity. Laboratory results from 6/27/12 provided evidence that the [MEDICATION NAME] level was 2.8 g/dl and the dietitian recommends [MEDICATION NAME] but it was not given to the resident. The resident also states that she has not defecated for various days and nursing documentation from 7/3/12 through 7/9/12 and from 7/13/12 through 7/17/12 no evidence was found that nursing personnel documented daily fecal elimination. The Quality Assurance officer (employee #2) stated during an interview on 7/20/12 at 10:45 am that the physician order [REDACTED]. The facility failed to ensure that this resident receives pain medications, sufficient fluids or treated for [REDACTED]. 2. Resident #1 is an [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 7/18/12 at 2:00 pm. The record provided evidence that the weight of the resident was not taken because he was bedridden and the dietitian did not have an actual weight when she performed the resident's initial nutritional evaluation for diet and fluid intake on 7/16/12. Laboratory results were found on 7/14/12 and provided evidence that the resident's [MEDICATION NAME] was 2.0 g/dl, but no evidence was found that these results were used by the dietitian and physician when performing the resident's diet plan of treatment. The dietitian recommended [MEDICATION NAME] on 7/14/12 but this was never given to the resident. The record provided evidence that when the dietitian evaluated the resident she recommended 1613 ml of water. However, from 7/13/12 through 7/17/12 the facility failed to ensure that the resident received the minimum recommended amount of water for 5 out of 5 days. The facility failed to ensure that laboratory results are considered and act upon to improve the resident's nutritional status and failed to have a scale to weigh bedridden residents. 3. Resident #8 is a [AGE] years old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The clinical record was reviewed on 7/20/12 at 11:00 am. The record provided evidence that the weight of the resident was not taken because he was bedridden and the dietitian did not have an actual weight when she performed the resident's initial nutritional evaluation for diet and fluid intake on 7/17/12. The record provided evidence that when the dietitian evaluated the resident she recommended 1,795 ml of water. However, from 7/16/12 through 7/19/12 the facility failed to ensure that the resident received the minimum recommended amount of water for 4 out of 4 days. The facility failed to ensure that the resident is given appropriate amounts of fluid and failed to have a scale to weigh bedridden residents. 9. Resident #6 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. This resident does not have impaired cognitive skills for daily decision making and has the ability to understand others. The record review was performed on 7/19/12 at 10:00 am and provided evidence that the first weight of the resident was taken on 6/27/12 which is approximately four days after admission and the dietitian did not have an actual weight when she performed the resident's initial nutritional evaluation for diet and fluid intake on 6/25/12. On 6/27/12 the resident was weighed and it was documented that she weighed 175.5 lbs, on 7/3/12 she was weighed and was 189.0 lbs and on 7/9/12 she weighed 174.0 lbs. No evidence was found of the facility's intervention related to the weight gain/loss and if it was real or an error. Also, from 7/9/12 through 7/19/12 the resident was not weighed, the head nurse (employee #3) stated during an interview on 7/20/12 at 11:00 am that residents are weighed once a week. 10. Resident #6 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review was performed on 7/19/12 at 10:00 am and provided evidence of the following related [MEDICATION NAME] performed, results and insulin coverage: a. Nursing personnel are performing [MEDICATION NAME] twice a day and from 6/24/12 through 7/20/12 25 [MEDICATION NAME] were performed. Of these 25 [MEDICATION NAME], 14 results were between 136mg/dl and 196mg/dl and on 7/4/12 at 5:00 am the result was 169mg/dl and 2 units of regular insulin was administered. Eleven of the 25 [MEDICATION NAME] were between 197mg/dl and 335mg/dl and 4 units of insulin was given at 236mg/dl and 8 units were given at 335mg/dl. Also, no evidence was found of the [MEDICATION NAME] results for the days of 7/7/12 and 7/15/12. The facility failed to implement procedures to ensure that insulin is administered according with the residents' [MEDICATION NAME] results. 11. Resident #6 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review was performed on 7/19/12 at 10:00 am and provided evidence that the physician requested a Physical Medicine & Rehabilitation physician consult on 6/24/12, however it is not until 7/19/12 that it is answered. The head nurse (employee #3) was interviewed on 7/20/12 at 8:30 am and she stated that consults must be answered within 24 hours. 12. Resident #6 is an [AGE] years old female who was admitted on [DATE] with a [DIAGNOSES REDACTED]. The record review was performed on 7/19/12 at 10:00 am and provided evidence that the dietitian evaluated the resident on 6/25/12 and recommended 840 ml of water. However, from 6/23/12 through 7/19/12 the facility failed to ensure that the resident received the minimum recommended amount of water for 22 out of 27 days. 13. During the initial observational tour of resident's rooms on 7/18/12 at 10:15 am with the head nurse (employee #3), it was found that the resident in room [ROOM NUMBER] (random sample resident #18) had a neck brace. The neck brace was observed too big for the resident and it covered his mouth and went high up on his neck which did not allow him to rest his head properly when in the lying position. This situation was brought to the attention of the facility and they found and placed an appropriate neck brace for the resident which the resident stated on 7/18/12 at 2:00 pm that was much more comfortable. The facility failed to identify the needs of the resident to ensure that the appropriate equipment is used to maximize his stay at the facility.