Every finding on record at Sharkey-Issaquena Nursing Home

Based on interview, record review, and consultant pharmacist job description review the facility failed to ensure a monthly medication regimen review (MMR) was conducted by the consultant pharmacist for residents residing in the facility for twelve (12) of (12) months reviewed, with the potential to affect all 50 residents residing in the facility. Findings include:A review of the facility's, Consultant Pharmacist Job Description, revealed, .The Consultant Pharmacist is responsible for overseeing and monitoring the pharmaceutical services provided to residents.The Consultant Pharmacist ensures compliance with federal and state regulations, promotes safe medication practices, conducts monthly medication regimen reviews, and serves as a resource to the interdisciplinary healthcare team to optimize resident outcomes and quality of care.Essential Duties and Responsibilities Medication Regimen Review Conduct monthly drug regiment reviews (DRR) for all residents as required by federal and state regulations.Complete monthly drug regimen reviews with required timeframes .A review of the facility's records revealed there were no documented MMRs completed by the Consultant Pharmacist for residents in the facility from [DATE] through [DATE].On [DATE] at 10:00 AM, during an interview, the Director of Nursing (DON) reviewed the facility's records and confirmed the facility did not have documentation to verify the consultant pharmacist conducted the required MMRs for the past year. On [DATE] at 10:15 AM, during an interview with the Pharmacy Consultant, he stated that he has not been to the facility to do MMRs since the facility was re-opened from the tornado that occurred in May of 2023. He explained the facility was closed for 16 to 17 months and his license for that software used to complete MMRs had expired during that time. The pharmacist stated that he went to renew his license for the software, but it was no longer available. He stated that he was looking for another type of software to provide the pharmacy reviews for the facility, however, he has not been able to find one at this time.On [DATE] at 10:30 AM, during an interview, the Administrator confirmed the facility did not have MMR documentation by the pharmacist for a twelve-month period. The Administrator reported MMRs were expected to occur in accordance with regulatory requirements.

Based on interview, record review, and facility policy review, the facility failed to submit Payroll-Based Journal (PBJ) staffing data to the Centers for Medicare & Medicaid Services (CMS) for one (1) of (1) quarter reviewed. (Fiscal Year Quarter 2 2026) Findings include:A review of the facility's, Payroll-Based Journal (PBJ) Reporting Policy and Procedure undated revealed, .Purpose To establish standardized procedures for the accurate collection, verification, maintenance, and submission of Payroll-Based Journal. (PBJ) staffing data in compliance with CMS requirements. This policy ensures accurate reporting of staffing information and supports compliance with federal regulations governing long term care facilities.shall accurately collect and electronically submit staffing and census information through the CMS Payroll-Based Journal (PBJ) system as required by federal regulations. All staffing information submitted to CMS must be complete, accurate, supported by documentation and submitted by established CMS deadlines. Failure to submit accurate PBJ data may negatively impact the facility's Five-Star Quality Rating, survey outcomes, and regulatory compliance status.A record review of the PBJ Staffing Data Report for Fiscal Year Quarter 2, 2026, revealed the facility failed to submit Payroll Based Journal staffing data for the reporting period of January 1, 2026, through March 31, 2026. On 6/9/26 at 1:00 PM, during an interview, the Chief Financial Officer (CFO) responsible for payroll reporting confirmed the facility failed to submit the second quarter PBJ data for the period January 1, 2026, through March 31, 2026. The CFO reported the facility experienced a tornado in 2023 and payroll records were maintained manually for a period of time due to nonfunctioning time clocks. The CFO reported she was responsible for payroll processing for the hospital, nursing home, two clinics, and administrative staff. The CFO explained that due to time constraints she did not complete and submit the required PBJ data. The CFO reported time clocks were reinstalled in January 2026 and she anticipated future PBJ submissions would be completed timely.On 6/9/26 at 1:30 PM, during an interview, the Administrator confirmed the facility failed to submit PBJ data to CMS for the second quarter of 2026. The Administrator reported she had previously been informed by the CFO that the PBJ submission had been completed. The Administrator reported the CFO later acknowledged the submission had not been completed due to time constraints. The Administrator reported the facility had experienced PBJ submission issues prior to this reporting quarter and had discussed transferring responsibility for PBJ submission to facility staff; however, corporate leadership elected to continue assigning the responsibility to the CFO.On 6/9/26 at 2:00 PM, during an interview, the Chief Executive Officer (CEO) reported he expected PBJ data to be submitted to CMS in accordance with CMS requirements. The CEO reported he was unaware the second quarter PBJ data had not been submitted and had been informed the submission was completed. The CEO reported measures would be implemented to ensure future PBJ submissions were completed timely.

Based on staff interview, record review, and admission Package review, the facility failed to ensure residents or their Resident Representatives (RRs) were informed of their rights regarding Advance Directives (ADs), including whether an AD existed and whether they wished to receive information or assistance in formulating an AD, for two (2) of (16) sampled residents. Resident #11 and Resident #22.Findings included:A record review of the medical records for Resident #11 and Resident #22 revealed there was no documentation that the resident or the Resident Representative (RR) received information regarding formulating an Advance Directive (AD).A record review of the facility's admission Package revealed two (2) separate forms titled Advance Directive Consent, which included language regarding the level of treatment, including code status, and an Acknowledgement of Advance Directives, which provided documentation regarding advance directive rights and whether an advance directive existed.On 6/8/26 at 4:13 PM, during an interview and record review of Resident #11's medical record with the Director of Nursing (DON), she reported that she was not exactly sure about Advance Directive forms. The DON stated each resident should have a code status in the chart and there should be an Acknowledgement Form completed on admission for all residents.On 6/9/26 at 9:20 AM, during an interview with Social Services #1, she confirmed she was responsible for completing the admission Package with residents and family members upon admission. Social Services #1 reported the facility used the Advance Directive Consent forms in the package because she felt the Advance Directive Consent form contained the same information and more, and the Acknowledgement of Advance Directives form was not used. After reviewing the forms, Social Services #1 and the DON confirmed the forms contained different information. The Advance Directive Consent form did not include information regarding whether the resident had an Advance Directive or whether the resident wished to receive information regarding formulating an Advance Directive, Living Will, or Power of Attorney.On 6/11/26 at 1:37 PM, during a phone interview with the Administrator, she reported she thought the Advance Directive Consent forms were to be completed upon admission.On 6/11/26 at 2:00 PM, during an interview with the DON, she reported the facility did not have a policy regarding Advance Directives.Resident #11A record review of the admission Record revealed the facility admitted Resident #11 on 11/17/25 with diagnoses including nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/26 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) Summary Score of 00, which indicated the resident was severely cognitively impaired.Resident #22A record review of the admission Record revealed the facility admitted Resident #22 on 11/1/24 with diagnoses including hemiplegia and hemiparesis.A record review of the Quarterly MDS with an ARD of 3/21/26 revealed Resident #22 had a BIMS Summary Score of 7, which indicated the resident was severely cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to personal privacy for one (1) of (16) sampled residents reviewed for resident rights, as evidenced by posting of identifying personal care directions including Nothing by Mouth (NPO), Keep Head of Bed (HOB) elevated at 45 degrees, safe swallow precautions, and elevate my legs while in bed. Resident #33. Findings included:A review of the facility's policy Resident Rights undated, revealed . It is the policy of this facility to ensure that the rights of the residents residing at this facility upheld in the highest regard. Staff will be trained on resident rights upon hire and at a minimum annually thereafter. Resident's Rights . 13. Each resident has the right to personal privacy and the right to privacy in written communication as evidenced by the following: . f. Medical record maintained confidentially .On 6/8/26 at 11:53 AM, during an observation, Resident #33 was lying in bed with eyes closed. There were five (5) signs above Resident #33's headboard that included Family will do laundry, NPO (Nothing by Mouth), Keep HOB elevated at 45 degrees, safe swallow precautions, and turn schedule. Another sign was observed on the wall by the window that stated to elevate my legs while in bed.On 6/8/26 at 1:15 PM, during an interview with Certified Nurse Aide (CNA) #2, she reported Resident #33 has a percutaneous endoscopic gastrostomy (PEG) tube and eats nothing by mouth, and that is why the signs are posted to alert all staff. CNA #2 stated she works agency and has been coming to the facility for eight (8) months. She did not know how long the signs had been posted on the wall. CNA #2 further explained that the information regarding NPO status and keeping the head of the bed elevated is documented on the Kardex and care plan to inform staff how to care for Resident #33.On 6/8/26 at 1:55 PM, during an interview with Registered Nurse (RN) #1, she reported Resident #33 is NPO and receives bolus tube feedings every six (6) hours. RN #1 stated the posted resident information is included on the physician orders, Medication Administration Record (MAR), Treatment Administration Record (TAR), and care plan.On 6/9/26 at 11:05 AM, during an observation, Resident #33 had a visitor in his room. All signs containing personal care information remained on the wall intact and visible.On 6/9/26 at 2:15 PM, during an interview with Licensed Practical Nurse (LPN) #1, she reported the signage on Resident #33's wall was posted by the Minimum Data Set (MDS) nurse and the social worker. LPN #1 stated the facility uses agency staffing and the signs were posted to remind staff of the precautions necessary to prevent complications, but she was unsure when the signs were posted. LPN #1 reported the information displayed on the wall included care information that was also available in Resident #33's chart, Kardex, and care plan.On 6/10/26 at 3:15 PM, during an interview with RN #2, she confirmed that she and social services placed the signs on Resident #33's wall to inform staff of the precautions and included personal care information regarding Resident #33's NPO status, swallow precautions, and the need to elevate the resident's legs. RN #2 stated this information was also available on Resident #33's care plan, Kardex, and physician orders. RN #2 reported she was not aware the facility could not post signs containing resident care information on the walls.On 6/10/26 at 3:30 PM, during an interview with the Director of Nursing (DON), she reported that signage on a resident's wall regarding personal care information is a dignity issue and a resident rights concern. The DON stated she expects all staff to honor resident rights at all times and not post personal or care information where others can see it.A record review of the admission Record revealed the facility admitted Resident #33 on 10/6/25 with diagnoses including Aphasia Following Cerebral Infarction.A record review of the Order Summary Report revealed Resident #33 had physician orders for . NPO diet, NPO texture, NPO consistency May have small pleasure pureed snack in between meals (dated 4/27/26) . Bolus Jevity 1.5 237 cc (cubic centimeter) q (every) 6h (hours) (dated 5/29/62). Elevate head of bed at least 45 degrees at all time to prevent aspiration (dated 11/20/25) . Enteral Bolus Give Jevity 1.5 237cc q6h (4 times a day) via peg tube every 6 hours related to GASTROSTOMY STATUS (dated 5/29/26) . head of bed up 45 degrees (dated 10/6/25) . Off load heels while in bed (dated 4/10/26) A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/26 revealed Resident #33 had a Brief Interview for Mental Status (BIMS) Summary Score of 00, which indicated her cognition was severely impaired. Section K, K0520, Nutritional Approaches revealed Feeding tube (e.g., nasogastric or abdominal) (PEG).

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure Resident #34's right to have grievances investigated and resolved by failing to initiate the grievance process after the resident reported three (3) missing clothing outfits for one (1) of (16) sampled residents reviewed.Findings included:A review of the facility's Grievance Policy, undated, revealed .It is the policy.that all residents are to be encouraged and assisted if necessary in filing grievance in the event that they have a need to make a concern knowns.The facility will document all grievances in the electronic health record. The social service department will retain evidence of grievances and actions taken for the required length determined by the retention log. Procedure: 1. Upon receipt of a grievance/complaint the staff receiving the complaint will initiate the Grievance/Complaint Form.5. In all grievance cases, the resident and or legal representative will be informed of the result of the investigation, the recommendations made by the investigating parties, and of the action(s) contemplated by the appropriate Department Head and Administrator.A record review of the handwritten copy of an inventory list, dated 3/27/26 and signed by Licensed Practical Nurse (LPN) #1, revealed Resident #34 had clothing items inventoried and signed upon admission.On 6/9/26 at 3:00 PM, during an interview at the Resident Council meeting, Resident #34 reported (3) outfits were missing after being sent to laundry and had not been returned after reporting the concern to staff. Resident #34 reported the concern had been communicated to staff a few weeks earlier, including Certified Nurse Aide (CNA) #2, and reported being directed to search the laundry room themselves for missing items.On 6/9/26 at 4:30 PM, during an interview with the Activities Director (Activities #1), she reported the Administrator was aware of concerns regarding missing clothing. Activities #1 reported clothing identification methods included the use of permanent marker, which may fade or not be visible on dark clothing. Activities #1 further reported clothing labels were available but responsibility for labeling was unclear. Activities #1 reported a large amount of unclaimed clothing was maintained in the laundry room and residents were permitted to search for items. Activities #1 reported she was unaware of a process for replacement of missing clothing items.On 6/10/26 at 9:10 AM, during an interview with CNA #2, she reported Resident #34 and the resident's family had reported missing clothing items. CNA #2 confirmed the items were listed on the inventory sheet and reported searching the laundry area without locating the items.On 6/10/26 at 9:45 AM, during an interview with the Social Services Designee (SS #1), she reported she was unaware of the missing clothing concerns because no formal grievance had been filed. SS #1 reported clothing items generally were not replaced if not documented on the inventory sheet and reported she was unaware of additional missing clothing reports from other residents.On 6/10/26 at 1:10 PM, during an interview with Housekeeping Supervisor (HSK #1), she reported awareness of Resident #34's concerns regarding missing clothing items and stated she had received communication from CNA #2 regarding the missing clothing. HSK #1 reported that when items are missing, staff document the missing items and search the laundry and lost-and-found areas. On 6/10/26 at 1:48 PM, during an observation and interview, there were multiple bags of unidentified clothing and unmatched socks in the laundry area. HSK #1 reported there was no reliable method to identify clothing that was not labeled and confirmed the reported missing clothing items for Resident #34 had not been located.On 6/11/26 at 12:45 PM, during an interview with the Administrator, she reported awareness of the missing clothing for Resident #34 and stated she intended to purchase replacement clothing items the previous week and confirmed replacement had not been completed yet. On 6/11/26 at 1:00 PM, during an interview with the CNA Supervisor, she reported notification had been received from laundry staff that the missing items for Resident #34 could not be located and communication had been made to the nurse who signed the inventory list. The CNA Supervisor stated this occurred the previous month. (May 2026)On 6/11/26 at 1:05 PM, during an interview with Licensed Practical Nurse (LPN) #1, she reported awareness that Resident #34's clothing items could not be located and confirmed no formal grievance was initiated and no follow-up actions were completed.A record review of the admission Record revealed the facility admitted Resident #34 on 3/26/26 with diagnoses including Chronic Obstructive Pulmonary Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/26 revealed Resident #34 had a Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicated the resident was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical restraints by failing to identify a self-releasing seat belt as a restraint for one (1) of (16) sampled residents, Resident #21, who was unable to independently release the device.Findings included:A review of the facility's Restraint Reduction and Use Policy, undated, revealed, Purpose To promote resident dignity, safety, and quality of life through restraint-free care whenever possible and to ensure compliance with federal and state regulations governing restraint use. Policy.is committed to maintaining a restraint-free environment. Physical.restraints shall not be imposed for discipline or staff convenience and shall only be used when medically necessary.Definitions Physical Restraint: Any manual method, device, material, or equipment attached or adjacent to the resident's body that restricts freedom of movement and cannot be easily removed by the resident .Assessment Prior to the use of any restraint, the interdisciplinary team shall assess the resident to identify causes of behaviors, risks, alternatives attempted, and potential consequences. Alternatives The facility shall utilize restraint alternatives whenever possible Physician Orders Restraints shall only be used pursuant to a physician order when clinically justified.On 6/8/26 at 10:15 AM, during an observation, Resident #21 was seated in a wheelchair with a self-releasing seat belt secured across the lap. Resident #21 manipulated the buckle but was unable to independently release the seat belt.On 6/8/26 at 10:30 AM, during an interview with Certified Nursing Assistant (CNA) #1, she reported Resident #21 required staff assistance throughout the day and frequently forgot how to perform routine tasks due to dementia.On 6/8/26 at 10:45 AM, during an interview with Registered Nurse (RN) #2, she reported the self-releasing seat belt was utilized for positioning and was not considered a restraint.On 6/8/26 at 11:00 AM, during an interview with Licensed Practical Nurse (LPN) #1, she reported Resident #21 used the self-releasing seat belt to prevent sliding from the wheelchair. LPN #1 was unable to provide documentation demonstrating Resident #21 could independently release the device. LPN #1 further reported Resident #21 was unable to release the self-releasing seat belt due to confusion and dementia.On 6/9/26 at 1:00 PM, during an interview and record review with the Director of Nursing (DON), she reviewed Resident #21's records and confirmed there was no documentation demonstrating Resident #21 had been assessed and determined capable of independently releasing the self-releasing seat belt. The DON acknowledged that if a resident could not independently release the device, the seat belt would be considered a restraint. The DON reported the facility was a restraint-free facility and the seat belt was being utilized for positioning.On 6/10/26 at 4:15 PM, during an observation and interview with the DON and Minimum Data Set (MDS) nurse, Resident #21 was sitting in a wheelchair in the dayroom with the self-releasing seat belt secured across the lap. Resident #21 was asked to stand up and remove the self-releasing seat belt. Resident #21 was unable to recognize that the seat belt needed to be released in order to stand and was unable to release the belt independently.On 6/11/26 at 10:18 AM, during an interview with the Administrator, she reported staff were expected to follow the facility's restraint policy when utilizing any device that could restrict a resident's freedom of movement.A record review of the admission Record revealed the facility admitted Resident #21 on 11/1/24 with diagnoses including Parkinson's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/14/26 revealed Resident #21 had a Brief Interview for Mental Status (BIMS) Summary Score of 04, which indicated severely impaired cognition. A review of Section P of the assessment revealed Resident #21 was not coded as having a restraint.A record review of Resident #21's medical record revealed there was no restraint assessment completed for a self-releasing seat belt.

Based on record review, staff interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed and coded in accordance with MDS requirements for three (3) of (16) sampled residents reviewed for MDS accuracy, as evidenced by failing to complete discharge assessment and entry assessments (Resident #2 and Resident #56) and inaccurately coding Resident #55's MDS to indicate Death in Facility when the resident expired at the hospital. Findings include:A review of the facility's Minimum Data Set (MDS) Assessment and Completion Policy, undated, revealed . Purpose To establish procedures for the timely, accurate, and comprehensive completion of Minimum Data Set (MDS) assessments in accordance with CMS (Center for Medicare and Medicaid Services) requirements . state regulations, and facility standards. Responsibilities The MDS Coordinator is responsible for scheduling assessments, coordinating IDT (interdisciplinary team) input, coding assessments, ensuring timely completion and transmission, monitoring validation reports, and maintaining records. The Director of Nursing (DON) will ensure nursing documentation supports MDS coding and care planning. Assessment Schedule The facility will complete assessments as required by CMS . Documentation Requirements . Documentation must be accurate, objective, complete, timely, and consistent across disciplines.Resident #2A record review of the admission Record revealed the facility admitted Resident #2 on [DATE] with diagnoses including Cerebral Ischemia. A record review of Resident #2's Progress Note dated [DATE] at 2:14 PM revealed . Sent out via ambulance. A record review of Resident #2's Progress Note dated [DATE] at 6:55 PM revealed . returned from several days stay at (Proper Name) Hospital .A record review of the clinical electronic health record MDS tab revealed Resident #2 had a Discharge Return Anticipated ([DATE]), an Entry ([DATE]), and a Medicare-5 Day ([DATE]) with a Status of In Progress, indicating the assessments had not been completed and transmitted to CMS.Resident #56 A record review of the admission Record revealed the facility admitted Resident #56 on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified.A record review of Resident #56's Progress Notes dated [DATE] at 6:25 PM revealed .sent to.ER (Emergency Room) via ambulance. A record review of Resident #56's Progress Notes dated [DATE] 12:10 PM revealed . returned from several days admit .A record review of Resident #56's Progress Notes dated [DATE] at 8:37 AM revealed . the resident departed the facility by ambulance.A record review of Resident #56's Progress Notes dated [DATE] at 6:59 PM revealed, .Returned from several days in hospital.A record review of the clinical electronic health record MDS tab revealed Resident #56 had an Entry ([DATE]), and a Discharge Return Anticipated ([DATE]) with a Status of In Progress, indicating the assessments had not been completed and transmitted to CMS. There was no Entry created for [DATE] when the resident returned from the hospital.Resident #55A record review of the admission Record revealed the facility admitted Resident #55 on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified.A record review of Resident #55's Progress Notes dated [DATE] at 3:52 PM revealed . EMS (Emergency Medical Services) arrive to facility to transport resident to emergency room .A record review of Resident #55's Progress Notes dated [DATE] at 9:35 AM revealed . residents RP (Responsible Party) contacted facility and notified that resident passed away last night .A record review of the Discharge MDS with an ARD of [DATE] for Resident #55 revealed . Section A0310 Type of Assessment . F. Entry/discharge reporting . Discharge-return anticipated . A2105. Discharge Status . Short-term General Hospital .A record review of the Death in Facility MDS with an ARD of [DATE] for Resident #55 revealed . Section A0310 Type of Assessment . F. Entry/discharge reporting . Death in Facility . which indicated Resident #55 expired in the facility and not an acute care hospital.On [DATE] at 2:36 PM, during an interview with the Director of Nursing (DON), she explained that Resident #55 was sent out to the hospital for respiratory distress and he never came back to the facility. He was in the hospital for several weeks until he died at the hospital. On [DATE] 3:33 PM, during an interview with Registered Nurse (RN) #2, she confirmed that she completes all the MDS assessments and transmissions. She confirmed that the resident's recent MDS was death in the facility, but he died at the hospital that he was discharged to. She explained that the resident was discharged to the hospital on [DATE] and later died at the hospital on [DATE]. She confirmed that the MDS was coded inaccurately due to resident died weeks after being discharged to the hospital. On [DATE] at 4:11 PM, during a follow up interview with RN #2, she reported that she is aware that some of the residents' MDS assessments are not up to date. She reported that she has been working the cart and assisting the new DON with getting systems in place and doing other duties in the facility. She is aware of the timeframe for the completion of the MDS and she tries to complete all the assessments in the required timeframes. On [DATE] at 1:29 PM, during a follow up interview with the DON, she reported that she was not aware that the residents' assessments were not submitted timely. She stated she expected all residents' MDS assessments to be completed accurately and submitted timely and confirmed that she had not been conducting any record checks to ensure the assessments were submitted timely. On [DATE] at 1:37 PM, during a phone interview with the Administrator, she reported that she expects staff to complete the required duties of their job and complete the tasks daily. She was not aware that the residents' MDS assessments were not being completed accurately or timely.

Based on staff interview, record review, and facility policy review, the facility failed to develop a comprehensive, person-centered care plan related to hospice services for Resident #41 and for all care and services for Resident #42 for two (2) of (16) sampled residents. Findings include: A review of the facility's Comprehensive Care Plan Policy undated, revealed . Purpose To establish a standardized process for developing.comprehensive person-centered care plans that address each resident's physical, psychosocial, emotional, dietary, functional, and spiritual needs in accordance with federal and state regulations. Responsibilities The MDS (Minimum Data Set) Coordinator shall coordinate the care planning process, schedule care plan meetings, and ensure care plans are developed and updated timely.Development of Care Plans A Comprehensive care plan shall be developed within seven (7) days after completion of the comprehensive assessment. Resident #41 A record review of the admission Record revealed the facility admitted Resident #41 on 4/10/26 with the diagnoses including Chronic Obstructive Pulmonary Disease. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/20/2026 revealed Resident #41 had a Brief Interview for Mental Status (BIMS) summary score of 15, indicating cognitively intact. A record review of the Order Details revealed Resident #41 had a Physician's Order, dated 4/13/26, to admit to hospice (04/10/26). A record review of the Progress Notes revealed Resident #41 had a Nurses Note, dated 6/10/26 at 11:47 PM for .Resident remains on hospice. A record review of the Comprehensive Care Plan for Resident #41 revealed there was no care plan developed with a focus, goals, or interventions related to hospice services. On 6/9/26 at 3:24 PM, an interview with MDS/Care Plan Nurse (RN #2) revealed Resident #41 currently received hospice services and confirmed the care plan did not reflect hospice services, goals, or interventions. RN #2 reported the care plan should be consistent with physician orders to guide nursing staff in providing care and reported the care plan was reviewed daily, quarterly, annually, and as needed when changes occur. On 6/10/26 at 11:20 AM, an interview with Social Services Designee (SS #1) revealed Resident #41 was admitted to the facility on hospice services. Resident #42 A record review of the admission Record revealed Resident #42 was admitted by the facility on 4/14/26 with diagnoses including Encephalopathy, Type 2 Diabetes Mellitus, and Unspecified Dementia. A record review of the admission MDS with an ARD of 04/21/2026 revealed Resident #42 had a BIMS Summary Score of 2, which indicated severely cognitively impaired. A review of the clinical record for Resident #42 revealed there was no comprehensive care plan, only a Baseline Care Plan dated 4/14/26. On 06/09/2026 at 4:11 PM, during an interview with Registered Nurse (RN)#2, she explained she was facility's MDS and care plan nurse. She reported that she is aware that she is behind on developing resident comprehensive care plans and explained that she has been assisting the new Director of Nursing (DON). She reported that the purpose of the care plan is to tell staff how to care for the residents and without a care plan, the resident may not receive the correct care. On 06/11/2026 at 1:29 PM, during an interview with the DON, she reported that she was not aware that the residents' care plan was not developed. She expects all residents to have a person-centered care plan developed, implemented, and revised per guidelines. On 06/11/2026 at 1:37 PM, during a phone interview with the Administrator, she stated that she expects staff to complete the required duties of their job and complete the tasks daily. She was not aware that the residents' care plans were not developed.

Based on interviews, record review, and the facility policy review the facility failed to revise a resident's care plan for two (2) of (16) sampled residents related to significant weight loss and pressure injuries (Resident #2) and changes in psychotropic medication (Resident #13). Findings include: A record review of the facility's Comprehensive Care Plan Policy undated, revealed . Purpose To establish a standardized process for.reviewing, and revising comprehensive person-centered care plans that address each resident's physical, psychosocial, emotional, dietary, functional, and spiritual needs in accordance with federal and state regulations. Responsibilities The MDS (Minimum Data Set) Coordinator shall coordinate the care planning process, schedule care plan meetings, and ensure care plans are developed and updated timely. The Director of Nursing (DON) shall oversee nursing participation and implementation of care plan interventions. Review and Revision Care plans shall be reviewed and revised: Following comprehensive assessments . upon significant change in condition . following accidents, incidents, or adverse events when indicated . Whenever resident needs, preferences, or services change. Revisions shall be documented and communicated to appropriate staff. Documentation Care plan documentation shall accurately reflect resident needs, goals, interventions, and outcomes. All updates, revisions, and interdisciplinary participation shall be documented in the medical record. Resident #2 A record review of the Comprehensive Care Plan revealed the care plan with a Focus of Nutritional Status General was not revised to reflect Resident #2's weight loss or pressure injury. A record review of the Order Summary Report revealed Resident #2 had Physician's Orders for a House Supplement after meals for Weight Management (Order date: 06/05/2026), Prostat 30 ml (milli liters) by mouth twice a day two times for to promote wound healing (Order date: 04/09/2026), and to clean deep tissue injury to left heel with normal saline, pat dry, place foam with silver dressing daily until resolved every shift and as needed (Order date: 5/22/26). On 06/09/2026 at 4:11 PM, during an interview with Registered Nurse (RN)#2, she explained that she is behind on revising and updating resident care plans. She reported that the purpose of the care plan is to tell staff how to care for the resident and without the care plan in place, the resident may not receive the correct care. A record review of the admission Record revealed the facility admitted Resident #2 on 10/15/25 with diagnoses including Cerebral Ischemia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2026 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) Summary score of 12, which indicated moderate cognitive impairment. Section K0300 revealed yes to weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. Section M0210 revealed one (1) unhealed pressure ulcer/injury. Resident #13 A record review of the Comprehensive Care Plan for Resident #13 revealed a Focus of .receives antipsychotic medication. with Interventions/Tasks including Administer Psychotropic medication: quetiapine Fumerate 20 mg. A record review of the Order Details revealed Resident #13 had a current Physician's Order, dated 12/16/25 for Quetiapine Fumarate tablet 50 milligrams (mg) daily. A record review of the Medication Administration Record (MAR) for May 2025 for Resident #13 revealed the resident was administered 50 mg of Quetiapine Fumarate daily. A record review of the admission Record revealed the facility admitted Resident #13 on 5/15/25 with diagnoses including Parkinson's Disease. On 6/9/26 at 3:24 PM, an interview with MDS/Care Plan Nurse (RN #2) revealed Resident #13 currently received Seroquel (Quetiapine Fumarate) 50 mg and confirmed the care plan interventions reflected 20 mg. She explained that the care plan interventions had not been revised to reflect the resident's current orders. RN #2 reported the care plan should be consistent with physician orders to guide nursing staff in providing care. On 06/11/2026 at 1:29 PM, during an interview with the Director of Nursing (DON), she reported that she was not aware that the residents' care plan was not revised to accurately reflect residents' care and services. She stated she expected resident care plans to be revised per guidelines. On 06/11/2026 at 1:37 PM, during a phone interview with the Administrator, she stated she expected staff to complete the required duties of their job and complete the tasks daily. She was not aware that the residents' care plans were not being revised.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure smoking and vaping activities were assessed, supervised, and conducted in accordance with facility policy and resident safety requirements for one (1) of three (3) residents reviewed for accident/hazards. (Resident #51). Findings include:A review of the facility's Smoking and Smokeless Tobacco Policy, effective 12/31/17 revealed, .It is the policy.to endure precautions are taken for the resident's individual safety, as well as the safety of others in the facility. Residents are able to participate in novelty activities such as smokeless tobacco and e-cigarettes.A Smoking Safety Evaluation will be completed upon admission for all residents.Safety measures must be followed in order to participate in smoking activities.No.e-cigarettes.may be kept in the resident's rooms.Smoking times are daily at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 Pm, and 7:00 PM. Residents will be accompanied by a staff member at each smoking time.On 6/8/26 at 1:40 PM, during an interview, Resident #51 reported vaping in the room, keeping the vape device in the room, and receiving vape supplies from the resident's daughter.On 6/9/26 at 3:48 PM, during an interview with the Director of Nursing (DON), she reported she was unaware that Resident #51 was vaping in the room.On 6/9/26 at 4:59 PM, during an observation, Resident #51 demonstrated use of a vape device in the room prior to dinner. Resident #51 reported not being informed that vaping was prohibited in the room, reported using the vape device only in the room, and reported keeping the vape device on the resident's person at all times. Resident #51 reported never going outside during designated smoking times. An oxygen concentrator was present in the room near Resident #51's chair.On 6/10/26 at 9:45 AM, during an interview with the Social Services Director (SS #1), she reported smoking assessments were completed upon admission and quarterly and that vaping products should be treated the same as tobacco and not used inside the facility. SS #1 reported she was unaware that Resident #51 was vaping in the room and had observed Resident #51 wearing the vape device around the resident's neck.On 6/11/26 at 2:45 PM, during an interview with the Administrator, she reported there had been prior discussion with Resident #51's family regarding the smoking policy and believed Resident #51 was aware of the policy. The Administrator reported Resident #51 had access to scheduled smoking times outside but acknowledged Resident #51 reported vaping in the room and had not considered vaping use in relation to oxygen equipment or policy compliance. The Administrator stated her expectation was for Resident #51 to go outside to vape.A record review of the admission Record revealed the facility admitted Resident #51 on 11/27/25 with diagnoses that included Dementia, Mild.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/26 revealed Resident #51 had a Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicated she was cognitively intact.A record review of the Smoking Safety Evaluation, dated 4/14/26, revealed Resident #51 had Follow the facility's policy on location and time of smoking marked as Yes. There were no other questions specifically regarding vaping safety.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident with bed rails had an entrapment assessment and consent completed for the use of bed rails for one (1) of (16) sampled residents. Resident #42.Findings included:A review of the facility's policy Bed Rail undated, revealed . It is the policy.that each resident and resident responsible party be informed of the benefits and risks of all bed rails when applicable . A consent form will be signed by resident representative (RR) prior to new bed rails are installed if deemed by evaluation for side rail installation . Procedure At the time of admission, bed rail policy, side rail consent form, and side rail assessment form are to be reviewed by resident responsible party and/or self. The facility representative will assist in the explanation of the policy and perform the side rail use assessment form. The facility will ensure that each resident has a bed rail consent when a bed rail is in use .On 6/8/26 at 11:23 AM, during an observation, Resident #42 was lying in bed. There were four (4) half bed rails raised.On 6/9/26 at 11:21 AM, during an observation, Resident #42 was lying in bed. There were two (2) half bed rails raised at the top of the bed.On 6/9/26 at 1:45 PM, during an interview with Certified Nursing Assistant (CNA) #2, she reported Resident #42 required limited assistance with turning and transfers and that the top bed rails were always raised because the resident used them to assist with turning and repositioning. CNA #2 confirmed Resident #42 had (2) bed rails raised at all times while in bed to prevent falls but should not have had (4) bed rails raised.On 6/9/26 at 2:30 PM, during an interview with Licensed Practical Nurse (LPN) #2, she confirmed Resident #42 used the bed rails to assist with moving and rolling over. LPN #2 stated she had observed the top (2) bed rails raised but did not know why the bottom rails would be raised. LPN #2 reported Resident #42 had a history of seizures but had not experienced seizures since admission to the facility.On 6/9/26 at 4:11 PM, during an interview with Registered Nurse (RN) #2, she confirmed Resident #42 had bed rails in use, but there was no bed rail consent or other supporting documentation. RN #2 stated consents should be obtained after bed rail assessments are completed. RN #2 confirmed that residents with bed rails in use should have an entrapment assessment and consent completed.On 6/11/26 at 1:29 PM, during an interview with the Director of Nursing (DON), she reported she was unaware that Resident #42's bed rail assessment and consent had not been completed. The DON stated all residents with bed rails in use are required to have a bed rail assessment and consent completed upon admission.On 6/11/26 at 1:37 PM, during a phone interview with the Administrator, she reported she was unaware that bed rail consents and assessments had not been completed and expected staff to complete their assigned duties.A record review of the admission Record revealed the facility admitted Resident #42 on 4/14/26 with diagnoses including Encephalopathy, Type 2 Diabetes Mellitus, and Unspecified Dementia.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/26 revealed Resident #42 had a Brief Interview for Mental Status (BIMS) Summary Score of 2, which indicated the resident was severely cognitively impaired.A record review of Resident #42's medical record revealed there was no documentation of a bed rail assessment, entrapment assessment, or consent related to the use of bed rails.

Based on interviews, record review, and facility policy review, the facility failed to ensure that all required members participated in the facility's Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI) meetings, as evidenced by the absence of the Medical Director from five (5) of (5) QAPI meetings reviewed.Findings included:A review of the facility's policy Quality Assurance and Performance Improvement Plan (QAPI), revised 12/31/18 revealed . It is the policy.to have a written QAPI plan provides guidance to all employees, all departments, and all service providers. all employees will participate in ongoing QAPI efforts which support the facilities mission focused on customer service, operational efficiency, and employee satisfaction. Procedure.all departments are involved.quality improvement.A record review of the facility's Quality Assurance Meeting sign-in sheets dated 6/30/25, 10/14/25, 1/21/26, 3/7/26, and 5/21/26 revealed the Medical Director was not present at any of the last five (5) QAPI meetings.On 6/11/26 at 12:00 PM, during an interview with the Director of Nursing (DON), she stated she had been employed at the facility since January 2026. The DON reported that the Medical Director had not attended the QAPI meeting she had participated in and had not attended either in person or by telephone.On 6/11/26 at 12:45 PM, during an interview with the Medical Director, he stated he had not attended a QAPI meeting in a long time. He reported the last QAPI meeting he attended was under the previous administration and stated the facility did not inform him of the meetings or discuss the information reviewed during the meetings.On 6/11/26 at 1:37 PM, during an interview with the Administrator, she stated she had served in her current position for four (4) years and had previously been the Business Office Manager. The Administrator reported the facility conducted QAPI meetings quarterly during the month following each quarter and stated she was unaware that the Medical Director was required to attend the meetings.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to check and record food temperatures before serving all meals for the last 30 of 30 days. Findings Included: A review of the facility's policy titled Monitoring Temperatures of Cooked Foods revealed, Policy: The temperature of potentially hazardous cooked foods will be monitored to ensure that the foods are not in the danger zone (above 41 degrees F (Fahrenheit) and below 135 degrees F) for more than six hours . Cooking, holding, and storage temperatures should be recorded on a Food Temperature Monitoring Log. These logs should be maintained for at least three (3) months. During an observation of the kitchen on 10/2/24 at 11:35 AM, it was noted that kitchen staff were serving lunch to the dining room residents from the steam table. A record review of the meal temperature logbook revealed there was no documentation for breakfast, lunch, or dinner since 9/2/24. In an interview with the Dietary Manager (DM) on 10/2/24 at 11:40 AM, she stated that the kitchen staff had not been checking or recording the meal temperatures because they did not have a logbook. She admitted that she hadn't considered using a piece of paper to log the temperatures and the logbook had just arrived the previous Friday. She stated that she had instructed the kitchen staff to begin recording meal temperatures before serving food and confirmed that no temperatures had been documented. In an interview with the Dietary [NAME] on 10/2/24 at 11:45 AM, she revealed that food temperatures had not been checked because they did not have a thermometer and stated that they had a thermometer the previous day, but it could not be calibrated. She acknowledged that temperatures were not being taken and recognized that this could pose a health risk to the residents. During a follow-up interview with the Dietary Manager on 10/2/24 at 11:52 AM, she confirmed that the thermometer from the previous day was not working and that she needed to purchase a new one. She stated that she had ordered food thermometers for the kitchen, but they had not yet arrived. She admitted that it did not occur to her to obtain a thermometer from another source. She also verified that failing to check food temperatures could result in foodborne illnesses. In an interview with the Administrator (ADM) on 10/2/24 at 11:58 AM, she confirmed that she was unaware the kitchen did not have a food thermometer and did not check food temperatures at each meal. She emphasized that the purpose of checking food temperatures is to prevent burns to the residents and to reduce the risk of foodborne illness if the food is not maintained at a certain temperature.

Based on record reviews, staff interviews, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to prevent the transmission of communicable diseases and infections. This failure was evidenced by the facility's failure to administer a second-step tuberculin (TB) skin test to one (1) of 17 residents (Resident #104) and 34 of 37 employees, who had no documentation of a negative TB skin test within the last 12 months. Findings Include: A review of the facility's policy titled TB Testing MS, with a revision date of 4/14, stated: Resident Testing for Tuberculosis .Residents .shall have a baseline Tuberculin Skin Test (TST) performed with the initial step of a two-step Mantoux TST placed within 30 days prior to the day of admission. The second step shall be administered, read, and documented within 10-21 days of the first step . Employee Testing for Tuberculosis .Employees with a negative tuberculin skin test and a negative symptom assessment shall have the second step of the two-step Mantoux tuberculin skin test administered, read, and documented in the employee's personnel record within fourteen (14) days of employment. Resident #104 A record review of Medication Details for Resident #104 revealed that she received a TB skin test prior to being admitted to the facility on [DATE]. This test was read on 8/30/24 and the result was negative. There was no documentation present indicating that Resident #104 received a second-step TB skin test. In an interview with the DON on 10/3/24 at 10:02 AM, she verified that Resident #104 did not have a second-step TB skin test. Record review of the Face Sheet revealed the facility admitted Resident #104 on 9/4/24 with a diagnosis of Essential Hypertension. Employee Testing A review of the facility's TB Skin Test Placement documentation for new hires revealed that 34 of 37 employees had no documentation of a second-step TB skin test or proof of a negative TB skin test within the last 12 months prior to hire. There was no evidence that any of these employees were offered or received a second-step TB skin test. In an interview with the Business Office Manager on 10/3/24 at 9:15 AM, she stated that she was responsible for coordinating and ensuring that new employees receive TB skin tests. She admitted that she was not aware that employees were required to have a two-step TB skin test if they did not have proof of a negative TB skin test within the last 12 months. During an interview with the Administrator (ADM) and Director of Nursing (DON) on 10/3/24 at 10:00 AM, they both stated that they had never heard that a two-step TB skin test was required for staff or residents and confirmed that the facility had always only performed one TB skin test. In an interview with the Social Worker (SW) on 10/3/24 at 10:10 AM, she explained that she is responsible for coordinating admissions and ensuring that residents have the required paperwork before admission. She stated that the first step of the TB skin test is required before admission, and one of the TB Certified Registered Nurses (RN's) is responsible for following up and completing the second-step TB skin test. The SW added that the facility used to perform a two-step TB skin test but had stopped doing so, and she was unsure why. In a follow-up interview with the ADM, on 10/3/24 at 10:15 AM, she agreed that a second-step TB skin test should have been performed on the 34 employees and Resident #104. She acknowledged that not administering a TB skin test to staff or residents could potentially spread TB within the facility.

Based on observations, staff interviews, and facility policy review, the facility failed to conceal the urine collection bag for a resident's indwelling urinary catheter, thus failing to maintain the dignity of a resident, for one (1) of two (2) residents with urinary catheters. (Resident #51). Findings Include: A review of the facility's policy titled Resident Rights revealed, It is the policy of this facility to ensure that the rights of the residents residing at this facility are upheld in the highest regard . 2. Each resident has the right to a dignified existence . During observations on 10/01/24 at 10:50 AM and 1:28 PM, it was noted that Resident #51's door was open, and an indwelling catheter bag was visible hanging on the side of the bed, without a privacy cover. In a follow-up observation and interview on 10/01/24 at 1:29 PM, Registered Nurse (RN) #1 confirmed that the catheter bag had no privacy cover and agreed that it should have been covered to maintain the resident's dignity. During an interview on 10/01/24 at 1:31 PM, the Director of Nursing (DON) verified that Resident #51's catheter bag should have been covered and stated that leaving it uncovered could cause embarrassment for the resident. A record review of the Face Sheet revealed that the facility admitted Resident #51 on 9/11/24 with diagnoses including Neuromuscular dysfunction of bladder.

Based on record review, staff interviews and facility policy review, the facility failed to accurately complete and request a Preadmission Screening and Resident Review (PASARR) for a resident with a history of mental illness for one (1) of 12 residents reviewed. Resident #106 Findings Include: Record review of the facility policy titled, Pre-Admission Screening PAS/PASRR with a revision date of 6/13 revealed under, Level II PASRR . When Level 1 screening on the PAS (Preadmission Screening) indicates possible Mental Illness or Intellectual Disability/Developmental Disability and related conditions (RC) the DOM (Division of Medicaid) will notify Proper Name to review the case. Record review of the Level 1 PAS (Pre Admission Screening) for Resident #106, with a submission date of 9/30/24, revealed under, Referral Question #28. Does resident have any history of abusing alcohol or drugs? No was marked. #31. Does resident have any history of mental illness? No was marked. #32. Does resident take, or have a history of taking psychotropic medication(s)? No was marked. Record review of the Face Sheet revealed the facility admitted Resident #106 on 9/2/24 with medical diagnoses that included Schizophrenia, Unspecified psychosis, Alcohol use unspecified with intoxication delirium, and Major Depressive Disorder. Record review of the Physician Orders for Resident #106 revealed an order dated, 9/2/24, Cymbalta (antidepressant) 60 MG (milligrams) PO (by mouth) daily. An interview with Social Services (SS) #1 on 10/2/24 at 9:20 AM revealed, she was the person responsible for completing the PAS for residents. She confirmed that she made an error when completing Resident #106's level 1 screening and stated, I did not see that she had a Schizophrenia diagnosis. SS #1 revealed she was aware the resident took an antidepressant medication, but was not aware it was considered a psychotropic medication. She revealed the resident did have a history of alcohol abuse and agreed she did not answer the questions accurately. SS #1 confirmed, if the initial level 1 screen was not completed accurately, Resident #106 might not get the mental health services needed. An interview with the Administrator (ADM) on 10/2/24 at 9:25 AM revealed, it was her expectation for the PASARR's to be completed accurately, so Resident #106 gets any specialized services indicated.

Based on observations, record review, interviews and facility policy review, the facility failed to provide adequate care and treatment to a pressure ulcer to improve healing for Resident #104, for one (1) of 1 resident reviewed for pressure ulcers. Findings Include: Review of the facility policy titled Wound Care with a revision date of 10/2/24 revealed under, Purpose: To provide standardized procedures for the prevention, identification, treatment, and ongoing management of wounds, ensuring the highest quality of care for all residents while maintaining compliance with local, state, and federal regulations . Also revealed under, a. Treatment Plan - A treatment plan will be developed by the wound care team and documented in the resident's medical record. This plan may include: - Cleansing and dressing the wound. - Use of appropriate topical medications or advanced wound care products . An interview with the Director of Nursing (DON) on 10/1/24 at 12:32 PM revealed, she was doing the wound care until the facility hired someone, and explained that Resident #104 came from home with an area like a skin tear on her bottom. She revealed the family told her the resident had the area for a while and thought it was from sitting in a chair for long periods of time. An observation of the sacral area for Resident #104, with the DON, on 10/2/24 at 12:30 PM revealed a broken area of skin that was open, round and located over a bony prominence between the upper aspects of the gluteal fold. The wound bed was 80 percent (%) red granulation tissue and 20 percent (%) white tissue (adherent slough). The wound edges were well-defined and rolled. No redness observed to the peri-wound and no sign of infection was noted. Record review of the Weekly Body Audit for Resident #104 revealed the following documentation: 9/4/24 -Superficial open area measures 1-inch mild redness around area - Lantiseptic applied signed by the DON. 9/11/24 - No redness with no change in open area Lantiseptic applied signed by the DON. 9/16/24 - No change in open area Lantiseptic applied signed by the DON. 9/24/24 - Lantiseptic applied - open area is the same and redness Duoderm ordered per Medical Director signed by the DON. Record review of the Weekly Wound Assessment for Resident #104 revealed the following documentation: Date 9/4/24, Stage 1 & (and) 2, Size .55 inch, Tissue Appearance red, Wound Edge Appearance round intact, Drainage none, Wound Pain Yes sore, Response to Treatment applied Lantiseptic signed by the DON. Date 9/9/24, Stage 1 & (and) 2, Size .55 inch Tissue Appearance red, Wound Edge Appearance round intact, Drainage none, Wound pain sore, Response to Treatment no change signed by the DON. Date 9/24/24, Stage 1 &(and) 2 Size .5-inch x 3/4 (three-fourths) inch, Tissue Appearance, red/white, Wound Appearance red and white, Wound Edges intact, Drainage none, Wound Pain sore Response to Treatment Duoderm q (every) 72 hours signed by the DON. Record review of Resident #104's Medication Administration Record (MAR) for September 2024 revealed an order dated 9/9/24, Lantiseptic Skin Protectant PRN (as needed) not initialed as administered for the month of September. Also revealed an order dated 9/24/24, Duoderm CGF (controlled gel formula) 2.5-inch x 2.5-inch dressing change every 72 hours, begin 9/24/24. An interview with the DON on 10/2/24 at 12:38 PM revealed Resident #104 admitted to the facility on [DATE] with the area of broken skin to her sacral area. She revealed that she thought the wound was a skin tear or a shearing and was not pressure related. She revealed she called the Medical Director (MD) the day the resident admitted , and he gave an order for Lantiseptic to be applied as needed. The DON acknowledged, I might not have described the wound correctly. She confirmed they had been applying Lantiseptic (barrier ointment) to the open wound from admit until 9/24/24. The DON explained that the MD assessed the wound on 9/23/24 and changed the order to Duoderm for debridement. She confirmed that Lantiseptic was not an appropriate treatment to assist with healing for an open pressure wound and confirmed this could cause deterioration in the wound. She confirmed that her documentation lacked the total area (length x width x depth) of the wound, which was needed to determine if the wound was healing or getting larger. A telephone interview with the Medical Director (MD) on 10/2/24 at 2:12 PM revealed, the first time he assessed Resident #104's sacral wound was on 9/23/24. He revealed that he did not give the wound a number (stage) and described the wound as, Red and had a white film on it. He revealed that the information that was relayed to him when the resident admitted was the wound was a stage 1 and that was why he ordered Lantiseptic. The MD explained that Lantiseptic was a barrier and reduced friction and would be beneficial for a stage 1 wound. He confirmed, after assessing the wound, he determined the wound was not a stage 1, stopped the Lantiseptic and ordered Duoderm. An interview with the Administrator (ADM) on 10/2/24 at 2:30 PM revealed she was not aware that the resident had a pressure wound. She revealed she was told the resident had something like a bite that was being treated. She confirmed Lantiseptic was not an appropriate treatment to promote healing of a pressure wound. The ADM confirmed the wound needed weekly assessments and measurements to track the status to determine if the wound was responding to the treatment or deteriorating. Record review of the Face Sheet revealed the facility admitted Resident #104 on 9/4/24 with a medical diagnosis that included Unspecified dementia.

Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident receiving an as needed (PRN) psychotropic medication had a stop date for one (1) of two (2) medication reviews. Resident #108 Findings Include: Review of the facility policy titled Psychotropic Medications for PRN (as needed) Use and Gradual Dose Reduction (GDR) Reviews undated, revealed under, Policy: . PRN use of psychotropic medications will be strictly regulated and monitored to comply with CMS (Centers for Medicare and Medicaid Services) regulations and ensure resident safety .Time Limitation: PRN orders for psychotropic medications must be limited to 14 days. After 14 days, the attending physician must review the resident's condition before extending the PRN order for continued use. This review must include a clinical evaluation to determine if continued PRN use is necessary. Record review of the September 2024 Medication Administration Record (MAR) for Resident #108, revealed an order dated 9/3/24, Lorazepam 1 MG (milligram) tablet administer 1 mg (milligram) q (every) 12 hours as needed for anxiety or agitation with no stop date. Documentation revealed the resident received doses on 9/5/24, 9/6/24, 9/11/24, and 9/20/24. An interview with the Administrator (ADM) on 10/2/24 at 9:36 AM confirmed, Resident #108's lorazepam order did not have a stop date. She confirmed the medication should have had a stop date after 14 days to ensure the resident got the least amount of medication required to control her symptoms and re-evaluated by the physician to ensure the continued need. Record review of the Face Sheet revealed the facility admitted Resident #108 on 9/2/24 with a medical diagnosis of Hemiplegia following unspecified cerebrovascular disease affecting the right dominant side.

Based on observation, interview, and facility policy review, the facility failed to label and date food stored in the refrigerator and freezer for one (1) of two (2) kitchen tours. Findings include: Record review of the Storage of Frozen Food policy, undated, revealed the facility ensures the quality and safety of frozen food through accepted storage practices. Frozen foods are dated when received. The first in, first out method is used: products with the earliest date are stored in front of products with a later date. Frozen food is stored in the original package. Record review of the Storage of Refrigerated Food policy, undated, revealed the facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. All opened foods are labeled with common name of food, date stored, and use-by-date. On 12/15/19 at 10:51 AM, observation in the kitchen, revealed a zip-lock plastic bag of squash, in the freezer, without a date or label, a plastic bag of cut broccoli, without a date or label, and eight (8) cups of pudding on a metal pan, covered with plastic wrap, were in the cooler, without a date or label. On 12/15/19 at 10:57 AM, an interview with Dietary Staff (DS) #1, confirmed the squash and broccoli were in plastic bags, without a date or label. DS #1 revealed she did not know when they were put in the freezer, she thought it might have been last week. DS #1 confirmed the pudding did not have a date, and she thought it was from 12/14/19. DS #1 revealed whoever places the food in the freezer, or cooler, is responsible for labeling it with the date. On 12/15/19 at 11:57 AM, an interview with the Dietary Manager (DM), revealed the DS called her and told her about the pudding, squash, and broccoli, not labeled or dated. The DM revealed staff knew if they find anything without a label or date, they should throw it away, no matter what it is.

Based on record review, staff interview, and facility policy review, the facility failed to develop a care plan for anticoagulant medication for two (2) of 12 resident care plans reviewed, Residents #24 and #34. Findings include: Record review of the Care Plan policy, undated, revealed a comprehensive care plan will be developed for each resident, that includes measurable, objective goals, with specific timeframes for meeting those goals. Resident #24 Record review of the comprehensive care plan for Resident #24, revealed no care plan was developed for the anticoagulant, [MEDICATION NAME], and its possible side effects, which would include bleeding. Record review of Resident #24's (MONTH) 2019 Physician Orders, revealed an order dated 11/20/19, for [MEDICATION NAME] 3 milligram (mg) daily at bedtime. Resident #34 Record review of the care plan for Resident #34, revealed a care plan for administering an anticoagulant as ordered, however, there was no care plan developed for monitoring possible side effects, which would include bleeding. Record review of Resident #34's (MONTH) 2019 Physician Orders, revealed an order dated 10/31/19, for Eliquis 5 mg twice daily. Record review of the nurse's notes, dated 10/31/19 at 11:56 AM, revealed the physician visited Resident #34, with new orders noted to send to a local clinic for an ultrasound for [MEDICAL CONDITION] to the left leg, discontinue Xarelto, and add Eliquis 5 mg twice daily. On 12/16/19 at 4:20 PM, an interview with Registered Nurse (RN) #2 revealed she is responsible for developing resident care plans. RN #2 confirmed Resident #34 did not have a care plan developed for the Eliquis medication, and Resident #24 did not have a care plan developed for taking the anticoagulant [MEDICATION NAME], or the monitoring for signs and symptoms related to taking an anticoagulant. On 12/17/19 at 10:00 AM, an interview with the Director of Nursing (DON) confirmed a care plan should be developed for any resident that is taking an anticoagulant, with interventions, which should include: monitor for bruising, bleeding or signs of bleeding, and the staff should be cautious shaving residents on an anticoagulant.

Based on record review, staff interview, and facility policy review, the facility failed to notify the physician of a change in condition for one (1) of five (5) residents observed for foot care, Resident #1. On 05/09/19, Resident #1 was observed with a detached toenail of the left 4th toe. As a result of the facility's failure to notify the MD, no orders were received for the treatment of [REDACTED].#1. Resident #1 required hospitalization , on 06/04/19, due to the development of redness, swelling, bleeding, and pus to the 4th left toe. On 06/04/19, Resident #1 was transferred to the local hospital for evaluation, and diagnosed with [REDACTED]. During the hospitalization , Resident #1 required an amputation of his 4th left toe, due to Infection, Multiple Fractures to the Left 4th Toe, and [MEDICAL CONDITION]. Findings include: Review of the facility policy titled, Change in Resident Medical Status, Resident Care-MS-06/94, revised 06/02/99, revealed, A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment. A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention; 2. A significant change in the resident's physical, mental or psychological status. An observation of Resident #1's feet, on 8/20/19 at 3:44 PM, with the Director of Nursing (DON), revealed the absence of the 4th toe on the left foot. Skin was intact with no swelling. Review of the Departmental Notes-Charge Nurse, dated 05/09/19 at 10 :45 AM, documented by LPN #2, revealed, Resident pulled toenail bed on left foot. Area cleaned and wrapped. There was no documentation the Physician or Nurse Practitioner (NP) were notified. Further review of the Departmental Notes-Charge Nurse, dated 05/31/19 at 10:52 AM,documented by LPN #1/Treatment Nurse, revealed, (Name of Physician) made rounds today. No new orders at this time. The Department Note-Charge Nurse, dated 06/04/19 at 4:48 PM, documented by LPN #2, revealed: +1 (Plus One) [MEDICAL CONDITION] noted to left foot. Nurse removes bandage wrapped around 4th toe next to pinky toe. Cyanosis. Moderate bleeding, and pus noted. 4:45 PM resident transferred to (Initials For Local Hospital) ER. Transported from w/c (wheelchair) to stretcher safely by EMT (Emergency Medical Technicians). RP (Responsible Person) notified. There was no documentation of MD notification. In an interview with LPN #1/Treatment Nurse, on 08/20/19, at 1:30 PM, she confirmed she was called into the Whirlpool Room on 05/09/19, and that Resident #1's left fourth toenail was hanging by a little piece. She stated she did not observe any blood to the toenail bed. LPN #1 said she asked Resident #1 if the toe hurt, and he said no. She stated she cleaned the nail bed with normal saline, and thought she put antibiotic ointment on it and a band aid. LPN #1 said she told the NP, that Resident #1 had pulled his toenail off and what she had done to dress it. LPN #1 stated the NP said that was fine and gave no further orders. LPN #1 said she did not document this in the medical record, or write an order for [REDACTED].#1 stated that no further treatment was needed, it really wasn't an open area and there was no swelling or deformity noted to the left 4th toe that day. LPN #1 confirmed she did not notify the physician or receive further orders when the resident's toenail was pulled off. The SA called the name of the medical clinic where the NP worked, on 8/22/19 at 10:21 AM, but was not able to speak to the NP at that time. The SA left a message with the Receptionist to have the NP return the call. The SA did not get a return call from the NP. An interview, on 08/20/19 at 1:08 AM, with LPN #2 revealed she was aware of a prior incident, on 05/09/19, in which she was called into the Whirlpool Room by CNA #1 and CNA #4/Whirlpool CN[NAME] LPN #2 said the CNAs reported Resident #1 was picking at the toenail and pulled it off. LPN #2 said she observed the toenail of the left fourth toe was detached and there was blood over the nail bed. LPN #2 said she did not observe any swelling or redness to the left 4th toe that day. LPN #2 said she called LPN #1, the Treatment Nurse, into the Whirlpool Room and LPN#1 actually dressed the toe that day. LPN #2 said she documented the incident in the nurse's note that the resident had pulled his toenail off per report by the CNAs on 05/09/19, but did not perform the dressing change, or notify the resident's Physician. During an interview with Licensed Practical Nurse (LPN) #2, on 08/20/19, at 1:53 PM, she stated she was assigned to Resident #1 on 06/04/19, but had not been assigned to Resident #1 that month. LPN #2 said she was called into the Whirlpool Room by the Certified Nursing Assistants (CNAs), but unable to recall the CNAs' names. LPN #2 reported Resident #1's left foot was very swollen, and what alarmed her was the swelling seemed to be coming from the left fourth toe. LPN #2 stated the other toes were not swollen. LPN #2 said she took a blue bandage off the left fourth toe carefully because Resident #1 was hollering out in pain. LPN #2 said she observed pus and a little blood on the bandage, and the toe appeared deformed and blue. LPN #2 said she had no knowledge of any treatment ordered for the left fourth toe. An interview with the Medical Doctor (MD) for Resident #1, on 08/21/19, at 9:09 AM, revealed he was not notified of the detached toenail on 05/09/19, and the NP should have notified him. The MD stated he had seen the resident on 05/31/19, and he looked at his ankles for [MEDICAL CONDITION], but did not remove his shoes. The MD stated the staff did not report any problems to him and he had not given any orders for a bandage to the left 4th toe. He recalled being surprised when he was told of the amputation, and stated that the staff should notify him of any incidents and he had concerns he was not being notified. The MD stated that he recently held a meeting with the facility staff about reporting and was trying to come up with better procedures and protocols for reporting. Record review of the second receiving hospital Emergency Department (ED) History and Physical, dated 6/4/19, at 9:00 PM, revealed Resident #1 was brought into the ED with severe swelling and redness of the left foot, and severe swelling and redness of the left fourth toe, a foul smell to the left foot and a laceration of the plantar surface of the left fourth digit. and, suspected [MEDICAL CONDITION] fourth toe. X-ray of the left foot, on 06/04/19, revealed, Fourth toe fractures with widened distal interphalangeal joint (DIP). The resident required multiple antibiotics in the ED and the wound was aggressively washed out. It was unable to be closed due to MD documentation that the wound was old and would require additional evaluation and wash out. The resident was admitted to the hospital with [REDACTED]. Orthopedic was consulted. Review of the (Name of Regional Hospital) Discharge Summary, dated 06/16/19, revealed Resident #1 was admitted to the hospital from a local nursing home for left foot infections. The resident was successfully treated and underwent amputation of 3rd-4th left toes. (Observation of Resident #1's feet during the survey revealed only the 4th left toe was amputated). Record review of Ultra Sound Lower Extremity Arterial Duplex Bilateral, performed on 06/11/19, revealed only mild [MEDICAL CONDITION] changes. Left ankle pressure was unobtainable. No other evidence of hemodynamically significant stenosis in either lower extremity was found. Resident #1 was discharged back to the nursing home on 06/13/19. Record review of a Resident Incident Report, dated 06/04/19 at 4:15 PM, revealed, Type of Injury: Localized tissue [MEDICAL CONDITION]. The Narrative of incident and description of injuries: Nurse summoned to shower room. [MEDICAL CONDITION] noted to left foot leading to fourth toe with bandage wrapped around. Pus and blood noted to bandage. Nurse carefully removed bandage. Cyanosis and moderate bleeding noted. Pain scale of 9. (Name of local hospital's emergency room ) nurse called. The Incident Report was signed and dated 06/06/19, by Licensed Practical Nurse (LPN) #2. The Incident Report documented the resident's family was notified on 06/04/19 at 5:00 PM, but no documentation that the physician was notified. Review of Resident #1's Physician's Orders and Electronic Treatment Administration Records (ETARs) for May, June, July, and (MONTH) 2019 revealed no orders or treatment for [REDACTED]. An interview with the Director of Nursing (DON) on 8/21/19, at 2:06 PM, revealed it is the facility policy that the MD should be notified of any changes in the resident's condition and the policy was not followed for Resident #1's toenail. She stated LPN #1 should have followed up on it, and also should have reported it to the RN and MD. The DON stated she was not in the building, on 05/09/19, when Resident #1's toenail was detached, or on 06/04/19, when the worsening condition of the toe was discovered. The DON stated RN #1 was the supervisor while she was out, and would have been responsible for following up on the incident. An interview with the Administrator, on 08/21/19, at 3:30 PM, revealed Resident #1 was self-propelled in his wheelchair and it was reported to him by staff that earlier in the day on 06/04/19, the resident had been going about his normal routine with no complaints of pain until the left foot was noted to be swollen in the shower room. He stated an incident report should have been done for the detached toenail on 05/09/19, the MD should have been notified, and a doctor's order obtained for treatment of [REDACTED]. The Administrator stated the staff should have followed up on the toe from 05/09/19. Record review of the Face Sheet revealed Resident #1 was admitted by the facility, on 01/25/18, with a [DIAGNOSES REDACTED]. Review of the Physician Orders for the month of (MONTH) 2019, revealed current [DIAGNOSES REDACTED]. Record review of the 30 Day Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/11/19, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognitive skills for daily decision making. Section G of the assessment revealed that the resident required extensive assistance of two (2) persons for bed mobility, dressing, and toileting and that he was totally dependent for bathing.

Based on record review, staff interview, and facility policy review, the facility failed to provide necessary care and services to prevent neglect for one (1) of five (5) residents reviewed for wounds/skin alterations, Resident #1. The facility identified a detached toenail to Resident #1's left 4th toe, on 05/09/19, and failed to perform assessments and provide treatments to the toenail to prevent further skin alteration. On, 06/04/09, the facility identified a wound to the left 4th toe with redness, swelling, moderate bleeding, and pus. Resident #1 was sent to the local hospital for evaluation, and then transferred to the regional hospital for surgical intervention. Resident #1 was diagnosed with [REDACTED]. Resident #1 was admitted to the hospital and received intravenous (IV) antibiotics for infection. Resident #1 required an amputation to the Left 4th toe during the hospitalization . Resident #1 returned to the facility on [DATE]. Findings include: Review of the facility's policy titled, Abuse and Neglect, revised 12/31/17, revealed, POLICY: It is the policy of the facility to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Definitions-Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Prevention: The facility will identify, perform ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. An observation of Resident #1, with the Director of Nursing (DON), on 08/20/19 at 3:44 PM, revealed the absence of the 4th toe on Resident #1's left foot. The skin was intact with no swelling. Treatment Administration Records (ETARs) for May, June, July, and (MONTH) 2019, revealed no orders or treatment for [REDACTED]. Review of Resident #1's Physician's Orders revealed an order dated, 05/21/18, for Weekly Body Audits, and on 01/25/18, for toenail care by RN PRN. Review of the Departmental Notes-Charge Nurse, dated 05/09/19 at 10 :45 AM, documented by LPN #2, revealed, Resident pulled toenail bed on left foot. Area cleaned and wrapped. There was no documentation the Physician or NP were notified. Record review of the Departmental Notes, from 05/09/19 until 06/04/19, revealed no documentation of any concerns regarding Resident #1's left 4th toe. The documentation of skin assessments reflected that Resident #1's skin was intact, with the exception, on 05/21/19, when a skin tear was noted on an unspecified arm. Review of the Departmental Notes-Charge Nurse, dated 05/31/19 at 10:52 AM, documented by LPN #1/Treatment Nurse, revealed, (Name of Physician) made rounds today. No new orders at this time. The Department Note-Charge Nurse, dated 06/04/19 at 4:48 PM, documented by LPN #2, revealed: +1 (Plus One) [MEDICAL CONDITION] noted to left foot. Nurse removes bandage wrapped around 4th toe next to pinky toe. Cyanosis. Moderate bleeding, and pus noted. 4:45 PM resident transferred to (Initials For Local Hospital) ER. Transported from w/c (wheelchair) to stretcher safely by EMT (Emergency Medical Technicians). Record review of a Resident Incident Report, dated 06/04/19 at 4:15 PM, revealed localized tissue [MEDICAL CONDITION] to Resident #1's left toe. The report documented: Nurse summoned to shower room. [MEDICAL CONDITION] noted to left foot leading to fourth toe with bandage wrapped around. Pus and blood noted to bandage. Nurse carefully removed bandage. Cyanosis and moderate bleeding noted. Pain scale of 9. (Initials of Local Hospital emergency room ) nurse called. The Incident Report was signed and dated 06/06/19, by Licensed Practical Nurse (LPN) #2. The Incident Report documented the resident's family was notified on 06/04/19 at 5:00 PM. Further review of the Incident Report revealed Transportation by: (local) Emergency Medical Technician to local ER. Review of the Resident Incident Followup, no name or date on the form, revealed the 24 Hour Followup for the condition and injury appearance stated the left 4th toe was amputated due to pathological fracture. Additional Followup stated the resident returned from the hospital on [DATE], with orders to clean the left 4th toe with sterile water and cover with 2 x 2 and Kling. Review of the facility's Investigation, dated 06/04/19, revealed Certified Nursing Assistant (CNA) #3 noted Resident #1's 3rd left toe was red and warm, bleeding was noted under the third toe, and there was an open area under the 3rd left toe. (An interview, on 08/20/19 at 1:13 PM, with the Administrator revealed he had documented the wrong toe, should have been the 4th toe). The report documented: Small [MEDICAL CONDITION] through the base of the distal phalanx (end of toe) of the third toe. The report revealed Resident #1 propelled himself in a wheelchair. The Nurse Practitioner (NP) assessed the wound on 06/04/19, and stated he believed it could be due to trauma or athlete's foot. The NP also noted the resident had poor circulation. The last Body Audit was done on 05/28/19 by LPN #1, and she noted skin was intact. Body Audits were performed on all residents between 06/03/19 and 06/07/19. (Record review after this report, revealed Resident #1's Body Audit on 06/04/19 by LPN #1/Treatment Nurse revealed his skin was intact. LPN #1 documented a Body Audit,on 06/12/19, that documented Resident #1's skin was intact, and the resident was in the hospital at this time). Record review of the (local hospital) emergency room Note, dated 06/04/19, at 5:03 PM, revealed upon physical exam by the Medical Doctor, Extremities remarkable for swelling of the left foot and calf. There is [DIAGNOSES REDACTED] primarily of the distal foot, and the toes. There is an open wound on the plantar surface, at the proximal joint of the left forth toe. Wound goes all the way across the joint, and it is deep, possibly extending to bone. Impression: [MEDICAL CONDITION], wound infection, Plan: Transfer for surgical attention. Start antibiotics prior to transfer, unless he can be moved quickly. Record review revealed that Resident #1 was transferred to a regional hospital by ambulance on 06/04/19, at 5:43 PM. Record review of the regional/second receiving hospital Emergency Department (ED) History and Physical, dated 06/04/19, at 9:00 PM, revealed Resident #1 was brought into the ED with severe swelling and redness of the left fourth toe, with suspected [MEDICAL CONDITION] fourth toe. X-ray of the left foot on 06/04/19, revealed, Fourth toe fractures with widened distal interphalangeal joint (DIP). Physical examination revealed, Foul smell from the left foot. Laceration of the plantar surface at the left fourth digit at the metatarsophalangeal joint (MTP) Musculoskeletal: Ankle/foot: Diffuse swelling of the left fourth digit, foot, [DIAGNOSES REDACTED]tous, laceration as above. Foul smell area of [DIAGNOSES REDACTED] to that digit and diffusely over the dorsal aspect of the left foot. Multiple antibiotics were given in the ED on 06/04/19. Review of the hospital's Discharge Summary, dated 06/13/19, revealed Resident #1 was admitted to the hospital, on 06/04/19, with [DIAGNOSES REDACTED]. Orthopedic was consulted and the resident underwent [REDACTED]. Record review of Ultra Sound Lower Extremity Arterial Duplex Bilateral, performed on 06/11/19, revealed only mild [MEDICAL CONDITION] changes. Left ankle pressure was unobtainable. No other evidence of hemodynamically significant stenosis in either lower extremity was found. Resident #1 was discharged back to the nursing home on 06/13/19. An interview, with Certified Nursing Assistant (CNA) #2, on 08/21/19 at 1:06 PM, revealed on 06/04/19, she was in the Whirlpool Room, and she said to CNA #3, Look at that man's toe, how did they miss that. CNA #2 said when she saw it, it was just hanging by a thread. She stated Resident #1 had been refusing baths, and that was why she hadn't seen it until that day. CNA #2 said Resident #1 did not act like the toe hurt him. CNA #2 reported Resident #1 usually got his baths in the evening due to he attended a daytime activity usually till 2:00 PM. An interview, with CNA #3, on 08/21/19, at 1:15 PM, revealed she did not remember Resident #1's toenail falling off. CNA #3 said they were bathing Resident #1 on 06/04/19, and noticed his left foot was swollen, and they (CNAs) reported it to the nurse. CNA #3 said the toe was reddish looking and that the toe didn't look good at all. It kinda (sic) scared me, it was something like I'd never seen before. It looked like it was going to pop or something. CNA #3 stated there was a blue bandage wrapped around the 4th toe of the left foot. CNA #3 reported Resident #1 would pick at his toenails and he would sometimes have a bandage on the toe he was picking at the time. CNA #3 said Resident #1 had refused baths a couple of times and that was why she had not seen his feet. She stated he never complained of anything and always had socks on when she put him to bed. An interview, on 08/20/19 at 1:22 PM, revealed CNA #1/Whirlpool CNA stated she remembered Resident #1's toe was bleeding, and she called the nurse. She thinks it was LPN#2. CNA #1 said she could not remember the date of the incident. CNA #1 said she did not recall seeing Resident #1's feet because he refused a tub bath and preferred to keep his socks on. Record review of Resident #1's Completed Care Tasks, revealed the resident received a shower bath on 05/09/19, 05/11/19, 05/18/19, 05/21/19, and 05/25/19. A sponge bath on 5/14/19, 05/28/19 and 6/01/19. Skip baths due to medical condition on, 05/17/19, 05/31/19, and 06/05/19. A whirlpool bath on 05/23/19. Review of Resident #1's Daily Care Guide revealed the resident was as risk for skin problems. Bath assistance was two (2) person physical assist. Whirlpool bath on Tuesdays, Thursday, and Saturdays, and offer sponge bath on opposite days. Mobile via wheelchair. During an interview with LPN #2, on 08/20/19 at 1:08 PM, LPN #2 stated she was aware of the prior incident, on 05/09/19, in which she was called into the Whirlpool Room by the CNAs due to Resident #1's toenail of the left fourth toe was detached and that there was blood over the nail bed. LPN #2 said there was no swelling or redness to the left 4th toe that day, and she called LPN #1, the Treatment Nurse, into the Whirlpool Room. LPN #2 reported LPN #1 dressed the toe that day. LPN #2 said she documented in the nurses note Resident #1 had pulled his toenail off per report by the CNAs, on 05/09/19, and she did not perform the dressing change. LPN #2 said she did not notify the Medical Doctor of the detached toenail or get an order for [REDACTED].>Interview with Licensed Practical Nurse (LPN) #2, on 08/20/19, at 1:53 PM, revealed she was the nurse assigned to Resident #1 on 06/04/19, and was called into the Whirlpool Room by the CNAs. LPN #2 reported Resident #1's left foot was very swollen, and what alarmed her was that the swelling seemed to be coming from the left 4th toe. LPN #2 said the other toes were not swollen. LPN #2 said there was a blue bandage on the left 4th toe, and she removed the blue bandage carefully. LPN #2 said she observed pus and a little blood on the bandage, and the toe appeared deformed and blue. LPN #2 said she had no knowledge of any treatment ordered for the left 4th toe. On 08/20/19 at 1:30 PM, an interview with LPN #1/Treatment Nurse, revealed she was called to the Whirlpool Room, on 05/09/19, by a CNA and observed Resident #1's left fourth toenail was hanging by a little piece. LPN #1 stated she did not observe any blood to the toenail bed. LPN #1 stated she cleaned the nail bed with normal saline, and she thought she put antibiotic ointment on it and a band aid. LPN #1 stated she told the Nurse Practitioner (NP) that Resident #1 had pulled his toenail off and what she had done to dress it. LPN #1 stated the NP said that was fine and gave no further orders, but she did not document this in the medical record. LPN #1 said the following day, she took the band aid off and cleaned the nail bed again and it was fine. LPN #1 confirmed no further treatment was needed, due to it really wasn't an open area and there was no swelling or deformity noted to the left 4th toe that day. LPN #1 stated in regards to the incident, on 06/04/19, she was already gone for the day when the Social Worker called her reporting that Resident #1 was taken to the emergency room (ER). LPN #1 stated she had performed body audits on Resident #1 weekly while he was in the Whirlpool Room, and she documented a body audit in the medical record, on 06/04/19, that Resident #1's skin was intact. LPN #1 said she had heard the left foot was wrapped and LPN #2 or a Whirlpool CNA had removed the dressing. LPN #1 revealed she did not know who had applied a dressing to the foot. LPN #1 said someone had to have seen it before that day, wrapped it, and not told her. LPN #1 stated she went to talk to the NP to ask how it got that bad that fast and the NP said he could have hit it on something or it could have been athletes foot fungus, but she thought it was determined a fracture. LPN #1 stated she was responsible for skin audits and she usually does them in the Whirlpool Room. LPN #1 said she looks at the resident's face, front and back, and the feet. LPN #1 stated, I wouldn't have missed that. Review of Resident #1's Skin Inspection Reports, dated 05/07/19, 05/14/19, 05/21/19, and 06/04/19 revealed the skin was intact. The skin inspections were documented by LPN #1/Treatment Nurse. LPN #1 documented a Skin Inspection Report on 06/12/19, that stated the skin was intact. Resident #1 was in the hospital on [DATE]. In an interview, on 08/21/19 at 1:45 PM, LPN #1 confirmed she documented a skin audit for Resident #1, on 06/04/19, but she actually did not do a skin inspection. LPN #1 said sometimes she would write the body audits down, and then go the the computer and log them in. LPN #1 said she thinks she may have clicked the wrong name. LPN #1 said these skin reports were done on Tuesdays, even though the Physician's Orders were for Thursdays. An interview, with LPN #3 on 08/21/19, revealed she was not aware that Resident #1's left 4th toe nail had come off. LPN #3 recalled LPN #2 called her into the Whirlpool Room on 06/04/19. LPN #3 said Resident #1's left 4th toe was big and red, and his whole left foot was red and swollen. LPN #3 said she looked at the foot and toe, and said, you need to send him out. An interview with the Medical Doctor (MD) for Resident #1, on 08/21/19, at 9:09 AM, revealed he was not notified of the detached toenail on 05/09/19, and he recalled being surprised when he was told of the amputation. The MD confirmed he had not given any orders for a bandage to the left 4th toe. The MD stated he had seen the resident on 05/31/19, and he looked at his ankles for [MEDICAL CONDITION], but did not remove his shoes. The MD stated there was a concern regarding notification of changes. Review of the MD's Nursing Home Visit note, dated 05/31/19 at 9:36 AM, revealed no swelling to the right or left foot. Nursing staff was present during the visit and all concerns were reviewed. Will continue current plan of care and treatment. During an interview with the Director of Nursing (DON), on 08/21/19 at 2:06 PM, she revealed the facility's policy was not followed for Resident #1's toenail injury, due to the MD should be notified of any changes in the resident's condition. The DON stated LPN #1 should have followed up on the injury and should have reported it to the Registered Nurse (RN) and MD. The DON stated she was not in the building, on 05/09/19, when Resident #1's toenail detached, or on 06/04/19, when the worsening condition of the toe was discovered. The DON stated RN #1 was the supervisor while she was out, and would have been responsible for following up on the incidents. During the interview with Registered Nurse (RN) #1, on 08/21/19, at 9:57 AM, she stated, I didn't know about the toenail. I remember discussing it after he went to the hospital on [DATE]. Further interview, on 8/21/19, at 3:16 PM, and record review of the Electronic Treatment Administration Records (ETARs), with RN #1, revealed no toenail care was documented on the (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 eTARs. RN #1 stated, Just whatever RN is doing toenail care would do it. Usually on the weekends. I guess it wasn't done. If it's not documented, it's not done. The interview with the Administrator, on 08/20/19 at 1:13 PM, revealed the facility did not do an Accident/Incident Report, on 05/09/19, regarding Resident #1's left 4th toe nail. The Administrator confirmed there was no Physician's Orders for the left 4th toe wound care. Further interview with the Administrator, on 08/21/19 at 3:30 PM, revealed an incident report should have been done on 05/09/19, the MD should have been notified, and a doctor's order obtained for treatment of [REDACTED]. The Administrator also said the staff should have followed up on the toe from 05/09/19, after the nail was detached. The Administrator revealed in-services were began, on 06/05/19, with Nursing Services for treatments, orders, and reporting injuries when they were found, and the Quality Assurance Team met to review this incident on 06/07/19. Review of the Face Sheet revealed the facility admitted Resident #1 on 01/25/18, with a [DIAGNOSES REDACTED]. Current [DIAGNOSES REDACTED]. Review of the 30 Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/19, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS)score of 3, indicating severely impaired cognitive skills for daily decision making.

Based on staff interview, record review, and facility policy review, the facility failed to develop and implement a plan of care, which included accurate skin assessments and treatments for Resident #1's left fourth (4th) toenail detachment, identified by the facility on 05/09/19, which resulted in infection and amputation of the resident's toe. This concern was identified for one (1) of five (5) resident care plans reviewed. Findings include: Review of the facility's policy titled, Care Plan, undated, revealed, Policy: It is the policy of the facility that the interdisciplinary team, in accordance with the resident and his/her family and/or responsible party, as appropriate, will develop a comprehensive care plan for each resident that includes measurable goals, objective goals with specific timeframes for meeting those goals. The interventions developed in the care plan will be followed to meet the resident's medical, nursing, dietary, and psychosocial needs to maximize the resident's level of functioning and quality of life. Review of Resident #1's Care Plan, dated 02/05/18, revealed a potential for impaired skin integrity. The Goal included the resident would not have any skin breakdown or alterations. The most recent Target Dates were 10/26/19, 08/09/19, and 04/30/19. The Approaches included: Ensure staff observes the resident's skin daily with routine care and notifies the nurse so the nurse can notify the doctor. Ensure Body Audits are done at least once a week by a nurse. Further review of the Care Plan revealed there was no documentation for the identification of the detached toenail on 05/09/19, or the hospitalization on [DATE], and amputation of the Left 4th Toe. The Care Plan also did not address the behavior of Resident #1 picking his toenails. An interview, on 08/20/19 at 1:30 PM, revealed LPN #1/Treatment Nurse, confirmed she was called to the Whirlpool Room on 05/09/19, by a CN[NAME] LPN #1 said she observed Resident #1's left 4th toenail was hanging by a little piece. LPN #1 said she did not see any blood on the toenail bed. LPN #1 said she cleaned the nail bed and applied a band aid, but did not document in the medical record. LPN #1 stated she cleaned the toenail area the next day without any open areas noted. LPN said she did not observe any swelling or deformity to the left 4th toe at the time. LPN #1 stated she had already gone for the day, on 06/04/19, when the Social Worker called her to report Resident #1 was taken to the ER. LPN #1 stated she had performed body audits on Resident #1 weekly in the Whirlpool Room and that she had documented a body audit in the medical record as Skin Intact on 06/04/19. LPN #1 stated she was responsible for skin audits and that she usually does them in the Whirlpool Room. LPN #1 confirmed during a body audit she would look at the resident's face, front and back side, and the feet and that she wouldn't have missed the toe (if it looked bad). An interview conducted with LPN #2, on 08/20/19 at 1:08 PM, revealed she was not aware of any treatments at this time for Resident #1's toe. LPN #2 stated the CNA told her Resident #1 had pulled his toenail off while in the whirlpool room on 5/9/19. LPN #2 stated she assessed the toenail and found the toenail was detached, with blood over the nail bed. LPN #2 said she did not observe any swelling or redness to the left 4th toe at that time, and called LPN #1/Treatment Nurse to the Whirlpool Room, who dressed the toe. LPN #2 said she made a note in the nurse's notes regarding the resident pulling the toenail off, but did not document physician notification or get orders for treatment. An interview, with CNA #3, on 08/21/19, at 1:15 PM, revealed they were bathing Resident #1 on 06/04/19, and noticed his left foot was swollen, and reported it to the nurse. CNA #3 said the toe was reddish looking and that the toe didn't look good at all. It kinda (sic) scared me, it was something like I'd never seen before. It looked like it was going to pop or something. CNA #3 stated there was a blue bandage wrapped around the 4th toe of the left foot. CNA #3 reported that Resident #1 would pick at his toenails and he would sometimes have a bandage on the toe he was picking at the time. CNA #3 said Resident #1 had refused baths a couple of times and that was why she had not seen his feet. She stated he never complained of anything and always had socks on when she put him to bed. Record review of the regional receiving hospital Emergency Department (ED) History and Physical, dated 06/04/19, at 9:00 PM, revealed Resident #1 was brought to the ED with severe swelling and redness of the left fourth toe, with suspected fracture. X-ray of the left foot, on 06/04/19, revealed fractures of the left 4th toe. Physical exam revealed a foul smell from the left foot, a laceration of the plantar surface of the 4th toe and diffuse swelling of the left 4th toe and foot. Multiple antibiotics were given in the ED on 06/04/19. The resident was admitted to the hospital with [REDACTED]. Orthopedic was consulted and the resident underwent [REDACTED]. Resident #1 was discharged back to the nursing home on 06/13/19. During an interview, Licensed Practical Nurse (LPN) #2, on 08/20/19, at 1:53 PM, stated she was called into the Whirlpool Room on 06/04/19, by the Certified Nursing Assistant (CNA). LPN #2 said Resident #1's left foot was very swollen, and she was alarmed the swelling was coming from the left 4th toe. LPN #2 said there was a blue bandage on the left 4th toe, and when she removed the bandage, there was pus and a little blood on the bandage. LPN #1 said the toe looked deformed and blue. Review of Resident #1's Skin Inspection Reports, dated 05/07/19, 05/14/19, 05/21/19, and 06/04/19 revealed the skin was intact. The skin inspections were documented by LPN #1/Treatment Nurse. LPN #1 documented a Skin Inspection Report on 06/12/19, that stated the skin was intact. Resident #1 was in the hospital on [DATE]. In an interview, on 08/21/19 at 1:45 PM, LPN #1 confirmed she documented a skin audit for Resident #1, on 06/04/19, but she actually did not do a skin inspection. LPN #1 said sometimes she would write the body audits down, and then go the the computer and log them in. LPN #1 said she thinks she may have clicked the wrong name. LPN #1 said these skin reports were done on Tuesdays, even though the physician's orders [REDACTED]. There was no documented care plan in the medical record regarding the toenail detachment, assessments of the nail bed, or treatments to the nail bed. During an interview with Registered Nurse (RN) #1/ Minimum Data Set (MDS)/Care Plan Nurse, she revealed the toenail detachment, on 05/09/19, should have been care planned. She stated she did not know about the toenail until after Resident #1 was sent to the hospital on [DATE]. RN #1 stated it is the policy of the facility to update care plans every three (3) months with the MDS or develop a new one anytime there is a change with a resident's plan of care, for example a fall, skin problem, change in medicine or a new diagnosis. RN #1 confirmed the [MEDICAL CONDITION] resulting in the amputation of the left 4th toe, the resulting surgical incision aftercare, his toenail picking behavior, and his potential for injury were not care planned on his re-admission to the facility on [DATE]. RN #1 stated it is the policy of the facility to develop a new care plan for a new problem and that the policy was not followed. Record review of the Face Sheet revealed Resident #1 was admitted by the facility, on 01/25/18, with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Record review of the 30 Day Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 07/11/19, revealed in Section C that the resident had a Brief Interview for Mental Status score of 3, indicating severely impaired cognitive skills for daily decision making. Section G of the assessment revealed that the resident required extensive assistance of two (2) persons for bed mobility, dressing, and toileting and that he was totally dependent for bathing.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure proper foot treatment and care to prevent complications for one (1) of five (5) residents reviewed for foot care, Resident #1. Resident #1 had a detachment/injury to the left fourth (4th) toe on 05/09/19. On 06/04/19, due to the facility's lack of foot/skin care, treatment, and accurate assessments of the left 4th Toe, Resident #1 was admitted to the hospital for Severe [MEDICAL CONDITION], Infection, and Multiple Fractures to the Left Toe. Resident #1 required an amputation of the Left 4th Toe during the hospitalization . Findings include: Review of the facility's policy titled, Skin Care Policy & Procedure, latest revision 04/11, revealed: It is the policy of this facility that skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components. Those are: I. Prevention, Evaluation and Screening, II. Ongoing Surveillance, III. Treatment Orders, IV. Treatment Regimen. Overseeing these efforts will be the Director of Nursing, who will have ultimate responsibility of ensuring that this policy is applied consistently. I. Prevention, Evaluation and Screening- Lesion which are present, or which develop later will be followed carefully and treated according to medical direction. This will be accomplished by making rounds weekly on all residents through weekly body audits. II. Ongoing Surveillance: [NAME] Documentation, reporting and treatment of [REDACTED]. III. Treatment Orders: [NAME] After observation/evaluation of the affected skin area, notify physician for the treatment order. IV. Treatment Regimen: treatment for [REDACTED]. [NAME] Carefully document condition. B. The physician's order is sought for both direct care to the problem by nursing personnel and for any associated treatments. C. 9. Skin problems will be incorporated in the interdisciplinary plan of care along with approaches so that the entire staff has an increased awareness of those special needs. An observation, with the Director of Nursing (DON), on 08/20/19 at 3:44 PM, of Resident #1's feet revealed the absence of the 4th toe on the left foot. The skin was intact with no swelling. Review of the Departmental Notes-Charge Nurse, dated 05/09/19 at 10 :45 AM, documented by LPN #2, revealed, Resident pulled toenail bed on left foot. Area cleaned and wrapped. There was no documentation the Physician or NP were notified and there were no orders for treatment. The Department Note-Charge Nurse, dated 06/04/19 at 4:48 PM, documented by LPN #2, revealed: +1 (Plus One) [MEDICAL CONDITION] noted to left foot. Nurse removes bandage wrapped around 4th toe next to pinky toe. Cyanosis. Moderate bleeding, and pus noted. 4:45 PM resident transferred to (Initials for Local Hospital) ER. There was no MD notification documented. Record review of the Departmental Notes, from 05/09/19 until 06/04/19, revealed no documentation of the left 4th toe, and that Resident #1's skin was intact, with the exception, on 05/21/19, when a skin tear was noted on an unspecified arm. Review of Resident #1's Physician's Orders and Electronic Treatment Administration Records (ETARs) for May, June, July, and (MONTH) 2019 revealed no orders or treatment for [REDACTED]. The Physician's Orders revealed an order dated, 05/21/18, for Weekly Body Audits, and on 01/25/18 for toenail care by RN PRN. On 8/21/19, at 3:16 PM, an interview and record review of the Electronic Treatment Administration Records (eTARs) with RN #1 revealed no toenail care was documented on the (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 eTARs. RN #1 stated, Just whatever RN is doing toenail care would do it. Usually on the weekends. I guess it wasn't done. If it's not documented, it's not done. Record review of the Resident Incident Report, dated 06/04/19 at 4:15 PM, revealed, the nurse was called to the shower room where Resident #1's left foot was assessed with [REDACTED]. Pus and blood was noted to the bandage. Cyanosis and moderate bleeding noted. Pain scale of 9 out of 10. Resident #1 was transported to the emergency room . The Incident Report was signed and dated 06/06/19, by Licensed Practical Nurse (LPN) #2. Review of the Resident Incident Followup, no name or date on the form, revealed the 24 Hour Followup for the condition and injury appearance documented the left 4th toe was amputated due to pathological fracture. Record review of the facility's Investigation, dated 06/04/19, and signed by the Administrator, revealed: Small [MEDICAL CONDITION] through the base of the distal phalanx (end of toe) of the third toe. Resident #1's mobility was by propelling himself in a wheelchair. The Nurse Practitioner (NP) assessed the wound on 06/04/19, and stated he believed it could be due to trauma or athlete's foot. The NP also noted the resident had poor circulation. The last Body Audit was done on 05/28/19, by LPN #1, and she noted skin was intact. Body Audits were performed on all residents between 06/03/19 and 06/07/19. (Record review after this report, revealed Resident #1's Body Audit on 06/04/19 by LPN #1/Treatment Nurse revealed his skin was intact). Record review of the (local hospital) emergency room Note, dated 06/04/19, at 5:03 PM, revealed upon physical exam by the Medical Doctor, Extremities remarkable for swelling of the left foot and calf. There is [DIAGNOSES REDACTED] primarily of the distal foot, and the toes. There is an open wound on the plantar surface, at the proximal joint of the left forth toe. Wound goes all the way across the joint, and it is deep, possibly extending to bone. Impression: [MEDICAL CONDITION], wound infection, Plan: Transfer for surgical attention. Start antibiotics prior to transfer, unless he can be moved quickly. Record review revealed that Resident #1 was transferred to a regional hospital by ambulance on 06/04/19, at 5:43 PM. Record review of the regional/second receiving hospital Emergency Department (ED) History and Physical, dated 06/04/19, at 9:00 PM, revealed Resident #1 was brought into the ED with severe swelling and redness of the left fourth toe, with suspected [MEDICAL CONDITION] fourth toe. X-ray of the left foot on 06/04/19, revealed, Fourth toe fractures with widened distal interphalangeal joint (DIP). Physical examination revealed, Foul smell from the left foot. Laceration of the plantar surface at the left fourth digit at the metatarsophalangeal joint (MTP) Musculoskeletal: Ankle/foot: Diffuse swelling of the left fourth digit, foot, [DIAGNOSES REDACTED]tous, laceration as above. Foul smell area of [DIAGNOSES REDACTED] to that digit and diffusely over the dorsal aspect of the left foot. Multiple antibiotics were given in the ED on 06/04/19. Review of the hospital's Discharge Summary, dated 06/13/19, revealed Resident #1 was admitted to the hospital, on 06/04/19, with [DIAGNOSES REDACTED]. Orthopedic was consulted and the resident underwent [REDACTED]. Record review of Ultra Sound Lower Extremity Arterial Duplex Bilateral, performed on 06/11/19, revealed only mild [MEDICAL CONDITION] changes. Left ankle pressure was unobtainable. No other evidence of hemodynamically significant stenosis in either lower extremity was found. Resident #1 was discharged back to the nursing home on 06/13/19. An interview with LPN #2, on 08/20/19 at 1:08 PM, revealed there was an incident on 05/09/19, in which she was called into the Whirlpool Room by the CNA because the toenail of Resident #1's left fourth (4th) toe was detached and there was blood over the nail bed. LPN #2 stated she did not observe any swelling or redness to the left 4th toe that day. LPN #2 said she called the Treatment Nurse/LPN #1, into the Whirlpool Room and LPN#1 dressed the toe that day. LPN #2 said she documented in the nurses note Resident #1 had pulled his toenail off per report by the CNAs, on 05/09/19, but she did not perform the dressing change. LPN #2 did not document the physician was notified of the incident, or an order for [REDACTED].>On, 08/20/19 at 1:30 PM, an interview with LPN #1/Treatment Nurse confirmed she was called to the Whirlpool Room, on 05/09/19, by the CNA due to Resident #1's left fourth toenail was hanging by a little piece. LPN #1 stated she did not observe any blood to the toenail bed. LPN #1 said she cleaned the nail bed with normal saline, and she thought she put antibiotic ointment on it and a band aid. LPN #1 stated she told the Nurse Practitioner (NP) that Resident #1 had pulled his toenail off and what she had done to dress it. LPN #1 stated the NP said that was fine and gave no further orders. LPN #1 stated she did not document this in the medical record. LPN #1 said the following day, she took the band aid off and cleaned the area again and it was fine. LPN #1 confirmed no further treatment was needed due to it really wasn't an open area and there was no swelling or deformity noted to the left 4th toe that day. LPN #1 stated she was already gone for the day when the Social Worker called her reporting that Resident #1 was taken to the emergency room (ER) on 6/4/19. LPN #1 confirmed she performed weekly body audits on Resident #1 while he was in the Whirlpool Room. LPN #1 confirmed she documented a body audit in the medical record, on 06/04/19, that stated Resident #1's skin was intact. LPN #1 said she had heard the left foot was wrapped and LPN #2 or a Whirlpool CNA had removed the dressing. LPN #1 revealed she did not know who had applied a dressing to the foot. LPN #1 said someone had to have seen it before that day, wrapped it and not mention it to her. LPN #1 reported she went to talk to the NP to ask how it got that bad that fast and the NP said he could have hit it on something, or it could have been athletes foot fungus, but she thought it was determined it was a fracture. LPN #1 stated she was responsible for skin audits and she usually did the skin audits in the Whirlpool Room. LPN #1 said she looks at the resident's face, front and back, and the feet. LPN #1 stated, I wouldn't have missed that. The interview with Certified Nursing Assistant (CNA) #2, on 08/21/19 at 1:06 PM, revealed she was with Resident #1 in the Whirlpool Room, on 06/04/19, and she said to CNA #3, Look at that man's toe, how did they miss that. CNA #2 said when she saw it, it was just hanging by a thread. CNA #2 said Resident #1 had been refusing baths, and that was why she hadn't seen it until that day. During an interview on 08/21/19 at 1:15 PM, CNA #3 stated Resident #1 was in the Whirlpool Room and his toe was reddish looking and didn't look good at all. She stated it scared her, it was something like I'd never seen before. It looked like it was going to pop or something. CNA #3 said there was a blue bandage wrapped around the 4th toe of the left foot. CNA #3 reported Resident #1 would pick at his toenails and he would sometimes have a bandage on the toe he was picking at the time. CNA #3 said Resident #1 had refused baths a couple of times and that was why she had not seen his feet. She stated he never complained of anything and always had socks on when she put him to bed. During an interview, on 08/20/19 at 1:22 PM, CNA #1/Whirlpool CNA reported she remembered Resident #1's toe was bleeding, and she called the nurse, she thought it was LPN #2. CNA #1 said she could not remember the date of the incident. CNA #1 said she did not recall seeing Resident #1's feet because he refused a tub bath and preferred to keep his socks on. Interview on 08/20/19 at 1:53 PM, with Licensed Practical Nurse (LPN) #2, revealed she was the nurse assigned to Resident #1 on 06/04/19. LPN #2 said she was called into the Whirlpool Room by the Certified Nursing Assistant (CNA). LPN #2 reported Resident #1's left foot was very swollen, and what alarmed her was that the swelling seemed to be coming from the left fourth toe. LPN #2 reported the other toes were not swollen, and there was a blue bandage on the left 4th toe. LPN #2 said she removed the blue bandage carefully. LPN #2 said she observed pus and a little blood on the bandage, and the toe appeared deformed and blue. LPN #2 said she had no knowledge of any treatment ordered for the left fourth toe. An interview, with LPN #3, on 08/21/19, revealed she said she was not aware Resident #1's left 4th toe nail had come off. LPN #3 said she remembered LPN #2 called her into the Whirlpool Room on 06/04/19. LPN #3 said Resident #1's left 4th toe was big and red, and his whole left foot was red and swollen. LPN #3 said she looked at the foot and toe, and said you need to send him out. Review of Resident #1's Daily Care Guide revealed the resident was as risk for skin problems. Bath assistance was two (2) person physical assist. Whirlpool bath on Tuesdays, Thursday, and Saturdays, and offer sponge bath on opposite days. Mobile via wheelchair. Record review of Resident #1's Completed Care Tasks, revealed the resident received a shower bath on 05/09/19, 05/11/19, 05/18/19, 05/21/19, and 05/25/19. A sponge bath on 5/14/19, 05/28/19 and 6/01/19. Skip baths due to medical condition on, 05/17/19, 05/31/19, and 06/05/19. A whirlpool bath on 05/23/19. There were no documented reports of any concerns with Resident #1's feet. Review of Resident #1's Skin Inspection Reports, dated 05/07/19, 05/14/19, 05/21/19, and 06/04/19, revealed the skin was intact. The skin inspections were documented by LPN #1/Treatment Nurse. LPN #1 also documented a Skin Inspection Report, on 06/12/19, at which time Resident #1 was in the hospital. An interview, on 08/21/19 at 1:45 PM, revealed LPN #1 stated she documented a skin audit was done for Resident #1 on 06/04/19, but she did not actually do a skin inspection. LPN #1 said sometimes she would do the skin inspections, and go back to the computer later and log them in. LPN #1 also said she thinks she may have clicked on the wrong name. LPN #1 said she did the skin inspections on Tuesdays, even though the order is for Thursdays. An interview with Resident #1's Medical Doctor (MD), on 8/21/19, at 9:09 AM, revealed he was not notified of the detached toenail on 05/09/19, and he had not given any orders for a bandage to the left 4th toe. The MD stated he recalled being surprised when he was told of the amputation. The MD stated he had seen the resident on 05/31/19, and he looked at his ankles for [MEDICAL CONDITION], but did not remove his shoes. Review of the MD's Nursing Home Visit note, dated 05/31/19 at 9:36 AM, revealed no swelling to the right or left foot. Nursing staff was present during the visit and all concerns were reviewed. Will continue current plan of care and treatment. The Director of Nursing (DON) revealed during an interview, on 08/21/19, at 2:06 PM, the facility's policy was not followed due to the MD should be notified of any changes in the resident's condition. The DON stated LPN #1 should have followed up on the toe after toenail detachment, and should have reported it to the Registered Nurse (RN) and MD. The DON revealed she was not in the building, on 05/09/19, when Resident #1's toenail was detached, or on 06/04/19, when the worsening condition of the toe was discovered. The DON stated RN #1 was the supervisor while she was out and would have been responsible for following up on the incident. The interview, on 08/21/19 at 9:57 AM, with Registered Nurse (RN) #1, revealed she stated, I didn't know about the toenail. I remember discussing it after he went to the hospital on [DATE]. An interview with the Administrator, on 08/20/19 at 1:13 PM, revealed the facility did not do an Accident/Incident Report, on 05/09/19, regarding Resident #1's left 4th toe nail. The Administrator confirmed there was no Physician's Orders for the left 4th toe wound care. Further interview with the Administrator, on 08/21/19 at 3:30 PM, revealed it was reported to him by staff that earlier in the day, on 06/04/19, the resident had been going about his normal routine with no complaints of pain until the left foot was noted to be swollen in the shower room. The Administrator said Resident #1 self-propelled himself in a wheelchair. The Administrator stated an incident report should have been done on 05/09/19, the MD should have been notified and a doctor's order obtained for treatment of [REDACTED]. The Administrator also said the staff should have followed up on the toe from the incident on 05/09/19 (until 6/4/19). Record review of the Face Sheet revealed Resident #1 was admitted by the facility, on 01/25/18, with a [DIAGNOSES REDACTED]. Review of the Physician Orders for the month of (MONTH) 2019 revealed current [DIAGNOSES REDACTED]. Record review of the 30 Day Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/11/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognitive skills for daily decision making. Section G of the assessment revealed that the resident required extensive assistance of two (2) persons for bed mobility, dressing, and toileting and that he was totally dependent for bathing.

Based on observation, staff and resident interviews, record review, and Residents' Rights policy review, the facility failed to ensure a resident was protected from abuse as evidenced by verbal and physical abuse of Resident #1 by Licensed Practical Nurse (LPN) #1. Findings include: Review of the facility's policy entitled "Resident Rights", with a revision date of 05/11, reflected: "The facility will promote and care for each resident in a manner and in an environment that enhances and maximizes the resident's dignity and individuality." and "All residents have the right to be free from verbal, sexual, physical and/or mental abuse and involuntary seclusion." Review of the facility's policy entitled "Code of Conduct Regarding Personal Behavior While on Duty", dated July 2011, addressed disciplinary action for "discourteous conduct toward any resident", and employee violation of "resident's rights." Review of an incident report dated 3/2/14, signed by Licensed Practical Nurse (LPN) #1 reflected Resident #1 was sitting in the activity room on the unit and Certified Nurse Aide (CNA) #1 asked if he would like to have a shave, and Resident #1 jumped out of a chair and started cursing CNA #1 and LPN #1. The report reflected Resident #1 then punched LPN #1 in the ribs. Resident #1 was taken to his room. The record reflected en-route to his room, Resident #1 scratched CNA #1 on her face and neck. The report reflected when in the room, Resident #1 reached over and grabbed LPN #1's hair and pulled hair out. Interview with the Administrator on 4/1/14 at 9:15 AM revealed LPN #1 denied abuse and stated she was protecting herself while he was pulling her hair out and hitting her. The Administrator stated LPN had been terminated because she should have walked away, because she had been trained regarding how to handle residents with behavior problems. The Administrator stated CNA #2 was suspended during the investigation and had worked one (1) day since before resigning yesterday (3/31/14). A narrative statement, dated 3/4/14, reflected Resident #1 became angry when asked if he was ready to be shaved. The report revealed Resident #1 initially got upset with CNA #1 and hit LPN #1 in the ribs. An addendum was added that reflected that on 3/4/14 the DON (Director of Nursing) found a witness statement written by CNA #2 in her correspondence box, stating that the nurse on duty provoked Resident #1, telling him she was not scared of him, and that Resident #1 had a handful of LPN #1's hair. The note included the names of CNA #1 and CNA#3. Interview with CNA #1 on 4/1/14 at 11:30 AM was conducted. She stated LPN #1 was doing her blood sugars and told me Resident #1 needed a shave. She stated LPN #1 kept insisting he was going to get a shave, and he jumped out of his chair and started swinging. She stated he grabbed me (CNA #1) by the throat. CNA #1 stated she caught him by the arm and took him to his room but he kept fighting. She stated neither she nor LPN #1 hit the resident. Resident #1 did calm down and she (CNA #1) left the room. She stated she did see him hit LPN #1 but did not see her hit him. A telephone interview was conducted with CNA #2 on 4/1/14 at 11:45 AM. She stated they heard something happening and went down there and she saw LPN #1 holding Resident #1 down with a knee in his back and her hair was being pulled. She stated she (LPN #1) had a finger in his eye. She stated CNA #1 was leaving the room. CNA #2 stated things escalated. LPN #1 kept saying "I'm not scared of you." She stated she had never seen LPN #1 like this. She stated Resident #1 would calm down then LPN #1 would provoke him and he'd start up again. She stated CNA #3 came in and we separated them. A telephone interview with CNA #3 was conducted on 4/1/14 at 11:55 AM. She stated she and CNA #2 heard some yelling so they went down to the unit. She stated LPN #1 had Resident #1 "pinned to the bed" and CNA #1 left the room. LPN #1 and CNA #2 were in the room and she heard LPN #1 telling him to hit her. She stated she did not see her finger in his eye. CNA #3 stated they tried to calm him down and got his fingers off LPN #1's hair. She stated she had never seen LPN #1 do anything like that before. She added there was a housekeeper and lots of other people watching. A telephone interview was conducted with LPN #1 on 4/1/14 at 12:20 PM. She stated she had just finished her accuchecks and saw Resident #1 needed a shave. She said when she told him he needed a shave, he got agitated. She stated CNA #1 started helping me try to calm him down but he hit me in my ribs. She said they walked him to his room and then he grabbed my hair. I tried to pull back, but I never hit him or poked at him. She stated there were lots of people standing around. She stated she knew CNA #2 "had it in for me" because she would not make rounds. She would go sit in the beauty shop. "I told her I would have to write her up if she did not do rounds because I would be in trouble." LPN #1 stated she in no way tried to hurt Resident #1. She said CNA #3 and a laundry worker were in the doorway and she shut the door to try and calm him down. She said she did not poke him in the eye. An interview with Housekeeping Staff #1 was conducted on 4/1/14 at 12:35 PM. She stated she had observed LPN #1 yelling at Resident #1 and LPN #1 told her to go get LPN #2. She said LPN #1 was telling Resident #1 to let CNA #1 shave him, and he jumped up and hit her. She said LPN #1 said, "Don't hit me" and Resident #1 hit her again. CNA #1 took him to his room. LPN #1 and CNA #2 were there (in his room) and LPN #1 "slammed the door." She said she heard LPN #1 say he was not going to get away with this. Housekeeping Staff #1 added he had a handful of LPN #1's hair. Interview with LPN #2 on 4/1/14 at 1:00 PM revealed she was on the other unit and LPN #1 came to the nursing station and told her Resident #1 had hit her and pulled her hair and asked she call the RP (Responsible Party), the physician, the Director of Nurses (DON) and the Administrator. Interview with the DON on at 2:10 PM on 4/1/14 revealed she started the investigation on Tuesday when she came back to work. She stated CNA #2 had left her a note that accused LPN #1 of being abusive. The DON stated CNA #2 had called her on Monday but did not refer to what had happened. She stated she (DON) reported it to the administrator and they began the investigation. The DON stated she had heard all the stories before questioning LPN #1. The DON stated she went to the hospital where Resident #1 had been transferred after the incident and looked at his eye. She said there was a tiny red spot in the corner of one eye and she had a nurse there look at it also. They determined there was no harm. It could have been a normal irritation of the eye. Review of LPN #1's training records revealed that she had been trained in abuse and neglect, and review of the abuse policy. Review of the Resident Right's policy and the Code of Conduct Policy, signed as read by LPN #1 on 7/17/13, indicated LPN #1 failed to honor these policies. Observation and interview with Resident #1 on 4/1/14 at 1:50 PM revealed a neatly dressed male seated on a sofa in the day room, rocking back and forth. When verbally addressed, he rose and held out his hand for a handshake. When asked how he was treated by staff, he stated, "They are good to me." Record review revealed the facility admitted Resident #1 on 12/2/09 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Dated (ARD) of 3/21/14, revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident #1's cognitive status was severely impaired. This MDS coded Resident #1 being able to transfer, ambulate and feed self independently.

Based on observation, staff and resident interviews, and record review, the facility failed to implement the plan of care for Resident #1's behavior as evidenced by an escalation of behaviors and inappropriate interventions. Findings include: Review of the care plan for socially inappropriate/disruptive behavior, dated 12/02/2009, revealed under approaches to "approach resident warmly and positively", "talk with resident in calm voice when behavior is disruptive", and "remove resident from public area when behavior is unacceptable." Licensed Practical Nurse (LPN) #1 failed to follow these approaches on Resident #1's care plan as evidenced by the incident report dated 3/2/14. Review of the incident report dated 3/2/14, signed by LPN #1 reflected Certified Nurses Assistant (CNA) #1 asked if Resident #1 would like to have a shave. Resident #1 jumped out of a chair and started cursing CNA #1 and LPN #1, then punched LPN #1 in the ribs. Resident #1's arms were held, and Resident #1 was taken to his room. The record reflected Resident #1 scratched CNA #1 on her face and neck while being escorted to his room. The report reflected once in his room, Resident #1 reached over and grabbed LPN #1's hair and pulled hair. On 4/1/14 at 11:45 AM, a telephone interview was conducted with CNA #2. CNA #2 stated she heard something happening and went down there (to the resident's room). CNA #2 said she saw LPN #1 holding Resident #1 down with a knee in his back and the LPN's hair was being pulled by the resident. She stated LPN #1 had a finger in his eye. She stated CNA #1 was leaving the room. CNA #2 stated things escalated and LPN #1 kept saying "I'm not scared of you." CNA #2 stated Resident #1 would calm down. LPN #1 would provoke him, and he'd start up again. She stated CNA #3 came in, and we separated them (Resident #1 and LPN #1). Record review revealed the facility admitted Resident #1 on 12/2/09 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Dated (ARD) of 3/21/14, revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated Resident #1's cognitive status was severely impaired. This MDS coded Resident #1 was able to transfer, ambulate and feed self independently.

Based on observation, record review, policy review and documentation provided, the facility failed to ensure that residents receiving [MEDICATION NAME] had [MEDICATION NAME] Time/International Normalized Ratios (PT/INR) lab work done per physician's orders [REDACTED].#7, #9, #10, #11 and #12), and also failed to conduct other various lab studies as ordered by the physician for these same five (5) residents. A standard survey was conducted from 07/31/12 to 08/02/12 and the extended survey was conducted from 08/02/12 to 08/03/12. During the survey, the facility was found not be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy was identified on 08/01/12 at 5:25 p.m. and the Administrator and Director of Nursing were notified at that time. The Immediate Jeopardy was determined to begin on 08/01/12. The facility submitted an Allegation of Compliance on 08/02/12 at 5:15 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 08/03/12 and is considered ongoing. Findings include: Resident #11 Record review revealed that Resident #11 was admitted to the facility 3/16/06, and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview of Mental Status score of 0, indicating Resident #11's cognitive status was severely impaired. Observation on 8/2/12 at 8:10 a.m. revealed Resident #11 was lying on the bed in her room and well groomed. Review of the August 2012 physician's orders [REDACTED]. Review of PT/INR results obtained 8/2/12 revealed a physician's orders [REDACTED]. dose. Pt (patient) to receive [MEDICATION NAME] 2 mg (milligrams) on each night Mon - Fri. (Monday - Friday). Pt to receive [MEDICATION NAME] 4 mg on Sat (Saturday) and Sunday. Recheck PT/INR in 7 days... " There was an order for [REDACTED]. Resident #12 Record review revealed that Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 0, indicating Resident #12's cognitive status was moderately impaired. Observation on 8/2/12 at 11:47 a.m. revealed Resident #12 was seated in a wheelchair in the lobby area. Review of August 2012 physician's orders [REDACTED].? x 3 mg PO (by mouth) @ (at) HS (hours of sleep) Tues (Tuesday) & (and) Thur (Thursday) for [MEDICAL CONDITION]/Circulation. There was an order, dated 1/27/12, for [MEDICATION NAME] (Sodium [MEDICATION NAME] Sodium) 3 mg PO @ HS Mon (Monday)-Wed (Wednesday)-Fri (Friday)-Sat (Saturday)-Sun (Sunday) for [MEDICAL CONDITION]/Circulation. There was an order, dated 1/27/12, for PT/INR ([MEDICATION NAME] Time and International Normalized Ratio) QMO (every month). Record review there was no documentation of PT/INR results for 3/12, 4/12, 5/12 and 7/12. Review of lab work, dated 8/1/12, revealed the following results: PT- 42.3, INR 4.2. Review of lab work, dated 8/3/12 revealed PT - 58.7, and INR 4.9. Review of the physician's orders [REDACTED]. Recheck in 3 days 08/06/12." Resident #7 Record review revealed that Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview of Mental Status score of 12, indicating Resident #7's cognitive status was moderately impaired. Observation on 8/1/12 at 10:20 a.m. revealed Resident #7 was up in the wheelchair in the day room participating in activity. Review of the August 2012 physician's orders [REDACTED].@ (at) HS (bedtime) M-W-F (Monday-Wednesday-Friday) Circulation. " There was also an order [REDACTED]. Record review revealed that there was no documentation for PT/INR ([MEDICATION NAME] Time and International Normalized Ratio) results for 1/12, 3/12, 4/12, 5/12, 6/12, and 7/12; there was no documentation of CMP (Complete Metabolic Panel) results since 11/11; there was no documentation of a Lipid result since 6/11, and there was no documentation of a FBS (Fasting Blood Sugar) result since 11/11. Interview on 8/1/12 at 10:30 a.m. with the Director of Nurses regarding lab work revealed the (DON) stated, "I can't find any for the PT since 2/28/12, no CMP (Complete Metabolic Panel) since 12/12/11, I called the lab and they don't have any lab results either." Review of the facility's "Lab Work: policy, revised 8/08, noted " 1. Lab will be reviewed by Consultant Pharmacist on a monthly basis related to medication therapy. 2. Facility will develop a "tickler system" to monitor labs as ordered and done to maintain compliance. 3. Lab monitoring is a facility responsibility in conjunction with Pharmacist who will review monthly. " Review of the facility's "Laboratory Services" policy, revised 4/12, noted, " 1. The facility will provide or obtain the services of a clinical laboratory to meet the needs of the residents. 2. The facility will have an agreement to obtain the services from a lab that is approved for participation in the Medicare program either as a hospital or as an independent laboratory. 3. Laboratory services can be performed only when ordered by the attending physician. 4. The attending physician will be notified of abnormal laboratory results promptly after the facility has been advised of the results. "Guidelines for Reporting Abonormal (Abnormal) Test Results to Physician's" may be used when determining physician next office day notification. The notification of the physician will be documented in the medical record ... 7. All lab work must be retained in the residents chart and abnormal finding documented with report results and follow up from physician. " Review of the facility's "Suggested Laboratory Test" policy, revised 4/12, noted, " ... 6. Fasting blood sugar monthly for residents taking insulin ... 9. [MEDICATION NAME] INR at least monthly in residents receiving [MEDICATION NAME]/([MEDICATION NAME]) ... " Interview, via telephone, on 8/1/12 at 1:50 p.m. with the Registered Pharmacist (RPH) regarding the missing lab on charts revealed the RPH stated, "The problem is lab sends copy to the doctor and the facility relies on MD office to call with any changes. I look at the lab one month behind and send a report to the DON. In some other homes, the doctor and the facility get a copy of lab. The facility should cover this in high risk management meetings." Interview on 8/3/12 at 10:55 a.m. with the Registered Pharmacist revealed "After completing reviews, if something is serious it is brought to the DON's attention. After the report is finished, I send it to the facility ... " Interview on 8/3/12 at 9:18 a.m. with the Physician #1 regarding lab work not being obtained, revealed Physician #1 stated: "There are orders for labs, I don't know why they didn't get done. Resident #9 Record review revealed that Resident #9 was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 0, indicating Resident #9's cognitive status was severely impaired. Observation on 8/2/12 at 11:52 a.m. revealed Resident #9 was in bed in the room with her eyes closed. Review of August 2012 physician orders [REDACTED]. Record review revealed there was no documentation of PT/INRs for 4/12, 5/12, 6/12 and 7/12; there was no documentation of a B12, and there was no Liver Profile for 7/12 provided. Resident #10 Record review on 8/21/12 revealed that Resident #10 came to the home on 9/24/09 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, indicating Resident #10 was cognitively intact. Observation on 8/2/12 at 4:00 p.m. revealed Resident #10 was lying supine and was alert to name and place. Review of August 2012 physician's orders [REDACTED].@ (at) HS (hours of sleep) M-W-F (Monday, Wednesday, Friday; SUN (Sunday); [MEDICAL CONDITIONS]/Circulation. Review of the August 2012 physician's orders [REDACTED]. There was no documented evidence of PT/INRs for 11/11, 1/12, 2/12, 3/12, 4/12, 5/12, 6/12 and 7/12; there was no documentation of [MEDICATION NAME] for 2/12; there was no documentation of Ferritin levels since 2/12; there was no documentation of Protein since 2/12; there was no documentation of Iron since 2/12; there was no documentation of CBC since 2/12, and there was no documentation of CMP since 2/12.

Based on observation, record review, policy review and documentation provided, the facility failed to ensure that residents receiving [MEDICATION NAME] had [MEDICATION NAME] Time/International Normalized Ratios (PT/INR) lab work done per physician's orders [REDACTED].#7, #9, #10, #11 and #12), and also failed to conduct other various lab studies as ordered by the physician for these same five (5) residents. This was deemed Immediate Jeopardy on 8/1/12 at 5:25 p.m. A revisit survey was conducted on 08/24/12 to validate the Allegation of Compliance (AoC). The Immediate Jeopardy which began on 8/1/12 was determined to be removed on 8/20/2012. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, staff interview and record review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC. The Immediate Jeopardy was determined to be removed on 8/20/12. The facility remained out of compliance at a Scope and Severity of "F", widespread deficiencies that constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee. Findings include: Resident #11 Record review revealed that Resident #11 was admitted to the facility 3/16/06, and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview of Mental Status score of 0, indicating Resident #11's cognitive status was severely impaired. Observation on 8/2/12 at 8:10 a.m. revealed Resident #11 was lying on the bed in her room and well groomed. Review of the August 2012 physician's orders [REDACTED]. Review of PT/INR results obtained 8/2/12 revealed a physician's orders [REDACTED]. dose. Pt (patient) to receive [MEDICATION NAME] 2 mg (milligrams) on each night Mon - Fri. (Monday - Friday). Pt to receive [MEDICATION NAME] 4 mg on Sat (Saturday) and Sunday. Recheck PT/INR in 7 days..." There was an order for [REDACTED]. Resident #12 Record review revealed that Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 0, indicating Resident #12's cognitive status was moderately impaired. Observation on 8/2/12 at 11:47 a.m. revealed Resident #12 was seated in a wheelchair in the lobby area. Review of August 2012 physician's orders [REDACTED].? x 3 mg PO (by mouth) @ (at) HS (hours of sleep) Tues (Tuesday) & (and) Thur (Thursday) for [MEDICAL CONDITION]/Circulation. There was an order, dated 1/27/12, for [MEDICATION NAME] (Sodium [MEDICATION NAME] Sodium) 3 mg PO @ HS Mon (Monday)-Wed (Wednesday)-Fri (Friday)-Sat (Saturday)-Sun (Sunday) for [MEDICAL CONDITION]/Circulation. There was an order, dated 1/27/12, for PT/INR ([MEDICATION NAME] Time and International Normalized Ratio) QMO (every month). Record review there was no documentation of PT/INR results for 3/12, 4/12, 5/12 and 7/12. Review of lab work, dated 8/1/12, revealed the following results: PT- 42.3, INR 4.2. Review of lab work, dated 8/3/12 revealed PT - 58.7, and INR 4.9. Review of the physician's orders [REDACTED]. Recheck in 3 days 08/06/12." Resident #7 Record review revealed that Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview of Mental Status score of 12, indicating Resident #7's cognitive status was moderately impaired. Observation on 8/1/12 at 10:20 a.m. revealed Resident #7 was up in the wheelchair in the day room participating in activity. Review of the August 2012 physician's orders [REDACTED].@ (at) HS (bedtime) M-W-F (Monday-Wednesday-Friday) Circulation. " There was also an order [REDACTED]. Record review revealed that there was no documentation for PT/INR ([MEDICATION NAME] Time and International Normalized Ratio) results for 1/12, 3/12, 4/12, 5/12, 6/12, and 7/12; there was no documentation of CMP (Complete Metabolic Panel) results since 11/11; there was no documentation of a Lipid result since 6/11, and there was no documentation of a FBS (Fasting Blood Sugar) result since 11/11. Interview on 8/1/12 at 10:30 a.m. with the Director of Nurses regarding lab work revealed the (DON) stated, "I can't find any for the PT since 2/28/12, no CMP (Complete Metabolic Panel) since 12/12/11, I called the lab and they don't have any lab results either." Review of the facility's "Lab Work: policy, revised 8/08, noted " 1. Lab will be reviewed by Consultant Pharmacist on a monthly basis related to medication therapy. 2. Facility will develop a "tickler system" to monitor labs as ordered and done to maintain compliance. 3. Lab monitoring is a facility responsibility in conjunction with Pharmacist who will review monthly. " Review of the facility's "Laboratory Services" policy, revised 4/12, noted, " 1. The facility will provide or obtain the services of a clinical laboratory to meet the needs of the residents. 2. The facility will have an agreement to obtain the services from a lab that is approved for participation in the Medicare program either as a hospital or as an independent laboratory. 3. Laboratory services can be performed only when ordered by the attending physician. 4. The attending physician will be notified of abnormal laboratory results promptly after the facility has been advised of the results. "Guidelines for Reporting Abonormal (Abnormal) Test Results to Physician's" may be used when determining physician next office day notification. The notification of the physician will be documented in the medical record ... 7. All lab work must be retained in the residents chart and abnormal finding documented with report results and follow up from physician. " Review of the facility's "Suggested Laboratory Test" policy, revised 4/12, noted, " ... 6. Fasting blood sugar monthly for residents taking insulin ... 9. [MEDICATION NAME] INR at least monthly in residents receiving [MEDICATION NAME]/([MEDICATION NAME]) ... " Interview, via telephone, on 8/1/12 at 1:50 p.m. with the Registered Pharmacist (RPH) regarding the missing lab on charts revealed the RPH stated, "The problem is lab sends copy to the doctor and the facility relies on MD office to call with any changes. I look at the lab one month behind and send a report to the DON. In some other homes, the doctor and the facility get a copy of lab. The facility should cover this in high risk management meetings." Interview on 8/3/12 at 10:55 a.m. with the Registered Pharmacist revealed "After completing reviews, if something is serious it is brought to the DON's attention. After the report is finished, I send it to the facility ..." Interview on 8/3/12 at 9:18 a.m. with the Physician #1 regarding lab work not being obtained, revealed Physician #1 stated: "There are orders for labs, I don't know why they didn't get done. Resident #9 Record review revealed that Resident #9 was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 0, indicating Resident #9's cognitive status was severely impaired. Observation on 8/2/12 at 11:52 a.m. revealed Resident #9 was in bed in the room with her eyes closed. Review of August 2012 physician orders [REDACTED]. Record review revealed there was no documentation of PT/INRs for 4/12, 5/12, 6/12 and 7/12; there was no documentation of a B12, and there was no Liver Profile for 7/12 provided. Resident #10 Record review on 8/21/12 revealed that Resident #10 came to the home on 9/24/09 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, indicating Resident #10 was cognitively intact. Observation on 8/2/12 at 4:00 p.m. revealed Resident #10 was lying supine and was alert to name and place. Review of August 2012 physician's orders [REDACTED].@ (at) HS (hours of sleep) M-W-F (Monday, Wednesday, Friday; SUN (Sunday); [MEDICAL CONDITIONS]/Circulation. Review of the August 2012 physician's orders [REDACTED]. There was no documented evidence of PT/INRs for 11/11, 1/12, 2/12, 3/12, 4/12, 5/12, 6/12 and 7/12; there was no documentation of [MEDICATION NAME] for 2/12; there was no documentation of Ferritin levels since 2/12; there was no documentation of Protein since 2/12; there was no documentation of Iron since 2/12; there was no documentation of CBC since 2/12, and there was no documentation of CMP since 2/12. The facility provided an Allegation of Compliance (AoC) that was accepted on 8/23/12. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the immediate jeopardy. Allegation of Compliance: Heritage Manor of Rolling Fork was notified of Immediate Jeopardy status on 8/1/2012 at 5:25 pm. Medical Director (MD #2) was notified by the Administrator on 8/1/2012 at 5:55 PM of Immediate Jeopardy Status. Issues identified are 1) F-281 Services Provided Meet Professional Standards, 2) F-309 Provide Care/Services For Highest Well Being, 3) F-428 Drug Regimen Review, 4) F-501 Responsibilities of Medical Director 1. F-281 Services Provided Meet Professional Standards: For Residents that were identified during survey as receiving [MEDICATION NAME] but not having [MEDICATION NAME] Time/International Normalized Ratios (PT/INR) lab done per physician's orders [REDACTED]. a. Resident #7 admitted on [DATE]. In June 2009 Resident #7 was diagnosed with [REDACTED]. On 9/26/2011, 10/11/2011, 12/28/2011, 2/28/2012 and 8/1/2012 a PT/INR was obtained. On 11/2011, 1/2012, 3/2012, 4/2012, 5/2012, 6/2012 and 7/2012, no PT/INR was obtained. PT/INR was obtained on 8/1/2012 with results being PT - 15.4 and INR - 1.5 (Therapeutic Range for PT equals 12.4 - 14.6 and for INR equals 1.4 - 3.5.) Resident's physician was notified of results on 8/1/2012 with no new orders received. New orders were received on 8/4/2012 for FBS (Fasting Blood Sugar) every month and Complete Metabolic Panel (CMP) every six months. Labs were drawn on 8/4/2012. Physician was notified. No new orders. Lipid Panel original order was 11/2011 for Lipids to be drawn yearly. Lipids were drawn 12/29/2011, results are in record. Lipid Panel to be redrawn 12/2012. Resident was assessed on 8/4/2012 by the DON and no negative outcomes or adverse reactions were noted. b. Resident #9 was readmitted [DATE], with [DIAGNOSES REDACTED]. PT/INR was obtained 9/21/2011, 12/28/2011 and 8/1/2012. No PT/INR was obtained for 10/2011, 11/2011, 1/2012, 2/2012, 3/2012, 4/2012, 5/2012, 6/2012 or 7/2012. On 8/1/2012 an order was received to obtain a PT/INR monthly with results being PT - 13.9 and INR - 1.4. (Therapeutic Range for PT equals 12.4 - 14.6 and for INR equals 1.4 - 3.5.) Resident's physician was notified of results on 8/1/2012 with new orders received. Resident #9 was a readmission on 2/12/2011 with a [DIAGNOSES REDACTED]. On 4/9/12 and order was received for PT/INR every month, [MEDICATION NAME] level every 6 months, liver profile every 3 months and B-12 level every 6 months. The lab ordered 4/9/12 was not obtained. Resident's physician was contacted on 8/3/2012 with new orders obtained for Liver profile every 3 months (August, November, February, May) [MEDICATION NAME] level every 6 months (August/February), Vitamin B12 level every 6 months (August/ February) and PT/INR level every Month. On 8/4/2012 residents physician ordered a CBC without differential every 6 months (August/February). Liver profile obtained on 8/3/2012. Resident's physician notified on 8/4/2012 with no new orders received. [MEDICATION NAME] level obtained 8/2/2012. Resident's physician was notified on 8/3/2012 with new orders to repeat lab on 8/8/2012. Lab notified facility specimen was damaged. Physician was notified with new orders to obtain another specimen on 8/14/2012. Results obtained and physician notified on 8/15/2012 with no new orders received. Vitamin B12 specimen obtained 8/3/2012 and results received on 8/9/2012 and reported to physician. PT/INR obtained on 8/1/2012. Resident's physician notified of results on 8/1/2012 with no new orders received. CBC without differential was obtained on 8/5/2012. Resident's physician was notified of results on 8/6/2012 with no new orders received. Resident was assessed on 8/4/2012 by the DON and no negative outcomes or adverse reactions were noted. c. Resident #10 admitted [DATE] with a [DIAGNOSES REDACTED]. PT/INR was obtained 9/21/2011, order received on 9/21/2011 to repeat INR 9/27/2011. PT/INR obtained 9/27/2011, 10/11/2011, 11/25/2011, (see Appendix H), 12/28/2011, and on 8/1/2012. No PT/INR was obtained 1/2012, 2/2012, 3/2012, 4/2012, 5/2012, 6/2012 or 7/2012. On 8/1/2012 an order was received to obtain a PT/INR monthly with results being PT - 25.2 and INR - 2.5. (Therapeutic Range for PT equals 12.4 - 14.6 and for INR equals 1.4 - 3.5.) Resident's physician was notified of results on 8/1/2012 with no new orders received. Orders were received to obtain a CBC (Complete Blood Count), CMP (Complete Metabolic Panel), [MEDICATION NAME], Ferritin, Iron Level and Protein on 8/3/2012. CMP (Complete Metabolic Panel), [MEDICATION NAME], and Protein level were obtained and results received on 8/4/2012. Physician was notified with no new orders. Ferritin and Iron Level lab were obtained and results received on 8/5/12. Physician was notified on 8/5/2012 with orders received to start new med for Iron and repeat CBC (Complete Blood Count) and Iron Level in two months. Resident was assessed on 8/4/2012 by the DON and no negative outcomes or adverse reactions were noted. d. Resident #11 has had numerous hospitalization s since survey 9/3/2011. Hospital admit 8/29/2011 through 9/2/2011 no lab orders were received on return. Resident hosptalized on [DATE] and readmitted [DATE]. On 10/10/2011 order was received to repeat PT/INR on 10/11/2011. PT/INR was obtained. Resident was hospitalized [DATE] through 10/31/2011, on 10/31/2011 order was received to obtain PT/INR Level in two weeks. On 11/14/2011 a PT/INR was obtained. On 11/16/2011 order received to bring to clinic for repeat PT/INR, results obtained and on chart. Order received 11/17/2011 to repeat PT/INR in one week. PT/INR obtained 11/23/2011. On 12/8/2011 order was received to obtain PT/INR on 12/16/2011. PT/INR was not obtained on 12/16/2011. Resident hospitalized [DATE] through 1/18/2012 with no order for Labs received on return from hospital. Resident was hospitalized [DATE] and readmitted [DATE]. On 3/9/2012 orders received to obtain PT/INR on Monday 3/12/2012 and Friday 3/16/2012. PT/INR was obtained on both dates. On 3/18/2012 orders received to repeat PT/INR in 3 days on 3/21/2012. PT/INR was not obtained. hospitalized [DATE] through 4/25/2012, no PT/INR orders received upon return. hospitalized [DATE] through 5/21/2012, no orders were received for PT/INR. hospitalized [DATE] through 8/1/2012. Clarification order received on 8/2/2012 to only obtain an INR on 8/2/2012 and repeat the PT/INR in one month. INR results 1.4. Resident's physician was notified of results on 8/2/2012. New order on 8/3/2012 to adjust [MEDICATION NAME] dosage and repeat PT/INR on 8/9/2012 and monthly. Orders were received on 8/4/2012 to obtain a TSH ([MEDICAL CONDITION] Stimulating Hormone) every six months and an FBS (Fasting Blood Sugar) every month. TSH and FBS were obtained on 8/4/2012. Physician was notified. No new orders. Resident was assessed on 8/4/2012 by the DON and no negative outcomes or adverse reactions were noted. PT/INR was obtained on 8/9/2012 as ordered, Physician was notified with no new orders. e. Resident #12 was admitted [DATE] with a [DIAGNOSES REDACTED]. No order on admission for PT/INR. Order for 7/29/2011 was received to do a one time PT/INR, then every month. PT/INR was obtained 9/21/2011, 12/28/2011, 2/28/2012, 6/26/2012, 8/1/2012. No PT/INR was obtained for 10/2011, 1/2012, 3/2012, 4/2012, 5/2012, or 7/2012. PT/INR was obtained 8/1/2012 with results PT 42.3 and INR 4.2. Order received to hold [MEDICATION NAME] times 2 days and repeat PT/INR on Friday 8/3/2012. Results were PT 58.7 INR 4. New order received to hold [MEDICATION NAME] for 3 days and repeat PT/INR on 8/6/2012. PT/INR obtained and results as follows PT 27.5 and INR 2.3. Resident's physician was notified on 8/6/2012 and new orders received for an adjustment to [MEDICATION NAME] dosage and to repeat PT/INR in 2 weeks. PT/INR was obtained on 8/20/2012 and Physician was notified with new orders to hold [MEDICATION NAME] for 3 days & recheck in 3 days. Resident was assessed on 8/5/2012 by the DON and no negative outcomes or adverse reactions were noted. All residents have the potential to be affected by the alleged deficient practice and those residents were identified through chart audits conducted by Quality Improvement Nurse #1 (QI#1), Director of Nurses #1 (DON#1), Medical Records Clerk #1 (MR#1), and Pharmacy Consultant #1. 100% (One hundred percent) of active resident charts have been audited as of 8/5/2012 for lab results as ordered related to [MEDICATION NAME] and other ordered lab. The results of the audit are as follows: a. No other residents other than the identified ones above( #7, #9, #10, #11, and #12) are on [MEDICATION NAME] or any other anti-coagulant at this time requiring laboratory services. Lab Audit of other various lab studies are as follows: a. Resident #14 readmitted on [DATE] with orders for [MEDICATION NAME] Level to be drawn in February 2012 due to a [DIAGNOSES REDACTED]. There was no [MEDICATION NAME] Level drawn in February 2012. Resident's physician was notified on 8/4/2012 with new orders to obtain [MEDICATION NAME] level every six months (Aug/Feb). August [MEDICATION NAME] level obtained on 8/4/2012. Resident's physician was notified on 8/4/2012. No new orders received. b. Resident #16 admitted [DATE] with a [DIAGNOSES REDACTED]. A TSH Level was due 9/2011 and 3/2012, these levels were not drawn. On 6/28/2012 a TSH was obtained. New order 8/2/2012 for TSH now and monthly. TSH was obtained on 8/2/2012. Resident's physician was notified of results on 8/2/2012. No new orders received. c. Resident #15 admitted [DATE] with a [DIAGNOSES REDACTED]. [MEDICATION NAME] Level was due 12/2011. This lab was not drawn. An order was received 2/27/2012 for a [MEDICATION NAME] Level it was drawn on 2/27/2012. The next [MEDICATION NAME] level was due in August. Lab was obtained 8/2/2012. Resident's physician was notified of results on 8/2/2012 and no new orders received. d. Resident #17 admitted [DATE] with a [DIAGNOSES REDACTED]. An initial order was received on 4/30/1996 to obtain a [MEDICATION NAME] Level and [MEDICATION NAME] Level every 6 months. Levels were scheduled to be drawn on 10/2011 and 4/2012. Levels were not obtained. Resident #17 was readmitted on [DATE] from a hospital stay with orders to continue [MEDICATION NAME] and [MEDICATION NAME] Levels every 6 months. On 5/21/2012 these levels were obtained. On 6/26/2012 an order was obtained to draw the [MEDICATION NAME] Level and the [MEDICATION NAME] Level. These were obtained 6/30/2012. Resident's physician was contacted on 8/4/2012. New orders were received for [MEDICATION NAME] and [MEDICATION NAME] level every 6 months from last lab draw of 6/29/2012 (June/December). e. Resident #18 admitted on [DATE] with a [DIAGNOSES REDACTED]. A [MEDICATION NAME] Level had been drawn on 8/25/2011 from a previous order prior to the hospital return on 12/24/2011. A [MEDICATION NAME] Level was obtained 2/28/12, 6 months after the last level was drawn. An order was obtained for a [MEDICATION NAME] Level on 6/26/2012 and obtained 6/28/2012. On 12/23/2011 while in the hospital a [MEDICATION NAME] Level was obtained. On 12/24/2011 readmission an order was received to draw a [MEDICATION NAME] level every 6 months. A new order obtained 1/16/2012 for [MEDICATION NAME] Level. Level was obtained 1/17/2012. Order was written on 2/27/2012 to obtain a [MEDICATION NAME] Level. Level was obtained 2/28/2012. Resident received a [MEDICATION NAME] Level in the emergency roiagnom on [DATE]. On 6/26/2012 an order was obtained to draw a [MEDICATION NAME] Level. Level was obtained 6/28/2012. Resident ' s physician was contacted on 8/3/12 and new orders received for [MEDICATION NAME] level every 6 months from last lab draw of 6/29/12 (June/December) and [MEDICATION NAME] level on 8/3/12 and then every 6 months (August/February). [MEDICATION NAME] level was obtained on 8/3/12. Residents physician was notified of results on 8/5/2012. No new orders received. f. Resident #19 admitted [DATE] with a [DIAGNOSES REDACTED]. A TSH Level was obtained 8/24/2011 and on 11/02/2011. On 1/4/2012 a TSH was obtained upon admission to the hospital. An order was obtained on 2/27/2012 for a TSH level and it was obtained on 2/28/2012. The next TSH was due August 2012. TSH was obtained on 8/2/2012. Resident's physician was notified of results on 8/2/2012 with no new orders received. g. Resident #25-Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. [MEDICATION NAME] level was obtained on 5/28/2010, 12/03/2010, 2/25/2011, 8/24/2011. Residents physician was contacted on 8/4/2012. New orders received for [MEDICATION NAME] level every 6 months (August/February). August lab obtained 8/4/2012. Resident's physician was notified on 8/7/2012 with new orders to recheck in one week. [MEDICATION NAME] (Valporic Acid) Level was obtained on 8/13/2012, physician was notified on 8/14/2012 with no new orders received. h. Resident #20 was admitted [DATE] with [DIAGNOSES REDACTED]. On 1/7/2012 an order was obtained to draw a [MEDICATION NAME] Level this was obtained 1/10/2012. On 2/13/2012 an order was obtained to draw a [MEDICATION NAME] Level and this was obtained 2/18/2012. Resident #20 was admitted to the hospital on [DATE] and discharged from this facility to an outside Hospice on 8/1/2012. i. Resident #21 was admitted [DATE] with a [DIAGNOSES REDACTED]. On 6/22/2010 she was hospitalized and returned 6/23/2010 without orders for a TSH. On 6/26/2012 an order was given by Physician as a one time order to draw a TSH Level and this was obtained 6/29/12. Resident's physician was contacted on 8/4/2012 and new orders received for TSH annually in August. Lab was obtained on 8/6/2012. Residents physician was notified on 8/6/2012 of results with no new orders received. j. Resident #22 was admitted [DATE] with [DIAGNOSES REDACTED]. Order was received 1/16/2012 to obtain [MEDICATION NAME] Level and [MEDICATION NAME] Level on 1/18/2012. Levels were obtained on 1/18/2012 for a [MEDICATION NAME] Level. No [MEDICATION NAME] Level was received. admitted to Senior Care Unit 2/22/2012. A [MEDICATION NAME] level was obtained at that time. On 2/27/2012 a repeat [MEDICATION NAME] Level was obtained at the hospital. A [MEDICATION NAME] Level and [MEDICATION NAME] Level were obtained on 3/5/2012 before hospital discharge. Resident was readmitted with no orders to obtain a [MEDICATION NAME] Level nor a [MEDICATION NAME] Level. On 6/29/2012 a one time order was obtained for a [MEDICATION NAME] and a [MEDICATION NAME] Level and these were obtained. Physician was notified on 7/2/2012 with no new orders. Residents physician was contacted on 8/4/2012 and new orders were received for [MEDICATION NAME] level and [MEDICATION NAME] level every 6 months (August/February). [MEDICATION NAME] and [MEDICATION NAME] level were obtained 8/5/2012. Resident's physician was notified of [MEDICATION NAME] level on 8/5/2012 and [MEDICATION NAME] results on 8/7/2012 with no new orders obtained. k. Resident #23 was admitted [DATE] with a [DIAGNOSES REDACTED]. No orders were received for Lab to draw a [MEDICATION NAME] level on admission. Residents physician was contacted on 8/4/2012 with new orders obtained for [MEDICATION NAME], CBC, Magnesium level and Lipid panel every 6 months (August/February) and FBS every month. Lab was obtained on 8/6/2012. Resident's physician was notified of CBC, Magnesium, Lipid and FBS on 8/6/2012 and [MEDICATION NAME] level on 8/7/2012 of all results with no new orders. l. Resident #24 was admitted [DATE] with a [DIAGNOSES REDACTED]. No orders were received for Lab to draw a [MEDICATION NAME] level on admission. Resident's physician was contacted on 8/4/2012. New orders were received for [MEDICATION NAME] level and CBC every 6 months (August/February). August lab obtained on 8/5/2012. Resident's physician was notified of results on 8/6/2012. New orders were received to recheck [MEDICATION NAME] level in 7 days. [MEDICATION NAME] level obtained and results received on 8/13/2012. Physician was notified with no new orders. m. Resident #1 was admitted on [DATE] on [MEDICATION NAME] with no lab orders to monitor. Resident's physician was contacted on 8/4/2012. New orders received for [MEDICATION NAME] level, BMP and CBC every 6 months (August/February) August lab obtained on 8/5/2012. Resident's physician was notified on 8/6/2012 of results with no new orders received. All residents affected have been assessed by the DON and no negative outcomes or adverse reactions were noted. The following measures that have been put in place to ensure the deficient practice will not recur are as follows: a. Facility has identified all RN's (Registered Nurses) and LPN's (Licensed Practical Nurses). No nurses will be allowed to work until he/she has been inserviced on the following; Physicians Orders; transcription and implementation of Physicians Orders, standing orders, pharmacy services, and Laboratory Policies and Procedures. Licensed Staff Inservice was completed by DON#1 and Administrator #1. Directed Inservices for Licensed Staff was completed by RN# 2 and RN # 3 to cover these topics, Physicians Orders; transcription and implementation of Physicians Orders, standing orders, pharmacy services, and Laboratory Policies and Procedures on 8/7/2012. Staffing schedule for RN's and LPN's have been reviewed and adjusted. No nurses will be allowed to work until he/she has been inserviced. No agency staff will be placed on schedule until inservicing on laboratory policies and procedures are complete. All directed inservices to Licensed Staff was completed on 8/20/2012. DON #1 has resigned as of 8/17/2012 and DON #2 started her employment 8/20/2012. DON #2 received all of the directed inservices on 8/20/2012 by RN #2. b. Lab draws will be performed by Licensed Staff (RN's and LPN's) and transported, daily, if needed, after each blood draw is obtained by facility staff to a local lab for processing. The Director of Nursing, RN staff nurse or Weekend RN Supervisor will track ordered labs using a Lab Monitoring System in order to ensure labs have been drawn as ordered, results have been received, results have been placed on charts, Physician has been notified, and orders, if any, have been followed through as related to lab results. Medical Records clerk will audit the Resident's charts weekly to ensure ordered labs have been received and are on charts. c. On 8/1/2012 a Lab Monitoring System was developed and implemented and included in the directed inservices mentioned above. The Monitoring system is as follows: ? When an order for [REDACTED]. ? The Director of Nursing, RN staff nurse or Weekend RN Supervisor will check the appointment calendar daily and update lab that was drawn on the Lab Log (Appendix J) and the results of this monitoring will be recorded on Appendix A (attached). ? The Director of Nursing, RN staff nurse or Weekend RN Supervisor will follow-up to make sure lab was drawn, new orders, if any, were carried out, Physician has been notified of results and new orders for labs have been completed and added to the appointment calendar, if needed. ? The Director of Nursing, RN staff nurses or Weekend RN Supervisor will monitor new admit orders and newly ordered medications to ensure appropriate labs have been ordered and placed on appointment calendar. The results of this monitoring will be recorded on Appendix A (attached). d. The Pharmacy Consultant (PC#1) was notified on 8/1/2012 at 8:56 PM of lab and physician order [REDACTED].#1)has completed a 100% audit of charts on 8/3/2012. All Pharmacy Recommendations have been forwarded to the Physician and the DON upon completion of audit. All recommendations have been addressed as approved, amended, or declined by each Resident's physician by 8/6/2012. The Pharmacy Consultant will continue to forward the results of his/her audits directly to the attending Physician and directly to the DON monthly. e. Facility Administrator spoke with Medical Director #3 (MD#3)on 8/16/2012. He reviewed and stated his approval of the Allegation of Compliance and signed the updated Allegation of Compliance on 8/16/2012. Medical Director #1 and Medical Director #2 have resigned. Medical Director #3 is the Medical Director of record as of 8/15/2012. f. All resident's listed as having lab that needed to be completed and/or physicians orders requested, family was notified as orders w

Based on record review, staff interview, and policy review, the facility failed to ensure that the Physician and Director of Nurses (DON) consistently acted upon recommendations from the Pharmacist regarding irregularities for failure to obtain laboratory testing for Prothrombin Time/International Normalized Ratios (PT/INR) for five (5) of five (5) sampled residents (Residents #7, #9, #10, #11, and #12, A standard survey was conducted from 07/31/12 to 08/02/12 and the extended survey was conducted from 08/02/12 to 08/03/12. During the survey, the facility was found not be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy was identified on 08/01/12 at 5:25 p.m. and the Administrator and Director of Nursing were notified at that time. The Immediate Jeopardy was determined to begin on 08/01/12. The facility submitted an Allegation of Compliance on 08/02/12 at 5:15 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 08/03/12 and is considered ongoing. Findings include: Review of the Pharmacist's monthly consultative reports, revealed that the Pharmacist documented that laboratory testing was not being conducted for residents as follows: Resident #7 -- PT/INR for 09/11, 2/12, 4/12, 5/12, 6/12, and 7/12. Resident #9 -- PT/INR for 09/11, 11/11, 12/11, 1/12, 2/12, 3/12, 4/12, 5/12, 6/12, and 7/12; Resident #10 -- PT/INR for 12/11, 2/12, 3/12, 4/12, 5/12, 6/12, and 7/12; Resident #11 -- PT/INR for 10/11, 12/11, 1/12, 5/12 and 7/12; Resident #12 -- PT/INR for 9/11, 4/12, 5/12, and 6/12. The facility failed to respond to the reviews conducted by the Pharmacist based on the lack of corrective action taken to conduct laboratory testing as ordered by the Physician. Cross refer to F-281 for failure of the facility to ensure that the physician's orders [REDACTED]. Interview, via telephone, on 8/1/12 at 1:50 p.m. with the Registered Pharmacist (RPH) regarding the missing lab on charts revealed the RPH stated, "The problem is lab sends copy to the doctor and the facility relies on MD office to call with any changes. I look at the lab one month behind and send a report to the DON. In some other homes, the doctor and the facility get a copy of lab. The facility should cover this in high risk management meetings." Interview on 8/3/12 at 10:55 a.m. with the Registered Pharmacist revealed "After completing reviews, if something is serious it is brought to the DON's attention. After the report is finished, I send it to the facility ... "

Based on record review, staff interview, and policy review, the facility failed to ensure that the Physician and Director of Nurses (DON) consistently acted upon recommendations from the Pharmacist regarding irregularities for failure to obtain laboratory testing for Prothrombin Time/International Normalized Ratios (PT/INR) for five (5) of five (5) sampled residents (Residents #7, #9, #10, #11, and #12, This was deemed Immediate Jeopardy on 8/1/12 at 5:25 p.m. A revisit survey was conducted on 08/24/12 to validate the Allegation of Compliance (AoC). The Immediate Jeopardy began on 8/1/12 was determined to be removed on 8/20/2012. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible Allegation of Compliance (AoC) was accomplished through observation, interview and record review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC. The Immediate Jeopardy was determined to be removed on 8/20/12. The facility remained out of compliance at a Scope and Severity of "F", widespread deficiencies that constitute no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee. Findings include: Review of the Pharmacist's monthly consultative reports, revealed that the Pharmacist documented that laboratory testing was not being conducted for residents as follows: Resident #7 -- PT/INR for 09/11, 2/12, 4/12, 5/12, 6/12, and 7/12. Resident #9 -- PT/INR for 09/11, 11/11, 12/11, 1/12, 2/12, 3/12, 4/12, 5/12, 6/12, and 7/12; Resident #10 -- PT/INR for 12/11, 2/12, 3/12, 4/12, 5/12, 6/12, and 7/12; Resident #11 -- PT/INR for 10/11, 12/11, 1/12, 5/12 and 7/12; Resident #12 -- PT/INR for 9/11, 4/12, 5/12, and 6/12. The facility failed to respond to the reviews conducted by the Pharmacist based on the lack of corrective action taken to conduct laboratory testing as ordered by the Physician. Cross refer to F-281 for failure of the facility to ensure that the physician's orders [REDACTED]. Interview, via telephone, on 8/1/12 at 1:50 p.m. with the Registered Pharmacist (RPH) regarding the missing lab on charts revealed the RPH stated, "The problem is lab sends copy to the doctor and the facility relies on MD office to call with any changes. I look at the lab one month behind and send a report to the DON. In some other homes, the doctor and the facility get a copy of lab. The facility should cover this in high risk management meetings." Interview on 8/3/12 at 10:55 a.m. with the Registered Pharmacist revealed "After completing reviews, if something is serious it is brought to the DON's attention. After the report is finished, I send it to the facility ..." F-428 Drug Regimen Review, For Residents that were identified during survey as not ensuring that the Physician and Director of Nurses (DON#1) acted upon recommendations from the Pharmacist regarding irregularities, the following actions were taken: a. Resident #7 admitted on [DATE]. In June 2009 Resident #7 was diagnosed with [REDACTED]. On 9/26/2011, 10/11/2011, 12/28/2011, 2/28/2012 and 8/1/2012 a PT/INR was obtained. On 11/2011, 1/2012, 3/2012, 4/2012, 5/2012, 6/2012 and 7/2012, no PT/INR was obtained. PT/INR was obtained on 8/1/2012 with results being PT - 15.4 and INR - 1.5 (Therapeutic Range for PT equals 12.4 - 14.6 and for INR equals 1.4 - 3.5.) Resident ' s physician was notified of results on 8/1/2012 with no new orders received. b. Resident #9 was readmitted [DATE], with [DIAGNOSES REDACTED]. PT/INR was obtained 9/21/2011, 12/28/2011 and 8/1/2012. No PT/INR was obtained for 10/2011, 11/2011, 1/2012, 2/2012, 3/2012, 4/2012, 5/2012, 6/2012 or 7/2012. On 8/1/2012 an order was received to obtain a PT/INR monthly with results being PT - 13.9 and INR - 1.4. (Therapeutic Range for PT equals 12.4 - 14.6 and for INR equals 1.4 - 3.5.) Resident ' s physician was notified of results on 8/1/2012 with new orders received. c. Resident #10 admitted [DATE] with a [DIAGNOSES REDACTED]. PT/INR was obtained 9/21/2011, order received on 9/21/2011 to repeat INR 9/27/2011. PT/INR obtained 9/27/2011, 10/11/2011, 11/25/2011, 12/28/2011, and on 8/1/2012. No PT/INR was obtained 1/2012, 2/2012, 3/2012, 4/2012, 5/2012, 6/2012 or 7/2012. On 8/1/2012 an order was received to obtain a PT/INR monthly with results being PT - 25.2 and INR - 2.5. (Therapeutic Range for PT equals 12.4 - 14.6 and for INR equals 1.4 - 3.5.) Resident's physician was notified of results on 8/1/2012 with no new orders received. d. Resident #11 has had numerous hospitalization s since survey 9/3/2011. Hospital admit 8/29/2011 through 9/2/2011 no lab orders were received on return. Resident hosptalized on [DATE] and readmitted [DATE]. On 10/10/2011 order was received to repeat PT/INR on 10/11/2011. PT/INR was obtained. Resident was hospitalized [DATE] through 10/31/2011, on 10/31/2011 order was received to obtain PT/INR Level in two weeks. On 11/14/2011 a PT/INR was obtained. On 11/16/2011 order received to bring to clinic for repeat PT/INR, results obtained and on chart. Order received 11/17/2011 to repeat PT/INR in one week. PT/INR obtained 11/23/2011. On 12/8/2011 order was received to obtain PT/INR on 12/16/2011. PT/INR was not obtained on 12/16/2011. Resident hospitalized [DATE] through 1/18/2012 with no order for Labs was received on hospital return. Resident was hospitalized [DATE] and readmitted [DATE]. On 3/9/2012 orders received to obtain PT/INR on Monday 3/12/2012 and Friday 3/16/2012. PT/INR was obtained. On 3/18/2012 orders received to repeat PT/INR in 3 days on 3/21/2012. PT/INR was not obtained. hospitalized [DATE] through 4/25/2012, no PT/INR orders received upon return. hospitalized [DATE] through 5/21/2012, no orders were received for PT/INR. hospitalized [DATE] through 8/1/2012. Clarification order received on 8/2/2012 to only obtain an INR on 8/2/2012 and repeat the PT/INR in one month. INR results 1.4. Resident ' s physician was notified of results on 8/2/2012. New order on 8/3/2012 to repeat PT/INR on 8/9/2012 and monthly. e. Resident #12 was admitted [DATE] with a [DIAGNOSES REDACTED]. No order on admission for PT/INR. Order for 7/29/2011 was received to do a one time PT/INR, then every month. PT/INR was obtained 9/21/2011, 12/28/2011, 2/28/2012, 6/26/2012, 8/1/2012. No PT/INR was obtained for 10/2011, 1/2012, 3/2012, 4/2012, 5/2012, or 7/2012. PT/INR was obtained 8/1/2012 with results PT 42.3 and INR 4.2. Order received to hold Coumadin times 2 days and repeat PT/INR on Friday 8/3/2012. Results were PT 58.7 INR 4. New order received to hold Coumadin for 3 days and repeat PT/INR on 8/6/2012. PT/INR obtained and results as follows PT 27.5 and INR 2.3. Resident ' s physician was notified on 8/6/2012 and new orders received for an adjustment to Coumadin dosage and to repeat PT/INR in 2 weeks. PT/INR was obtained on 8/20/2012 and Physician was notified with new orders to hold Coumadin for 3 days & recheck in 3 days. All residents have the potential to be affected by the alleged deficient practice and those residents were identified through chart audits conducted by Quality Improvement Nurse #1 (QI#1), Director of Nurses #1 (DON#1), Medical Records Clerk #1 (MR#1), and Pharmacy Consultant #1 done from 8/1/2012 to 8/5/2012. 100% (One hundred percent) of active resident charts have been audited as of 8/5/2012 for lab results as ordered related to Coumadin and other ordered lab. The results of the audit are as follows: a. No other residents other than the identified ones above( #7, #9, #10, #11, and #12) are on Coumadin or any other anti-coagulant at this time requiring laboratory services. Lab Audit of other various lab studies are as follows: a. Resident #14 readmitted on [DATE] with orders for Digoxin Level to be drawn in February 2012 due to a [DIAGNOSES REDACTED]. There was no Digoxin Level drawn in February 2012. Resident ' s physician was notified on 8/4/2012 with new orders to obtain Digoxin level every six months (Aug/Feb). August Digoxin level obtained on 8/4/2012. Resident ' s physician was notified on 8/4/2012. No new orders received. b. Resident #16 admitted [DATE] with a [DIAGNOSES REDACTED]. A TSH Level was due 9/2011 and 3/2012, these levels were not drawn. On 6/28/2012 a TSH was obtained. New order 8/2/2012 for TSH now and monthly. TSH was obtained on 8/2/2012. Resident ' s physician was notified of results on 8/2/2012. No new orders received. c. Resident #15 admitted [DATE] with a [DIAGNOSES REDACTED]. Digoxin Level was due 12/2011. This lab was not drawn. An order was received 2/27/2012 for a Digoxin Level it was drawn on 2/27/2012. The next Digoxin level was due in August. Lab was obtained 8/2/2012. Resident 's physician was notified of results on 8/2/2012 and no new orders received. d. Resident #17 admitted [DATE] with a [DIAGNOSES REDACTED]. An initial order was received on 4/30/1996 to obtain a Tegretol Level and Phenobarbital Level every 6 months. Levels were scheduled to be drawn on 10/2011 and 4/2012. Levels were not obtained. Resident #17 was readmitted on [DATE] from a hospital stay with orders to continue Tegretol and Phenobarbital Levels every 6 months. On 5/21/2012 these levels were obtained. On 6/26/2012 an order was obtained to draw the Tegretol Level and the Phenobarbital Level. These were obtained 6/30/2012. Resident ' s physician was contacted on 8/4/2012. New orders were received for Tegretol and Phenobarbital level every 6 months from last lab draw of 6/29/2012 (June/December). e. Resident #18 admitted on [DATE] with a [DIAGNOSES REDACTED]. A Phenobarbital Level had been drawn on 8/25/2011 from a previous order prior to the hospital return on 12/24/2011. A Phenobarbital Level was obtained 2/28/12, 6 months after the last level was drawn. An order was obtained for a Phenobarbital Level on 6/26/2012 and obtained 6/28/2012. On 12/23/2011 while in the hospital a Dilantin Level was obtained. On 12/24/2011 readmission an order was received to draw a Dilantin level every 6 months . A new order obtained 1/16/2012 for Dilantin Level. Level was obtained 1/17/2012. Order was written on 2/27/2012 to obtain a Dilantin Level. Level was obtained 2/28/2012. Resident received a Dilantin Level in the emergency roiagnom on [DATE]. On 6/26/2012 an order was obtained to draw a Dilantin Level. Level was obtained 6/28/2012. Resident ' s physician was contacted on 8/3/12 and new orders received for Dilantin level every 6 months from last lab draw of 6/29/12 (June/December) and Phenobarbital level today (8/3/12) and then every 6 months (August/February). Phenobarbital level was obtained on 8/3/12. Residents physician was notified of results on 8/5/2012. No new orders received. f. Resident #19 admitted [DATE] with a [DIAGNOSES REDACTED]. A TSH Level was obtained 8/24/2011 and on 11/02/2011. On 1/4/2012 a TSH was obtained upon admission to the hospital. An order was obtained on 2/27/2012 for a TSH level and it was obtained on 2/28/2012. The next TSH was due August 2012. TSH was obtained on 8/2/2012. Resident ' s physician was notified of results on 8/2/2012 with no new orders received. g. Resident #25-Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Depakote level was obtained on 5/28/2010, 12/03/2010, 2/25/2011, 8/24/2011. Residents physician was contacted on 8/4/2012. New orders received for Depakote level every 6 months (August/February). August lab obtained 8/4/2012. Resident ' s physician was notified on 8/7/2012 with new orders to recheck in one week. h. Resident #20 was admitted [DATE] with [DIAGNOSES REDACTED]. On 1/7/2012 an order was obtained to draw a Tegretol Level this was obtained 1/10/2012. On 2/13/2012 an order was obtained to draw a Tegretol Level and this was obtained 2/18/2012. Resident #20 was admitted to the hospital on [DATE] and discharged from this facility to an outside Hospice on 8/1/2012. i. Resident #21 was admitted [DATE] with a [DIAGNOSES REDACTED]. On 6/22/2010 she was hospitalized and returned 6/23/2010 without orders for a TSH. On 6/26/2012 an order was given by Physician as a one time order to draw a TSH Level and this was obtained 6/29/12. Resident ' s physician was contacted on 8/4/2012 and new orders received for TSH annually in August. Lab was obtained on 8/6/2012. Residents physician was notified on 8/6/2012 of results with no new orders received. j. Resident #22 was admitted [DATE] with [DIAGNOSES REDACTED]. Order was received 1/16/2012 to obtain Dilantin Level and Phenobarbital Level on 1/18/2012. Levels were obtained on 1/18/2012 for a Dilantin Level. No Phenobarbital Level was received. admitted to Senior Care Unit 2/22/2012. A Phenobarbital level was obtained at that time. On 2/27/2012 a repeat Phenobarbital Level was obtained at the hospital. A Dilantin Level and Phenobarbital Level were obtained on 3/5/2012 before hospital discharge. Resident was readmitted with no orders to obtain a Phenobarbital Level nor a Dilantin Level. On 6/29/2012 a one time order was obtained for a Dilantin and a Phenobarbital Level and these were obtained. Physician notified with no new orders received. Residents physician was contacted on 8/4/2012 and new orders were received for Dilantin level and Phenobarbital level every 6 months (August/February). Dilantin and Phenobarbital level were obtained 8/5/2012. Resident ' s physician was notified of Dilantin level on 8/5/2012 and Phenobarbital results on 8/7/2012 with no new orders obtained. k. Resident #23 was admitted [DATE] with a [DIAGNOSES REDACTED]. No orders were received for Lab to draw a depakote level on admission.. Residents physician was contacted on 8/4/2012 with new orders obtained for Depakote, CBC, Magnesium level and Lipid panel every 6 months (August/February and FBS every month. Lab was obtained on 8/6/2012. Resident ' s physician was notified of CBC, Magnesium, Lipid and FBS on 8/6/2012 and Depakote level on 8/7/2012 of all results with no new orders. l. Resident #24 was admitted [DATE] with a [DIAGNOSES REDACTED]. No orders were received for Lab to draw a Dilantin level on admission. Resident ' s physician was contacted on 8/4/2012. New orders were received for Dilantin level and CBC every 6 months (August/February). August lab obtained on 8/5/2012. Resident ' s physician was notified of results on 8/6/2012. New orders were received to recheck Dilantin level in 7 days. Dilantin level obtained and results received on 8/13/2012. Physician was notified with no new orders. m. Resident #1 was admitted on [DATE] on Digoxin with no lab orders to monitor. Resident ' s physician was contacted on 8/4/2012. New orders received for Digoxin level, BMP and CBC every 6 months (August/February) August lab obtained on 8/5/2012. Resident ' s physician was notified on 8/6/2012 of results with no new orders received. n. Resident # 2- Resident physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for CBC every 6 months (August/February) August lab obtained on 8/5/2012. Resident ' s physician was notified on 8/6/2012 of results with no new orders received. o. Resident #3- Resident physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New order received for HgbA1C every 3 months (August, November, February, May), Liver profile and BMP every 6 months starting from last lab draw 4/2012. (April/October) CBC and Lipid Panel every 6 months ( August/February) FBS monthly. August lab was obtained 8/6/2012. Resident ' s physician was notified 8/6/2012 of results with no new orders. p. Resident #4- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for CBC every 6 months from last lab draw 3/23/2012 (March/September) CMP every 6 months from last lab draw 6/6/2012 (June/December). No lab due on this resident for August. q. Resident #5- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for HgbA1c every 3 months (August, November, February, May) CBC, Liver, Potassium level every 6 months (August/February) and FBS every month. August HgbA1c lab obtained on 8/6/2012 and CBC, Liver, Potassium and FBS obtained 8/4/2012. New orders were received to recheck CBC in two months. r. Resident # 6- Resident's physician contacted 8/3/2012 and 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for CBC and Magnesium level every 6 months (August/February) August CBC lab obtained 8/3/2012 and Magnesium level obtained on 8/5/2012. Resident's physician was notified of CBC results on 8/4/2012 and Magnesium level results on 8/6/2012. No new orders received. s. Resident #13-Resident was discharged on [DATE] from facility to home. Implementation of a corrective action plan not instituted. t. Resident #8- Resident's physician contacted on 8/5/2012 regarding residents list of active medications for routine lab monitoring. Resident received no new orders for lab monitoring based on current medication list. u. Resident # 26- Resident's physician contacted on 8/4/2012 regarding residents list of active medications for routine lab monitoring. Lab orders received on 8/4/2012 for HgbA1C every 3 months (August, November, February, May), BMP every 6 months (August/February), FBS monthly. August lab obtained 8/6/2012. Resident ' s physician was notified on 8/6/2012 of the results. No new lab orders received. v. Resident # 27-Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. Lab orders received on 8/4/2012 for FBS every 3 months (August, November, February, May) and BMP, CBC and Magnesium level every 6 months (August, February). August lab obtained 8/6/2012. Resident ' s physician was notified on 8/6/2012 of results. No new lab orders. w. Resident # 28- Resident's physician contacted on 8/3/2012 and 8/4/2012 regarding residents list of active medications for routine lab monitoring. New order received on 8/3/2012 for CBC every 6 months (August/February). New order received on 8/4/2012 for U/A every 6 months (August/February).August CBC lab obtained 8/3/2012 and U/A lab obtained 8/6/2012. Resident's physician was notified of CBC results on 8/4/2012 and U/A results on 8/6/2012 with new orders to obtain U/A in one week. U/A obtained with results received on 8/13/2012. Physician notified with no new orders received. x. Resident # 29- Resident's physician contacted on 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received on 8/4/2012 for HgbA1c every 3 months (August, November, February, May), Liver Profile and Potassium level every 6 months from last lab draw 6/6/2012 (June/December), Lipid Profile and CBC every 6 months (August/February), FBS every month. August lab obtained on 8/6/2012. Resident's physician was notified of the results on 8/6/2012 with no new orders. y. Resident # 30- Resident's physician contacted on 8/7/2012 regarding residents list of active medications for routine lab monitoring. Resident received no new orders for lab monitoring based on current medication list. z. Resident # 31- Resident's physician contacted on 8/3/2012 regarding residents list of active medications for routine lab monitoring. New orders received for CMP every 3 months (August, November, February, May). August lab obtained on 8/3/2012. Resident ' s physician was notified on 8/4/2012 of results with no new orders. aa. Resident # 32- Resident's physician contacted 8/7/2012 regarding residents list of active medications for routine lab monitoring. Resident received no new orders for lab monitoring based on current medication list bb. Resident # 33- Resident's physician contacted on 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for HgbA1c every 3 months (August, November, February, May), BMP, Magnesium level, Trileptal level, Lipid profile and CBC every 6 months (August/February) and FBS every month. August lab obtained on 8/6/2012. Physician was notified of all results. New orders received for Iron, Crestor, Trileptal dosage adjustment, and repeat Trileptal in one week. cc. Resident # 34- Resident's physician contacted on 8/3/2012 regarding residents list of active medications for routine lab monitoring. New orders received for BMP and CBC every 6 months (August/February). August lab obtained on 8/3/2012. Resident ' s physician was notified of results with no new orders received. dd. Resident # 35- Resident's physician contacted on 8/3/2012 and 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for BMP every 3 months (August, November, February, May) and CBC and Magnesium level every 6 months (August/February) August BMP lab obtained on 8/3/2012 and CBC and Magnesium obtained on 8/5/2012. Resident's physician was notified of BMP results on 8/4/2012 and CBC, Magnesium level on 8/5/2012 with no new orders received. ee. Resident # 36- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for HgbA1c every 3 months (August, November, February, May), CBC and Lipid Panel every 6 months (August/February) and FBS every month. August lab obtained on 8/6/2012. Resident's physician was notified on 8/6/2012 of results. New orders to check lipid panel in three months. ff. Resident # 37- Resident's physician contacted on 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received BMP, Magnesium level and HgbA1C every 6 months (August/February). August lab obtained on 8/5/2012. Resident's physician was notified on 8/5/2012 of results with no new orders received. gg. Resident # 38- Resident's physician contacted on 8/3/2012 and 8/4/2012 regarding residents list of active medications for routine lab monitoring. Chem 1 every 3 months ( August, November, February, May), Liver Profile, CBC and Magnesium level every 6 months (August/February) and TSH annually in August. August Chem 1 and Liver profile lab obtained on 8/3/2012 and CBC, Magnesium and TSH obtained 8/5/2012. Resident ' s physician was notified on 8/4/2012 of Chem 1 and Liver profile and physician was notified on 8/6/2012 of CBC, Magnesium and TSH results. Medication dosage adjustment to Synthroid. hh. Resident # 39- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for FBS every month and Liver, Magnesium and Lipid panel every 6 months (August/February) August lab obtained on 8/6/2012. Resident ' s physician was notified of results on 8/ 6/2012. New orders received for Crestor. ii. Resident # 40- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for BMP and HgbA1c every 3 months (August, November, February, May) Magnesium level, CBC, Lipid panel every 6 months (August/February) and FBS every month. August BMP lab obtained on 8/4/2012 and HgbA1c, Magnesium level, CBC, Lipid and FBS lab obtained on 8/6/2012. Resident ' s physician was notified of BMP on 8/4/2012 and HbgA1c, Magnesium, CBC, Lipid and FBS on 8/6/2012 results with no new orders received. jj. Resident #41- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for HgbA1C every 3 months (August, November, February, May) Magnesium Level, CBC and Lipid Panel every 6 months (August/February) FBS monthly. August lab obtained on 8/6/2012. Resident ' s physician was notified of results on 8/6/2012 with new orders to obtain Lipid panel in 3 months. kk. Resident #42- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for HgbA1c every 3 months (August, November, February, May) CBC, Keppra level, Valporic Acid, Magnesium level and Liver Profile every 6 months (August/February). August lab obtained on 8/6/2012. Resident ' s physician was notified on HbgA1c, CBC, Magnesium and Liver profile results on 8/6/2012. Keppra level and Valporic acid are still pending. No new orders received. ll. Resident # 43- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. HgbA1c every 3 months (August, November, February, May) Keppra level, CBC and Valporic acid level every 6 months (August/February) and FBS every monthly. August lab obtained on 8/6/2012. Resident ' s physician was notified of results of HbgA1c, CBC and FBS on 8/6/2012. Keppra and Valporic acid are still pending. No new orders received. mm. Resident # 44- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New orders received for HgbA1c every 3 months (May, August, November, February) CMP and Lipid panel every 6 months from last lab draw of 5/11/12 (May/Nov) FBS monthly. Resident was discharged to the hospital on [DATE] from the Physician office. August lab has not been obtained related to hospitalization on [DATE] with [DIAGNOSES REDACTED]. He was readmitted the Heritage Manor on 8/9/2012 with the same lab orders as mentioned above. An FBS and HgbA1c was obtained on 8/10/2012 and Physician was notified with no new orders. nn. Resident # 45- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New order for Magnesium level every 6 months (August/February). August lab obtained 8/5/2012. Resident ' s physician was notified of results on 8/6/2012 with no new orders received. oo. Resident # 46- Resident's physician contacted on 8/4/2012 regarding residents list of active medications for routine lab monitoring. HgbA1c every 3 months (August, November, February, May) Lipid panel and CBC every 6 months (August/February ) FBS every month. August lab obtained on 8/6/2012. Resident ' s physician was notified of results on 8/6/2012. No new orders received. pp. Resident # 47- Resident's physician contacted on 8/4/2012 regarding residents list of active medications for routine lab monitoring. New order obtained 8/4/2012 for HgbA1c every 3 months (August, November, February, May) Potassium level and Magnesium level every 6 months ( August/February) FBS every month. August lab obtained on 8/6/2012. Resident ' s physician was notified of results on 8/6/2012 with no new orders received. qq. Resident # 48- Resident's physician contacted 8/4/2012 regarding resident ' s list of active medications for routine lab monitoring. New orders received for HgbA1c every 3 months (August/November, February, May) Liver profile, CBC, Lipid panel every 6 months (August/February) FBS every month. August Liver profile lab obtained on 8/4/2012 and HgbA1C, CBC, Lipid panel and FBS obtained on 8/6/2012. Resident ' s physician notified of results of Liver profile on 8/4/2012 and HgbA1c, CBC, Lipid and FBS on 8/6/2012. No new orders received. rr. Resident # 49- Resident's physician contacted 8/4/2012 regarding residents list of active medications for routine lab monitoring. New order received for CBC every 6 months (August/February). August lab obtained on 8/6/2012. Resident ' s physician was notified on 8/6/2012 of results with no new orders. The following measures that have been put in place to ensure the deficient practice will not recur are as follows: a. Facility has identified all RN's (Registered Nurses) and LPN ' s (Licensed Practical Nurses). No nurses will be allowed to work until he/she has been inserviced on the following; Physicians Orders; transcription and implementation of Physicians Orders, standing orders, pharmacy services, and Laboratory Policies and Procedures. Facility Inservice completed by DON#1 and Administrator #1. Directed Inservices completed by RN# 2 and RN # 3 to cover these topics, Physicians Orders; transcription and implementation of Physicians Orders, standing orders, pharmacy services, and Laboratory Policies and Procedures on 8/7/2012. Staffing schedule for RN ' s and LPN ' s have been reviewed and adjusted. No nurses will be allowed to work until he/she has been inserviced. No agency staff will be placed on schedule until inservicing on laboratory policies and procedures are complete. All directed inservices to Licensed Staff was completed on 8/20/2012. DON #1 has resigned as of 8/17/2012 and DON #2 started her employment 8/20/2012. Don #2 received all of the directed inservices on 8/20/2012 by RN #2. b. Lab draws will be performed by Licensed Staff (RN's and LPN's) and transported, daily, if needed, after each blood draw is obtained by facility staff to a local lab for processing. The Director of Nursing, RN staff nurse or Weekend RN Supervisor will track ordered labs using a Lab Monitoring System in order to ensure labs have been drawn as ordered, results have been received, results have been placed on charts, Physician has been notified, and orders, if any, have been followed through as related to lab results. Medical Records clerk will audit the Resident ' s charts weekly to ensure ordered labs have been received and are on charts. c. On 8/1/2012 a Lab Monitoring System has been developed and implemented and included in directed inservices mentioned above. The Monitoring system is as follows: ? When an order for [REDACTED]. ? The Director of Nursing, RN staff Nurse or Weekend RN Supervisor will check the appointment calendar daily and update lab that was drawn on the Lab Log (Appendix J) and the results of this monitoring will be recorded on Appendix A (attached). ? The Director of Nursing, RN staff nurse or Weekend RN Supervisor will follow-up to make sure lab was drawn, new orders, if any, were carried out, Physician has been notified of results and new orders for labs have been completed and added to the appointment calendar, if needed. ? The Director of Nursing, RN staff nurses or Weekend RN Supervisor will monitor new admit orders and newly ordered medications to ensure appropriate labs have been ordered and placed on Appointment Calendar. The results of this monitoring will be recorded on Appendix A (attached). d. The Pharmacy Consultant (PC#1) was notified on 8/1/2012 at 8:56 PM of lab and physician order [REDACTED].#1)has completed a 100% audit of charts on 8/3/2012. All Pharmacy Recommendation

Based on observation, staff interview, record review, Pharmacist report review, and policy review, the Medical Director failed to ensure that the facility implemented resident care policies and failed to coordinate care in the facility for five (5) of five (5) residents reviewed. The facility failed to ensure that residents receiving [MEDICATION NAME] had [MEDICATION NAME] Time /International Normalized Ratios (PT/INR) lab work done per physician's orders [REDACTED].#7, #9. #10, #11, and #12). Additionally, the facility failed to ensure that residents receiving [MEDICATION NAME] were monitored for the effectiveness of the medication correct dosage. [MEDICATION NAME] Time/International Normalized Ratios (PT.INR) was not done per physician's orders [REDACTED].#11 and #12). A standard survey was conducted from 07/31/12 to 08/02/12 and the extended survey was conducted from 08/02/12 to 08/03/12. During the survey, the facility was found not be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy was identified on 08/01/12 at 5:25 p.m. and the Administrator and Director of Nursing were notified at that time. The Immediate Jeopardy was determined to begin on 08/01/12. The facility submitted an Allegation of Compliance on 08/02/12 at 5:15 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 08/03/12 and is considered ongoing. Findings include: Cross refer to F-281 for the facility's failure to ensure that the residents receiving [MEDICATION NAME] had [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) lab work done per physician's orders [REDACTED].#10, #11, and #12. Cross refer to F-309 for the facility's failure to ensure that Residents receiving [MEDICATION NAME] were monitored for the effectiveness of the medication correct dosage. Cross refer to F-428 for the facility's failure to review and act upon the irregularities noted/made by the Pharmacist as a result of the monthly. Based on the resident care concerns identified during the survey, the survey team attempted to interview the Medical Director related to the deficient findings identified at F-281, F-309, and F-428. However, the survey team was not successful in obtaining an interview as evidenced by the following: Interview on 08/01/12 at 12:30 p.m. with personnel at the Doctor's office, revealed that Physician #1 is out to lunch, try back about 2:30 p.m." Interview on 08/01/12 at 3:30 p.m. with personnel at the Doctor's office, revealed that Physician #1 "doesn't have time". Interview on 08/02/12 at 3:35 p.m. with personnel at the Doctor's office, revealed that Physician #2 only works Monday through Wednesday but he is out of town on family vacation and (Physician #1) is covering." A letter received by the doctor's office dated 08/03/12 revealed that "(Physician #2) is on an airplane in route to Boston today."

Based on observation, record review, policy review and documentation provided, the facility failed to identify through an effective quality assurance program the system failures related to physician order [REDACTED]. The facility failed to ensure that residents receiving [MEDICATION NAME] had [MEDICATION NAME] Time/International Normalized Ratios (PT/INR) lab work done per physician's orders [REDACTED].#7, #9, #10, #11 and #12), and also failed to conduct other various lab studies as ordered by the physician for these same five (5) residents. In addition, the facility failed to respond to the reviews conducted by the pharmacist for five (5) of five (5) residents (Residents #7, #9, #10, #11 and #12). A standard survey was conducted from 07/31/12 to 08/02/12 and the extended survey was conducted from 08/02/12 to 08/03/12. During the survey, the facility was found not be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy was identified on 08/01/12 at 5:25 p.m. and the Administrator and Director of Nursing were notified at that time. The Immediate Jeopardy was determined to begin on 08/01/12. The facility submitted an Allegation of Compliance on 08/02/12 at 5:15 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 08/03/12 and is considered ongoing. Findings include: Cross refer to F-281, F-309, F-428 and F-501 for the facility's failure to have an effective quality assessment and assurance program by failing to identify, monitor and conduct laboratory testing per the physician's orders [REDACTED]. Resident #11 Record review revealed that Resident #11 was admitted to the facility 3/16/06, and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview of Mental Status score of 0, indicating Resident #11's cognitive status was severely impaired. Observation on 8/2/12 at 8:10 a.m. revealed Resident #11 was lying on the bed in her room and well groomed. Review of the August 2012 physician's orders [REDACTED]. Review of PT/INR results obtained 8/2/12 revealed a physician's orders [REDACTED]. dose. Pt (patient) to receive [MEDICATION NAME] 2 mg (milligrams) on each night Mon - Fri. (Monday - Friday). Pt to receive [MEDICATION NAME] 4 mg on Sat (Saturday) and Sunday. Recheck PT/INR in 7 days... " There was an order for [REDACTED]. Resident #12 Record review revealed that Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 0, indicating Resident #12's cognitive status was moderately impaired. Observation on 8/2/12 at 11:47 a.m. revealed Resident #12 was seated in a wheelchair in the lobby area. Review of August 2012 physician's orders [REDACTED].? x 3 mg PO (by mouth) @ (at) HS (hours of sleep) Tues (Tuesday) & (and) Thur (Thursday) for [MEDICAL CONDITION]/Circulation. There was an order, dated 1/27/12, for [MEDICATION NAME] (Sodium [MEDICATION NAME] Sodium) 3 mg PO @ HS Mon (Monday)-Wed (Wednesday)-Fri (Friday)-Sat (Saturday)-Sun (Sunday) for [MEDICAL CONDITION]/Circulation. There was an order, dated 1/27/12, for PT/INR ([MEDICATION NAME] Time and International Normalized Ratio) QMO (every month). Record review there was no documentation of PT/INR results for 3/12, 4/12, 5/12 and 7/12. Review of lab work, dated 8/1/12, revealed the following results: PT- 42.3, INR 4.2. Review of lab work, dated 8/3/12 revealed PT - 58.7, and INR 4.9. Review of the physician's orders [REDACTED]. Recheck in 3 days 08/06/12." Resident #7 Record review revealed that Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview of Mental Status score of 12, indicating Resident #7's cognitive status was moderately impaired. Observation on 8/1/12 at 10:20 a.m. revealed Resident #7 was up in the wheelchair in the day room participating in activity. Review of the August 2012 physician's orders [REDACTED].@ (at) HS (bedtime) M-W-F (Monday-Wednesday-Friday) Circulation. " There was also an order [REDACTED]. Record review revealed that there was no documentation for PT/INR ([MEDICATION NAME] Time and International Normalized Ratio) results for 1/12, 3/12, 4/12, 5/12, 6/12, and 7/12; there was no documentation of CMP (Complete Metabolic Panel) results since 11/11; there was no documentation of a Lipid result since 6/11, and there was no documentation of a FBS (Fasting Blood Sugar) result since 11/11. Interview on 8/1/12 at 10:30 a.m. with the Director of Nurses regarding lab work revealed the (DON) stated, "I can't find any for the PT since 2/28/12, no CMP (Complete Metabolic Panel) since 12/12/11, I called the lab and they don't have any lab results either." Review of the facility's "Lab Work: policy, revised 8/08, noted " 1. Lab will be reviewed by Consultant Pharmacist on a monthly basis related to medication therapy. 2. Facility will develop a "tickler system" to monitor labs as ordered and done to maintain compliance. 3. Lab monitoring is a facility responsibility in conjunction with Pharmacist who will review monthly. " Review of the facility's "Laboratory Services" policy, revised 4/12, noted, " 1. The facility will provide or obtain the services of a clinical laboratory to meet the needs of the residents. 2. The facility will have an agreement to obtain the services from a lab that is approved for participation in the Medicare program either as a hospital or as an independent laboratory. 3. Laboratory services can be performed only when ordered by the attending physician. 4. The attending physician will be notified of abnormal laboratory results promptly after the facility has been advised of the results. "Guidelines for Reporting Abonormal (Abnormal) Test Results to Physician's" may be used when determining physician next office day notification. The notification of the physician will be documented in the medical record ... 7. All lab work must be retained in the residents chart and abnormal finding documented with report results and follow up from physician. " Review of the facility's "Suggested Laboratory Test" policy, revised 4/12, noted, " ... 6. Fasting blood sugar monthly for residents taking insulin ... 9. [MEDICATION NAME] INR at least monthly in residents receiving [MEDICATION NAME]/([MEDICATION NAME]) ... " Interview, via telephone, on 8/1/12 at 1:50 p.m. with the Registered Pharmacist (RPH) regarding the missing lab on charts revealed the RPH stated, "The problem is lab sends copy to the doctor and the facility relies on MD office to call with any changes. I look at the lab one month behind and send a report to the DON. In some other homes, the doctor and the facility get a copy of lab. The facility should cover this in high risk management meetings." Interview on 8/3/12 at 10:55 a.m. with the Registered Pharmacist revealed "After completing reviews, if something is serious it is brought to the DON's attention. After the report is finished, I send it to the facility ... " Interview on 8/3/12 at 9:18 a.m. with the Physician #1 regarding lab work not being obtained, revealed Physician #1 stated: "There are orders for labs, I don't know why they didn't get done. Resident #9 Record review revealed that Resident #9 was admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 0, indicating Resident #9's cognitive status was severely impaired. Observation on 8/2/12 at 11:52 a.m. revealed Resident #9 was in bed in the room with her eyes closed. Review of August 2012 physician orders [REDACTED]. Record review revealed there was no documentation of PT/INRs for 4/12, 5/12, 6/12 and 7/12; there was no documentation of a B12, and there was no Liver Profile for 7/12 provided. Resident #10 Record review on 8/21/12 revealed that Resident #10 came to the home on 9/24/09 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, indicating Resident #10 was cognitively intact. Observation on 8/2/12 at 4:00 p.m. revealed Resident #10 was lying supine and was alert to name and place. Review of August 2012 physician's orders [REDACTED].@ (at) HS (hours of sleep) M-W-F (Monday, Wednesday, Friday; SUN (Sunday); [MEDICAL CONDITIONS]/Circulation. Review of the August 2012 physician's orders [REDACTED]. There was no documented evidence of PT/INRs for 11/11, 1/12, 2/12, 3/12, 4/12, 5/12, 6/12 and 7/12; there was no documentation of [MEDICATION NAME] for 2/12; there was no documentation of Ferritin levels since 2/12; there was no documentation of Protein since 2/12; there was no documentation of Iron since 2/12; there was no documentation of CBC since 2/12, and there was no documentation of CMP since 2/12. Review of the Pharmacist's monthly consultative reports, revealed that the Pharmacist documented that laboratory testing was not being conducted for residents as follows: Resident #7 -- PT/INR for 09/11, 2/12, 4/12, 5/12, 6/12, and 7/12. Resident #9 -- PT/INR for 09/11, 11/11, 12/11, 1/12, 2/12, 3/12, 4/12, 5/12, 6/12, and 7/12; Resident #10 -- PT/INR for 12/11, 2/12, 3/12, 4/12, 5/12, 6/12, and 7/12; Resident #11 -- PT/INR for 10/11, 12/11, 1/12, 5/12 and 7/12; Resident #12 -- PT/INR for 9/11, 4/12, 5/12, and 6/12. The facility failed to respond to the reviews conducted by the Pharmacist based on the lack of corrective action taken to conduct laboratory testing as ordered by the physician.

Based on observation, record review, policy review and documentation provided, the facility failed to ensure that residents receiving [MEDICATION NAME] were monitored for the effectiveness of the medication correct dosage. [MEDICATION NAME] Time/International Normalized Ratios (PT/INR) lab was not done per physician's orders [REDACTED].#11 and #12). A standard survey was conducted from 07/31/12 to 08/02/12 and the extended survey was conducted from 08/02/12 to 08/03/12. During the survey, the facility was found not be in substantial compliance with Medicare and Medicaid requirements. An Immediate Jeopardy was identified on 08/01/12 at 5:25 p.m. and the Administrator and Director of Nursing were notified at that time. The Immediate Jeopardy was determined to begin on 08/01/12. The facility submitted an Allegation of Compliance on 08/02/12 at 5:15 p.m. and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on 08/03/12 and is considered ongoing. Findings included: Resident #11 Record review revealed that Resident #11 was admitted to the facility 3/16/06, and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview of Mental Status score of 0, indicating Resident #11's cognitive status was severely impaired. Observation on 8/2/12 at 8:10 a.m. revealed Resident #11 was lying on the bed in her room and well groomed. Review of the August 2012 physician's orders [REDACTED]. Review of PT/INR results obtained 8/2/12 revealed a physician's orders [REDACTED]. "Adjust pt's (patient's) [MEDICATION NAME] dose. Pt (patient) to receive [MEDICATION NAME] 2 mg (milligrams) on each night Mon - Fri. (Monday - Friday). Pt to receive [MEDICATION NAME] 4 mg on Sat (Saturday) and Sunday. Recheck PT/INR in 7 days... " There was an order for [REDACTED]. Resident #12 Record review revealed that Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 0, indicating Resident #12's cognitive status was moderately impaired. Observation on 8/2/12 at 11:47 a.m. revealed Resident #12 was seated in a wheelchair in the lobby area. Review of August 2012 physician's orders [REDACTED].? x 3 mg PO (by mouth) @ (at) HS (hours of sleep) Tues (Tuesday) & (and) Thur (Thursday) for [MEDICAL CONDITION]/Circulation. There was an order, dated 1/27/12, for [MEDICATION NAME] (Sodium [MEDICATION NAME] Sodium) 3 mg PO @ HS Mon (Monday)-Wed (Wednesday)-Fri (Friday)-Sat (Saturday)-Sun (Sunday) for [MEDICAL CONDITION]/Circulation. There was an order, dated 1/27/12, for PT/INR ([MEDICATION NAME] Time and International Normalized Ratio) QMO (every month). Record review there was no documentation of PT/INRs results for 3/12, 4/12, 5/12 and 7/12. Review of lab work, dated 8/1/12, revealed the following results: PT- 42.3, INR 4.2. Review of lab work, dated 8/3/12 revealed PT - 58.7, and INR 4.9. Review of the physician's orders [REDACTED]. Recheck in 3 days 08/06/12."

Based on record review, observation, and interview the facility failed to ensure that a resident who returned to the facility without pressure ulcers did not develop pressure ulcers or have worsening of pressure ulcers for one (1) of two (2) residents reviewed (Resident #5). Resident # 5 returned to the facility from the hospital on [DATE] and review of the Initial and Quarterly Nursing Data Skin Audit, dated 1/25/11 revealed no skin issues on the right and left heel. Nurse ' s notes on 1/30/2011 revealed blisters on the right heel and left heels. Findings include: Record review revealed that Resident # 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Initial and Quarterly Nursing Data Skin Audit dated 1/25/11 at 3:50 pm revealed no skin issues on the right and left heel. Review of the nurses notes at dated 1/30/2011 at 4:15 p.m. revealed that the resident had blisters on the right and left heels. There was no documented evidence of physician notification. The right heel measured 4 ? centimeters (cm) x (times) 4 cm and was described as a closed red purple no drainage. Surrounding tissue pink and dry. The left heel measured 3 ? cm x 3 ? cm and was described as a closed red purple blister. Review of the Documentation Record dated 1/31/2011 revealed the right heel stage I 4 x 3.6 cm dark reddish black in color without opening soft to touch surrounding skin firm and flesh color. The left heel was described as a Stage I 2.3 x 4 cm dark reddish in color soft to touch without opening surrounding skin pinkish red. Documentation on 1/31/11 revealed that the physician was notified. Resident #5 was hosptalized on [DATE] and returned on 2/4/2011 with the admitting [DIAGNOSES REDACTED]. Review of the Wound/Skin Management Documentation Record dated 2/4/11 revealed the Stage I ulcer on the left heel measured 2.3 x 4 cm and the Stage I ulcer on the right heel measured 4 x 3.6 cm. Review of the 2/9/11 on the Wound/Skin Management Documentation Record revealed a Stage II ulcer on the left heel which measured 2.3 x 4 cm. The right heel was described as unstageable - slough and/or eschar. The ulcer measured 4 x 3.6 cm. Review of the nurse's notes on 2/18/2011 revealed the resident had fluid filled blister on the left heel blackish in color with a pinpoint opening and clear drainage. The right heel was described as being black, but firm. The note indicated the physician was notified by fax. There was no documented follow up or response to the fax. Interview with RN #1 confirmed that there was no documented evidence of response to the fax on 9/16/11 at 1:57 p.m.. Review of the Nutritional Screening and Evaluation dated 2/1/2011, 2/11/11, and 3/3/11 revealed "None" was checked for Ulcers, Wounds, or other skin problems. Review of the RD (Registered Dietitian) Nutrition assessment dated [DATE] addressed Resident #5's ulcers. Review of the High Risk Management Committee Policy (4/07 revision) revealed that weekly meeting must be held to address resident ' s needs and reevaluated to assess outcomes and any need to change the plan of care. Meeting Minutes revealed the facility documented meetings on 2/8/11, 2/22/11, and 3/8/11 for Resident #5. Review of High Risk Management Meeting Minutes revealed: Problem Week #1 dated 2/8/11 revealed ulcers bilateral heels with interventions to float heels and heel protectors in bed. The next entry Follow Up Week # 2 is dated 2/22/11 and indicates no change/healing with the intervention for wound care consult and continues to float heels. Follow Up Week #3 dated 3/8/11 reveals the right heel debrided 3/1/11 healing and left heel blister with the intervention to elevate bilateral lower extremities, continue with treatment from wound center and float heels. Phone interview on 9/16/2011 at 1:57 PM, with RN (Registered Nurse) #1 confirmed that there were no additional notes for review. Review of the section for Treatment Orders in the Wound Care Manual Skin Care Program (Latest Revision: 06/11) revealed that after observation/evaluation of the affected skin care area, the physician is to be notified for treatment orders. Review of the nburse's notes dated 2/22/11 revealed that the physician made rounds and gave an order to send to wound care for treatment and care of bilateral heel ulceration. Review of the Patient Progress report from the wound care center on 3/1/2011 revealed the right foot pressure ulcer status was healed. Observations on 9/1/2011 at 5:00 p.m. revealed that Resident #5 was in the lobby with a heel protector on the left foot. There were no concerns identified during observation of wound care to the left heel on 9/2/2011 at 2:20 pm.