Every finding on record at Silver Spring

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly in the kitchen. The facility failed to dispose of foods after the use by / shelf-life date.These failures could place residents that eat out of the kitchen at risk for food borne illnesses.The findings included:During an observation on 01/28/2026 between 12:39 p.m. and 1:20 p.m., the kitchen revealed: Dry Storage: 1. One opened bag of chips in a see-through plastic bag that was closed to air labeled chips 1-14 UB 1-17 (11 days past),2. One unopened bag of what appeared to be 12 hamburger buns not labeled with a received date, use by date, or item description.3. One opened box of 6 flour tortilla with three unopened bags and one opened bag of tortillas in the box. All bags of tortillas had a best by date of 11/17/2025. Refrigerator Storage for 1 of 2 refrigerators:1. Two cartons of heavy whipping cream with best by date of 01-26-26 (2 days past),2. Two bags of corn tortillas with best by date of 12/21/25 (38 days past),3. One opened bag of what appeared to be white shredded cheese labeled with the date 1-26-26 with no use by date or item description.4. One opened container of pimento spread with no received date and the use by date was not legible,5. One unopened bag of what appeared to be hot dogs with a date of 1-14 written on top with no use by date or item description.6. One see-through plastic container of prepared food without a preparation date, use by date, or item description, and 7. One metal tin container of prepared food without a preparation date, use by date, or item description. Freezer Storage for 2 of 3 freezers:1. One opened bag of what appeared to be french fries that was not sealed, no delivered date, no use by date, or no item description.2. Three unopened bags of what appeared to be garlic toast labeled with 1-24, there was no use by date or no item description.During an observation on 01/28/2026 at 1:20 p.m., the kitchen had multiple postings that reflected Everything must have a label! Received Date Open Date Use by date.During an interview on 01/28/2026 at 12:30 p.m., the ADMN and the DON stated all residents ate out of the kitchen.During an interview on 01/28/2026 at 1:01 p.m., the DM stated all food items stored outside of their original container should have a received date and an item description labeled on them. She stated if that item had a use by date, that date needed to be labeled on the package as well. She stated items should not be stored past the best buy date and she would dispose of those items. She stated the UB on a label meant use by and the chips should have been discarded after that day. She stated foods that were prepared and being stored in the refrigerator should have an item description, and a date that the food needed to be used by. She stated not labeling food items appropriately and not discarding food appropriately could lead to residents becoming ill. She stated the person storing the food item was responsible for labeling the food and she monitored that food was stored appropriately. She stated she did not know why there were foods stored past the use by/best buy date or that they were not labeled appropriately.During an interview on 01/28/2026 at 4:55 p.m., the [contract dietary] Director of Operations stated she expected foods to be stored and labeled following the policy of the company. She stated the DM would take pictures of the food storage areas and she would review them daily through pictures on her phone when she was not present in the facility. She stated she was not sure why there were items of food not labeled appropriately with the item description, use by date, and received by date on them. She stated foods should be discarded when the use by date had passed. She stated not storing, labelling foods, and discarding foods appropriately could lead to potential illness. During a telephone interview on 01/29/2026 at 4:13 p.m., the dietician stated she did monitor the facility at that time but was not able to be in the facility frequently because she lived out of state. She stated the food company had been trying to hire a local dietician for the facility but did not have any interest in the position. She stated it was her expectation that all foods should be labeled with a description. She stated all foods should have an expiration date labeled if the foods were stored outside of their original packaging and should be discarded after the expiration date. She stated some foods would not require an expiration date but that if there was one on the original packaging, that date would need to be written on the packaging. She stated fresh vegetables would not have an expiration date and the dietary staff would go off of how the food appeared. She stated only items that had been opened would need an open date on them. She stated not labeling the foods properly or discarding them properly could cause a resident to become sick from eating a food that was no longer viable or inappropriate for them. She stated the dietary manager monitored that foods were labeled appropriately. During an interview on 01/30/2026 at 2:30 p.m., the ADMN stated his expectation would be for foods to be stored, labeled, and discarded per the dietary policy. He stated the DM was responsible for making sure the policy was followed. He stated the dietary staff were contracted as well as the dietitian. He stated the contracted company had corporate supervision that occurred weekly and the dietitian monitored monthly. He stated if the policy for food storage, labeling, and disposal was not followed it could cause residents to have GI discomfort and possible infection. Record review of the facility document titled MDS Resident Matrix, dated 01/28/2026, reflected no residents received enteral feeding (a method of delivering nutrition directly into the gastrointestinal tract through a feeding tube, used when oral intake is insufficient or unsafe). Record review of the facility policy titled Dry Goods Storage Policy and Procedure, no date, reflected: Storage areas shall be organized and maintained in a manner that allows for easy identification and access to items, with all goods appropriately date labeled.Record review of the facility policy titled Cold Food storage Policy and Procedure, no date, reflected: To prevent cross-contamination, all foods must be stored in a manner that is wrapped, covered, or contained within labeled and dated packages or containers. Review of the Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code, accessed 1/14/2026 reflected 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 2 (Resident #14 and Resident #79) of 81 residents reviewed for food and nutrition services. The facility failed to follow the menu for Resident #14 and Resident #79 on 01/28/2026. This failure could place residents at risk of poor intake from being disappointed they did not receive the menu items listed. Findings included: Resident #14Record review of Resident #14's Face Sheet dated 01/30/2026 revealed a [AGE] year-old female, was admitted on [DATE].Resident #14's medical diagnoses included unspecified dementia, cerebral infarction (stroke), weakness, reduced mobility and lack of coordination. Record review of Resident #14's Annual MDS dated [DATE] revealed in Section C - C0500. BIMS Summary Score of 08 indicating the resident was moderately impaired. Record review of Resident #14's Comprehensive Care Plan initiated 05/29/2019 and reviewed/revised 02/13/2024 revealed the following focused areas: *Nutrition: The resident has nutritional problems or potential nutritional problems r/t depression, Record review of Resident #14 Nutrition Assessment dated 05/08/2025 revealed; daily calories required: 1618 kcals. need more than provided daily via meals, supplements to promote healing. Record review of Resident #14's physician orders reviewed on 01/30/2026 revealed: Regular diet Dys Puree (Dysphasia Pureed Level 1) texture, Nectar consistency, speech therapy recommends resident be assisted with feedings, resident may use weighted spoon and plate guard to assist with feedings. for Difficulty chewing. Record review of Resident #14's Progress Notes dated 01/30/2026 with effective date of 08/19/2025 revealed .resident with noted weight fluctuations. Diet downgraded on 5/29/2025 and house supplements increased as well. Kennedy ulcer noted. Weight loss may be expected due to hospice/Kennedy ulcer. At risk for malnutrition due to Dysphagia Puree diet and wound. Resident #79Review of Resident #79's Face Sheet dated 01/30/2026 revealed a [AGE] year-old male initially admitted on [DATE] with a recent admission date of 01/14/2025 Resident #79's medical diagnoses included metabolic encephalopathy, diabetes mellites, obstructive and reflux uropathy, dementia, age related cognitive decline and cognitive communication deficit. Record review of Resident #79's Annual MDS dated [DATE] revealed in Section C - C0500. BIMS Summary Score of 00 indicating the resident was unable to complete the interview. Record review of Resident #79's Comprehensive Care Plan initiated 04/18/2018 and reviewed/revised on 12/27/2023 revealed the following focused areas: Nutrition: *Focus: The resident has nutritional problem [sic] or potential nutritional problem r/t depression *Goal: The resident will maintain adequate nutritional status as evidenced by maintaining wight within 10% of 170, no s/sx of malnutrition, and consuming at least 50% of at least 3 meals daily. *Interventions: Provide and serve diet as ordered. Review of Resident #79's Nutrition Assessment dated 11/19/2025 revealed; Goals: PO intake >75%, weight maintenance,wound healing. Record review of Resident #79's Nutrition Progress Note dated 01/27/2026 revealed: Regular Puree diet. Intake has been poor, most meals </= 50%. Resident receiving set-up and 1:1 feeding assistance.Resident is at risk for unavoidable weight loss, dehydration, skin decline r/t disease progression. Goal for comfort. Rec offerhouse supplement 60cc TID or as tolerated to sip if desired. Record review on 01/28/2026 of the facility menu Fall/ Winter, dated 25-26, Wednesday Week 5 revealed: Puree- Beef Stew, pureed, Salad, garden with dressing, pureed, Bread, Cornbread, Pureed, Apple slices, baked pureed. During an observation on 01/30/2026 at 5:36 p.m., the DM made the pureed food tray for Resident #14. On the tray there was pureed beef stew, pureed mixed vegetables, and pureed baked apples. There was no pureed cornbread placed on Resident #14's meal tray. The kitchen staff gave the dining room staff the tray for distribution to Resident #14. During an observation on 01/30/2026 at 5:50 p.m., observed the DM make the pureed food tray for Resident #79. On the tray there was pureed beef stew, pureed mixed vegetables, and pureed baked apples. There was no pureed cornbread placed on Resident #79's meal tray. The tray was placed on a cart for residents who ate in their rooms. During an observation on 01/30/2026 at 5:57 p.m., observed the DW pushed the cart with Resident #79's tray out of the kitchen and into the hallway area for distribution. CNA A and CNA B were observed as handing out the food trays to residents. During an interview on 01/30/2026 at 5:57 pm, CNA B stated she checked the trays for menu items and the right consistency of the food such as pureed or regular diets but did not catch the cornbread was not on the resident tray. During an interview and observation on 01/28/2026 at 5:58 p.m., the DM stated there should have been pureed cornbread provided to the two residents who had pureed diets. She left the kitchen and went down the hall to obtain Resident #79's tray. She came back and placed the pureed cornbread on the tray after surveyor intervention. She stated Resident #14 was no longer in the dining room eating. The DM stated she overlooked the cornbread since it was not in the same location as the other prepared pureed foods. She stated all residents should have been given all items that were listed on the menu. During an interview on 01/28/2026 at 6:00 p.m., the contracted company's Director of Healthcare Operations stated, residents on a pureed diet should have received all the menu items on the menu. She stated not providing all items could have led to weigh loss. During a telephone interview on 01/29/2026 at 4:13 p.m., the dietician stated she expected residents to be offered all foods on the menu. She stated the person plating the food was the first check that all menu items were provided and then nurse would be a second check. She stated not giving residents the opportunity to consume pureed cornbread could lead to calorie deficiency. During an interview on 01/30/2026 at 10:04 am, Resident #14 stated she liked cornbread and if it were on her tray she would have eaten it. During an interview on 01/30/2026 at 10:10 am, the DON stated that the ADMN monitored dietary overall. She stated that as the trays were being delivered to residents, the nurses should have been checking the trays and making sure residents had received what was listed on the menu. She stated her expectations were for residents to be provided what was on the menu. The DON stated for one of the missed resident puree's, the resident had not been eating anyway, so it did not matter whether he had gotten his cornbread or not. She stated she felt there was no negative effect on the residents in not receiving their cornbread. During an interview on 01/30/2026 at 2:45 pm, the ADMN stated all residents should get what was provided on the menu. He stated the first line of checking trays should be monitored by dietary prior to going to the resident, and if going to the hallway, a second check should have been performed. He stated that all trays from the ticket should have matched the food that was being delivered. The ADMN stated his expectations was that all items were placed appropriately on resident trays.The ADMN stated he thought the negative impact for residents was, if this failure consistently occurred in dietary and nursing staff, the residents that had not received an item could turn to a decrease in nutrients. Record review on 01/30/2026 of the facility's' undated policy Meal Service and Distribution Policy and Procedure, revealed; .4. Verification of Meal Delivery; The nursing staff is tasked with checking that meals are accurate to the resident's/patients' diet order and that delivery is both prompt and correct.5. Point-or-Service Dining Assembly; Under the supervision of licensed nursing personnel, Dietary Services staff will prepare meals according to each resident'/patient's individual meal card at the point of service, thereafter, presenting it directly to the resident/patient or to care staff for delivery.

Based on observation, interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety anfor 1 of 8 (Resident #1) resident reviewed for staffing, in that: Facility failed to ensure licensed nurses and nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents need. Facility nurse aides failed to relay resident complaint of pain to appropriate nurse after a fall so that resident could be promptly assessed. Facility nurse failed to provide the on-coming nurse with information about the residents assisted fall from earlier in the day in order for resident to be monitored. Facility nurse aides and staff (PT) moved a resident after a fall without a nurse completing an assessment of resident for pain or injury. Facility nurses did not fully assess resident pain before administering pain medication. An Immediate Jeopardy (IJ) situation was identified on 6.23.25. The IJ template was provided to the facility on 6.23.25 at 4:20 pm. While the IJ was removed on 6.25.25 at 4:27 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could put residents at risk of not being provided care by nursing staff with sufficient skills/training. Findings included: Record review of Resident #1's face sheet dated 6.5.25 revealed Resident #1 was admitted on 4.8.25 and was [AGE] years old. Resident #1 had diagnoses of metabolic encephalopathy (a condition where a systemic health issue or imbalance impairs brain function, causing a range of symptoms from confusion and memory loss to coma), type 2 diabetes, cirrhosis of liver (a condition where healthy liver tissue is replaced by scar tissue, preventing the liver from functioning properly), and sepsis due to Escherichia coli (occurs when an E. coli infection spreads to the bloodstream and triggers a dangerous overreaction of the body's immune system, potentially leading to organ damage and even death). Record review of Resident #1's comprehensive care plan reflected: No Care plan available. Resident #1 was only in building for 6 hours total. Record review of Resident #1's medical record dated 4.9.25 indicated: Department of Radiology and Nuclear Medicine. Exam: {lain films of the left knee (xray). Findings: On the AP view there is a cortical irregularity in the lateral distal femoral metaphysis consistent with fracture (fracture of femur). Record review of Resident #1's admit/readmit form indicated all sections to be completed by LVN A except for section mobility/safety. Record review of Resident #1's progress notes dated 4.8.25 indicated: Late Entry: Note Text: Pt. family member approached this nurse and reported that Pt. is c/o pain to the leg, according to family member the pain was R/T fall. This nurse explained to the family member that no fall, was reported during shift change. This nurse f/u to find out from Pt. when the fall occurred. It was reported that prior to shift change the resident was lowered to floor during toileting due to her legs getting too weak to stand. Pt. stated, I was being cleaned up in the restroom while standing and my legs gave up on me and sat in the floor. Head to toe assessment was completed, Pt. was A&O x2. Pt. was able to move the upper limb but refuse to move the lower limb and complained pain of 12 to the whole of left. Comparing L-leg to right leg, no shortness was noted however, Slight swelling was noted to left knee, but this nurse couldn't confirm if that was R/T fall because it was the 1st time seeing this Pt. Family explained that was not normal for Pt. Acetaminophen 325 mg po x 2 tabs was administered per order. Vital signs: T-97.3, BP-141/94. Day nurse, LVN A was contacted due to Pt. complain of fall, and LVN A said CNA B reported that Pt. had assisted fall. This explained to family that X-ray will be done to find out what was causing the pain but for stat X-ray pt. might has to transfer to the ER for and family said yes. EMT was contacted and at 9:03 pm Pt. together with family members left the facility to the ER. DON notified. During an interview on 6.3.25 at 11:45 am CNA B stated the resident was brand new that day. She stated that when she went to answer the call light the resident was already in her wheelchair. She stated before she went to the restroom, she asked the resident how stable she was and if she needed much help because she was not sure how much assistance the resident needed. She stated that the resident told her that at the hospital she really didn't even need much assistance to transfer from wheelchair to toilet. She stated that she took the resident to the restroom and told the resident to use her call light after she was done, and she would come help her. She stated the resident used to the call light indicating resident was complete. She stated that CNA D and herself went to the resident's room and went to assist the resident off the toilet. She stated the resident stood up and she was standing behind the resident while CNA D was on the front/side of the resident. She stated the resident stood fully up, then stated I can't do this, and went to sit back down. She stated the resident started to sit down and slowly slid down to the ground, basically using her legs as a slide down to the floor landing on her foot. She stated that CNA C let LVN A know of the assisted fall and then was called into Resident #1's room, the entire time the resident was on her foot, the resident was assisted back to the wheelchair and then put back into bed. She stated that roughly 15min later the resident complained of her left knee hurting. She stated this all happened around shift change, the resident was sent out and she is not sure what has happened since then. During an interview on 6.3.25 at 1:55 pm LVN A stated he did not go in and do an assessment of the resident because the way he was told it was like the resident just was assisted and sat on the floor. He stated he should have went and assessed Resident #1 before she was moved from the floor. He stated any resident that sustained a fall, must be assessed by a nurse before the resident was allowed to be moved. During an interview on 6.5.25 at 11:55 am CNA C stated that the nurse should have come and assessed the resident, but it did not happen. She stated she let him know and he said OK but never came down to assess the resident. She stated the protocol for any fall, assisted or not needs to be assessed by a nurse before moved. She stated blood pressure and vitals everything before the resident was moved, but this did not happen. During interview on 6.22.25 at 10:20 am PT E stated that when she went to report to LVN W that Resident #1 had a fall, she stated that all she told LVN W was that Resident #1 complained of left knee pain. She stated she did not tell the nurse that Resident #1 had a fall because she assumed LVN W already knew because CNA C let LVN A know about the fall. Record review of CNA B witness statement dated 4.8.25 indicated: CNA C then carefully raised Resident #1's leg so CNA D could put a pillow under Resident #1 knee and then CNA C carefully and slowly laid Resident #1 leg down on the pillow. The lady (Resident #1) didn't complain that it hurt until after CNA C had laid Resident #1 knee back down on the pillow. I gave Resident #1 the bed control as CNA D gave her the call light, I walked out of the room. Record review of CNA C witness statement dated 4.8.25 indicated: Me and CNA B held her up as PT E and CNA D tried to put the wheelchair underneath her. When she finally had the bottom in the wheelchair enough to pull her out of the bathroom, PT E told the lady to bend her knees so she can scoot back in the chair. At that time of bending the knee is when she yelled that it hurt. Record review of PT E witness statement dated 4.8.25 indicated: Transitioned resident from EOB to supine with 4 people. Resident complained of pain upon being positioned in supine and notified night shift nurse as day shift nurse was on the phone receiving report for new admission. During an interview on 6.20.25 at 6:45 pm LVN W stated that a fall is any change in position from one height to another. She stated this was a fall and the resident should have been assessed. She stated that PT E did let her know about Resident #1's knee pain so she went and gave Resident #1 two Tylenol. She stated she did not assess Resident #1 at this time, but only gave her Tylenol. She stated during shift change LVN A was usually good about letting her know about every situation, but he forgot to on the day of the incident. She stated that she was working at the nurse's station and the of the resident came to her and stated that the resident had a fall. She stated to the, when, thinking it just happened. She stated the said no earlier. She stated she went to assess the resident. She stated on doing an assessment you must do a head-to-toe assessment of the resident looking for any abnormalities. She stated, that can include, bruising, swelling, redness, etc. She stated that the resident's left leg/knee was a little bit swollen, and the resident did state it was painful. She stated this was the first time she had ever seen the resident since she was a new admit today, so she was not sure if this was the resident's baseline. She stated she went and called [NAME] to ask if he knew anything and found out about the incident over the phone. She stated at that point she let the daughter know that there was no portable stat xray available at this time, so the only other option was to send the resident out to the hospital via EMS to go get the residents xray complete. She stated that was what the family wanted and that was why the resident was sent out. She stated she has no idea why anyone would have moved the resident from the floor to the wheelchair without letting a nurse assess the resident first and she has no idea why all this information was not provided to her during shift change. She stated when it comes to a fall and the resident was on the ground they are to stay there until the resident was assessed by a nurse. She stated in this case, if a fall occurs and the resident was assessed and noted to have pain to hip or knee area, she would make the resident comfortable on the floor and call EMS because she would not want to move the resident if there was a break to the knee or hip. She stated but this did not happen. During an interview on 6.5.25 at 11:15 am Admin stated that from what he knows, any fall that occurs in the building a nurse must go and assess the resident before the resident is allowed to be moved from the ground. He stated this was protocol and from what he found out; this did not occur. During an interview on 6.5.25 at 1:25 pm DON stated this was absolutely a fall. She stated the first time she heard of the incident was when the night nurse LVN E reached out to her asking her if she was aware of any fall by that resident. She stated she didn't know, she stated she started to reach out to her aids via text and realized this was a fall. She stated that LVN A the nurse on shift during the incident should have gone and assessed the resident. She stated that the way it was described to LVN A it was not a fall, so he didn't assess. She stated it should have been treated as a fall. She stated overall there were a few misses here in this situation, but she started in-services on the situation to cover documentation and what was considered a fall. She stated a change in plane was considered a fall. Record review of facility policy dated September 2012 titled: Falls-Clinical Protocol indicated: 2. In addition, the nurse shall assess and document/report the following: a. vital signs, b. recent injury, especially fracture or head injury, c. musculoskeletal function, observing for changing in normal range of motion, weight bearing etc., d. change in cognition or level of consciousness, e. neurological status, f. pain, g. frequency and number of falls since last physician visit. H. precipitating factors, details on how fall occurred, i. all current medications, especially those associated with dizziness or lethargy, and j. all active diagnosis. This was determined to be an Immediate Jeopardy (IJ) on 6.23.25 at 4:20 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 6.23.25 at 4:20 pm. And a Pla of Removal was requested. The facility Plan of Removal was accepted on 6.24.25 at 12:10 PM and reflected the following: Impact Statement: On 6/23/2025 an abbreviated survey was initiated on 6/23/25 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to protect 1 of 87 residents in ensuring licensed nurses and nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident's needs. What corrective actions have been implemented for the identified residents? a. The resident involved in the incident on 4/8/25 received immediate pain management and evaluation once identified. The resident was sent to the emergency room on 4/8/25 and diagnosed with a femoral fracture. Resident's pain was managed per physician orders and follow-up care was provided. Resident was closely monitored for any complications related to the injury or delayed treatment on 4/8/25. b. On 6/23/25 all current residents who have had an incident in the last two weeks were reviewed to ensure the resident was not moved prior to a nurse assessing the patient and pain was assessed by licensed nurse prior to administering medication. No other discrepancies identified with licensed nurses and nurse aides being able to demonstrate competency in skills and techniques necessary to care for the residents needs. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. On 6/23/25 the Director of Nursing and/or nurse managers initiated an in-service direct care staff reporting recognized resident pain to the charge nurse, the charge nurse is to immediately assess the resident's pain, and administer pain medication in accordance to the results of the pain assessment completed. The in-service will be completed by 6/24/25. All Direct care staff employees will be in-serviced by the Director of Nursing and/or nurse managers on recognizing, properly assessing, and receiving pain management and any PRN or weekend staff will be in-serviced by 6/24/2025. If PRN or weekend staff are unable to be reached, they will be removed from the schedule until in-service is completed. Effectiveness of staff educated on reporting recognized resident pain to the charge nurse, the charge nurse is to immediately assess the resident's pain, and administer pain medication in accordance to the results of the pain assessment completed will be evaluated with staff reciting information and 5 staff interviews per day for seven days to ensure information is retained. b. On 6/23/25 an in-service was initiated by the Director of Nursing and nurse managers with nurse aides on relaying resident's complaint of pain to charge nurse when a resident expresses signs of pain and not moving a resident after a fall without a nurse completing an assessment of resident for pain or injury. All nursing assistants will be in-serviced by 6/24/2025 by the Director of Nursing and/or nurse managers on relaying resident's complaint of pain to charge nurse when a resident expresses signs of pain and not moving a resident after a fall without a nurse completing an assessment of resident for pain or injury including PRN and Weekend staff. If staff are unable to be reached to provide in-service by 6/24/25 they will removed from the schedule until in-service is completed. Effectiveness of staff educated on relaying resident's complaint of pain to charge nurse when a resident expresses signs of pain and not moving a resident after a fall without a nurse completing an assessment of resident for pain or injury will be evaluated with staff reciting information and 5 staff interviews per day for seven days to ensure information is retained. c. On 6/23/25 the Director of Nursing and nurse managers initiated an in-service with licensed nurses on completing a full assessment of a residents pain prior to administering pain medication. The in-service will be completed 6/24/25. All licensed nurses will be in-serviced by the Director of Nursing and/or nurse managers initiated an in-service with licensed nurses on completing a full assessment of a residents pain prior to administering pain medication including PRN and weekend staff by 6/24/25 or they will be removed from the schedule until in-service is completed. Effectiveness of staff educated on completing a full assessment of a residents pain prior to administering pain medication will be evaluated with staff reciting information and 5 staff interviews per day for seven days to ensure information is retained. d. The facility DON or nurse manager will in-service new hire nursing assistants and licensed nurses during orientation, relaying resident's complaint of pain to nurse so the resident can be properly assessed, not to move a resident post resident fall without a nurse completing an assessment of resident for pain or injury, and the need to fully assess a resident's pain before administering pain medication. Staff members will recite understanding of the education to the educator. How will the system be monitored to ensure compliance? a. Starting 6/23/25 the DON or nurse manager will complete interviews and/or assessments with residents daily for seven days to ensure pain was recognized, properly assessed and received pain medication in a timely manner. Post the daily monitoring on 6/30/25 the DON/nurse manager will round on residents to ensure pain was recognized, properly assessed and received pain medication in a timely manner effectively 2x week X 6 weeks or until it is determined the metric is met. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. b. Starting 6/23/25 the DON and/or nurse manager will review the 24 hour report in electronic medical record that identifies all nurse documentation, PRN pain administration, resident assessments completed, and progress note documentation daily for 7 days and then 5x week for 3 weeks to ensure any documented pain was recognized, properly assessed, the resident was fully assessed prior to pain medication administration, and received pain medication in a timely manner c. Starting on 6/23/25 the DON and/or nurse manager will review fall incident reports daily in the electronic medical record for seven days and then 3x week for six weeks to ensure resident was assessed for pain and/or injury by a licensed nurse prior to moving the resident post fall and that the resident was fully assessed for pain prior to providing pain medication by the licensed nurse. If it is identified that a resident was not assessed prior to being moved, the resident will immediately be assessed and the employee will receive further education. d. Administrator and/or designee will review the 24 hour report in the electronic medical record and round on residents daily for seven days and then on a weekly for six weeks basis to ensure nurse managers are following the plan of removal of ensuring staff are competent in skills and techniques necessary to care for resident needs or until it is determined the metric is met starting 6/23/25. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/23/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 06/24/2025 to 06/25/2025 revealed: During an interview on 6.24.25 at 1:10 pm CNA F stated she got in-serviced yesterday 6.23.25 at roughly late afternoon. She stated that there were so many that they molded together, but she knows she did at least 3. She stated one in-service covered falls. She stated that it covered what constitutes as a fall, what to do in case of a fall and who to call. She stated if a fall occurred assisted or not she was not allowed to touch the resident. She stated if there was another CNA with you that CNA can go and let the nurse know but if you were by yourself you need to call out for help because you do not leave the resident. She stated that nothing was to be done to the resident until the nursing assessment had been completed by the nurse. She stated the nursing assessment was to be completed by the nurse, and there was no reason for the resident to ever be moved until it was completed. She stated but if a resident did complain of pain, no associated to a fall or anything witnessed, then the CNA would ask the resident basic questions such as, how bad is the pain, how did you hurt yourself etc. She stated once that information was received she would go directly to the charge nurse to let them know the resident had pain. During an interview on 6.24.25 at 1:25 pm CNA G stated she has been doing this for many years and this was all a refresher for her. She stated that the topics discussed in the in-services were falls, nursing assessments and pain. She stated a fall is any time a resident ends up on the ground without intending to. She stated it did not matter if it was assisted or witnessed, with injury or no injury, a fall was to be reported to the charge nurse immediately. She stated she should not move the resident, sit the resident up, assist the resident in anyway. She stated the focus at that time was to make sure the resident did not move and stayed on the floor and then go and inform the charge nurse. She stated nothing at all was to be done even while waiting on the nurse to come and do the assessment. She stated ever fall in the building must have a nursing assessment completed. She stated lastly pain was discussed. She stated anytime a resident has any sort of pain, major or minor, she would repot to the charge nurse and let them know the resident was complaining of pain. During an interview on 6.24.25 at 1:35 pm CNA H stated she was in-serviced 3 different times over the past day or so. She stated pain was a big one she can remember. She stated she is not a nuse so assessing the resident for pain was not something required. She stated but inquiring about pain level and maybe how the resident hurt themselves was okay. She stated right when the resident let her know of any pain she would report it to the charge nurse. She stated the next two topics kind of went hand in hand. She stated that if a resident has a fall, assisted or not, it must be reported to the nurse and nothing should be done to the resident until the nuse has completed her assessment of the resident. She stated, essentially, if a resident falls, let charge nurse know, don't move the resident and wait for the nurse to do their assessment of the resident before any moving of the resident was allowed. During an interview on 6.24.25 at 1:45 pm CNA I stated any fall any was any change in residents plane. She stated even if it's a 3 inch movement, different plane means a fall. She stated it also doesn't matter if it was assisted, witnessed or unwitnessed it was still a fall and had to be reported to the nurse. She stated even while waiting on the nurse to get to the residents room, the resident was not to be moved or assisted in any way. She stated once the nurses assessment was complete she would be allowed to, with the help of the nurse, get the resident up. She stated the other in-service covered pain. She stated this could be any pain, in general or associated to a fall. She stated all pain should be immediately reported to the nurse and the nurse would come and do the assessment of the resident. During an interview on 6.24.25 at 2:00 pm RN J stated she has been nurse since 2023. She stated she was in-serviced this morning before she was allowed to work. She stated that she went through a few in-services. She stated the first one covered falls. She stated, it covered what constitutes as a fall, with injury or no injury. She stated that the in-service covered what a CNA must do related to a fall and what a nurse must do related to a fall. She stated that a CNA was not to assist or move the resident, but only too report the fall to the nurse and wait for the nurse to come do the nursing assessment. She stated second the nursing assessment covered a head to toe assessment that checked for swelling, bruising, bleeding, how the resident was acting, etc. she stated if there were concerns the resident hit their head the resident would not be moved at all and EMS would be called to come and get the resident. She stated after assessment was completed on resident then the resident could be moved and then monitored. She stated lastly, if any resident complains of any sort of pain, to CNA, the CNA should come report to the nurse immediately, but if the pain was notated directly from resident to nurse, the nurse must do a head to toe assessment and pull meds pending level of pain or reach out to physician if pain was high. During an interview on 6.24.25 at 2:15 pm LVN K stated that this was a refresher, but it was everything that she did consistently. She stated the main topic was about falls and pain associated to falls. She stated the CNA's got a little bit different of an in-service then the nurses did. She stated for the nurses, the requirement was no matter how big of a fall, a nurse must go and assess the resident before they were allowed to be moved by anyone. She stated pain was covered and the overview was that any resident who complains of any sort of pain, associated to a fall or not should be assessed from head to toe and meds could be given associated to the level of pain and what medications were available to the resident. She stated primary focus, no moving of any resident associated to any fall could be done until the nursing assessment was completed. During an interview on 6.24.25 at 2:25 pm RN L stated that she was in-serviced and it covered 3 parts. She stated two parts went together, any fall occurs in the building a nurse must respond to the resident and do a full body head to toe assessment of the resident before the resident was allowed to be moved by anyone. She stated that CNA's were to either call for help while still being able to see the resident or have another CNA who was with them to go and let the nurse know that they had a fall and a nursing assessment must be done. She stated that all pain in the same process should be notated to the nurse at this time as well. She stated beyond a fall, any pain a resident notates to any CNA, the CNA must immediately come to the nurse and let the nurse know of the pain and the nurse must go and perform a pain assessment on the resident and provide the resident with any medication the resident may have for pain or reach out to the physician. During an interview on 6.24.25 at 2:45 pm ADON stated that he was aware of the situation going on. He stated that he has been helping/part of every in-service provided by the DON to all nursing staff. He stated that the main topic was falls and pain, which went for both CNA's and nurses. He stated that any fall in the facility must be responded to and a nurse must do a nursing assessment before the resident was allowed to be moved at all. He stated that it was imperative that any CNA does not move the resident at all until the resident was assessed by the nurse. He stated it was also imperative that a nurse do a head to toe nursing assessment on all residents who had a fall, checking for swelling, bruising, blood, etc. he stated second topic for both CNA and nurse was to communicate fully to each other when any resident complains of pain anywhere on their body. He stated the CNA just needs to inform the nurse that resident complained of pain and where on the body. He stated it was then the nurses responsibility to go and assess the resident for any pain. During an interview on 6.24.25 at 3:00 pm CNA M stated she was in serviced last night before she came on shift. Phone interview. She stated that she got in-serviced the night before. She stated it was roughly around 5:30pm. She stated there were 3 topics covered, falls, pain, and nursing assessments. She stated the main thing for the CNA's that was covered was falls. She stated the definition of a call, which was anytime a residents body went to the floor. She stated it does not matter if it was assisted or not, it was still considered a fall. She stated second the topic that was associated to the fall was that a CNA's was not to move or get the resident up after the fall unless a nurse had completed the nursing assessment of the resident. She stated lastly was pain, she stated pain does not have to be only associated to a fall but anytime a resident complains of any pain on their body they are to report it to the nurse so the nurse could come and do a pain assessment of the resident. During a phone interview on 6.24.25 at 3:10 pm CNA N stated that there were 3 topics covered. She stated pain, falls, and nursing assessment. She stated that pain can be any complaint made by the resident no matter how big or small of a complaint, the complaint should be reported to the nurse immediately. She stated she was not a nurse so she would not assess the resident for pain but may ask how it happened or level of pain. She stated the other topic that was covered, was falls and reporting falls to the nurse. She stated not only do you have to report the fall to the nurse but stay with the resident, do not move them until the nurse has physically come and done a nursing assessment. She stated that it was drilled into the CNA's that they are not to move the resident for no reason until that nursing assessment was completed. During a phone interview on 6.24.25 at 3:15 pm CNA O stated she works nights and can work both sides. she stated she got in-serviced yesterday 6.23.25 at roughly late afternoon. She stated that there were so many that they molded together, but she knows she did at least 3. She stated one in-service covered falls. She stated that it covered what constitutes as a fall, what to do in case of a fall and who to call. She stated if a fall occurred assisted or not, she was not allowed to touch the resident. She stated if there was another CNA with you that CNA can go and let the nurse know but if you were by yourself you need to call out for help because you do not leave the resident. She stated that nothing was to be done to the resident until the nursing assessment had been completed by the nurse. She stated the nursing assessment was to be completed by the nurse, and there was no reason for the resident to ever be moved until it was completed. She stated but if a resident did complain of pain, no associated to a fall or anything witnessed, then the CNA would ask the resident basic questions such as, how bad is the pain, how did you hurt yourself etc. She stated once that information was received she would go directly to the charge nurse to let them know the resident had pain. Record Review of in-service presented by DON titled communication of complaints of pain-CNA's from residents, dated 6.23.25, signature page provided. Inservice covered CAN/CMA's: When a resident reports having pain, specifically after a fall, ask the resident where the pain is coming from on their body. Then tell the resident's charge nurse immediately. DO NOT MOVE RESIDENT AFTER A FALL WITHOUT A NURSE COMPLETING AN ASSESSMENT OF PAIN AND/OR INJURY. All employees interviewed were verified with signatures. During a phone interview on 6.24.25 at 3:20 pm LVN P stated she worked the north side. She stated that she got in-serviced last nig[TRUNCATED]

Based on observation, interviews and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 8 residents reviewed for pain. Facility failed to ensure Resident #1's pain was recognized, properly assessed and received pain management in accordance with professional standards of practice. Facility nurse aides and occupational therapy assistant moved Resident #1 from the floor to the wheelchair to the bed, after a fall without a nurse assessing the resident for any pain or injuries on 4/8/25 at approximately 6PM. Facility nurse aides failed to relay Resident #1's pain to nurse immediately after a fall on 4/8/25 at approximately 6PM. Facility nurse failed to complete a proper pain assessment on Resident #1 when later notified of a resident leg pain on 04/08/25 at approximately 7:00PM. Resident #1 was transported to the local community hospital and was diagnosed with a femoral fracture. An Immediate Jeopardy (IJ) situation was identified on 6.23.25. The IJ template was provided to the facility on 6.23.25 at 4:20 pm. While the IJ was lowered on 6.25.25 at 4:27 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could put residents at pain not being managed by the facility. The findings included: Record review of Resident #1's face sheet dated 6.5.25 revealed Resident #1 was admitted on 4.8.25 and was [AGE] years old. Resident #1 had diagnoses of metabolic encephalopathy (a condition where a systemic health issue or imbalance impairs brain function, causing a range of symptoms from confusion and memory loss to coma), type 2 diabetes, cirrhosis of liver (a condition where healthy liver tissue is replaced by scar tissue, preventing the liver from functioning properly), and sepsis due to Escherichia coli (occurs when an E. coli infection spreads to the bloodstream and triggers a dangerous overreaction of the body's immune system, potentially leading to organ damage and even death). Record review of Resident #1's comprehensive care plan reflected: No Care plan available. Resident #1 was only in building for 6 hours total. Record review of Resident #1's medical record dated 4.9.25 indicated: Department of Radiology and Nuclear Medicine. Exam: {lain films of the left knee (xray). Findings: On the AP view there is a cortical irregularity in the lateral distal femoral metaphysis consistent with fracture. Record review of Resident #1's progress notes written by LVN W dated 4.8.25 indicated: Late Entry: Note Text: Pt. family member approached this nurse and reported that Pt. is c/o pain to the leg, according to family member the pain was R/T fall. This nurse explained to the family member that no fall, was reported during shift change. This nurse f/u to find out from Pt. when the fall occurred. It was reported that prior to shift change the resident was lowered to floor during toileting due to her legs getting too weak to stand. Pt. stated, I was being cleaned up in the restroom while standing and my legs gave up on me and sat in the floor. Head to toe assessment was completed, Pt. was A&O x2. Pt. was able to move the upper limb but refuse to move the lower limb and complained pain of 12 to the whole of left. Comparing L-leg to right leg, no shortness was noted however, Slight swelling was noted to left knee, but this nurse couldn't confirm if that was R/T fall because it was the 1st time seeing this Pt. Family explained that was not normal for Pt. Acetaminophen 325 mg po x 2 tabs was administered per order. Vital signs: T-97.3, BP-141/94. Day nurse, LVN A was contacted due to Pt. complain of fall, and LVN A said CNA B reported that Pt. had assisted fall. This explained to family that X-ray will be done to find out what was causing the pain but for stat X-ray pt. might has to transfer to the ER for and family said yes. EMT was contacted and at 9:03 pm Pt. together with family members left the facility to the ER. DON notified. During an interview on 6.3.25 at 12:05 pm LVN A stated he does remember Resident #1. He stated that he did do her initial documentation when Resident #1 admitted to the facility. He stated that the hospital never mentioned that Resident #1 needed lift assistance or anything like that. He stated that the resident was seen to transfer with no assistance, but he would say he would recommend Resident #1 at least had two persons to assist her. He stated he must have missed filling out the mobility/safety section in Resident #1 initial assessment. He stated that he should have filled this part of the document out because it indicates to other staff the type of assistance Resident #1 needed. He stated this information could help Resident #1 not sustain any falls. Record review of CNA B witness statement dated 4.8.25 indicated: CNA C then carefully raised Resident #1's leg so CNA D could put a pillow under Resident #1 knee and then CNA C carefully and slowly laid Resident #1 leg down on the pillow. The lady (Resident #1) didn't complain that it hurt until after CNA C had laid Resident #1 knee back down on the pillow. I gave Resident #1 the bed control as CNA D gave her the call light, I walked out of the room. Record review of CNA C witness statement dated 4.8.25 indicated: Me and CNA B held her up as PT E and CNA D tried to put the wheelchair underneath her. When she finally had the bottom in the wheelchair enough to pull her out of the bathroom, PT E told the lady to bend her knees so she can scoot back in the chair. At that time of bending the knee is when she yelled that it hurt. Record review of PT E witness statement dated 4.8.25 indicated: Transitioned resident from EOB to supine with 4 people. Resident complained of pain upon being positioned in supine and notified night shift nurse as day shift nurse was on the phone receiving report for new admission. During interview on 6.22.25 at 10:20 am PT E stated that when she went to report to LVN W that Resident #1 had a fall, she stated that all she told LVN W was that Resident #1 complained of left knee pain. She stated she did not tell the nurse that Resident #1 had a fall because she assumed LVN W already knew because CNA C let LVN A know about the fall. During an interview on 6.20.25 at 6:45 pm LVN W stated that a fall is any change in position from one height to another. She stated this was a fall and the resident should have been assessed. She stated during shift change LVN A was usually good about letting her know about every situation, but he forgot to on the day of the incident. She stated she could not remember at what time, but PT E came to her and said Resident #1 was complaining of left leg pain. She stated she should have asked more questions but did not. She stated she was in the middle of giving out medications, so she took 2 Tylenol to Resident #1. She stated she did not do an assessment of Resident #1 at this time, only that she gave Resident #1 pain medication. She stated later when she was working at the nurse's station and the daughter of Resident #1 came to her and stated that Resident #1 had a fall. She stated to the daughter, when, thinking it just happened. She stated the daughter said no earlier. She stated she went to assess the resident. She stated on doing an assessment you must do a head-to-toe assessment of the resident looking for any abnormalities. She stated, that can include, bruising, swelling, redness, etc. She stated that Resident #1's left knee/leg was a little bit swollen, and the resident did state it was painful. She stated this was the first time she had ever seen the resident since she was a new admit today, so she was not sure if this was the resident's baseline. She stated she went and called LVN A to ask if he knew anything and found out about the incident over the phone. She stated at that point she let the daughter know that there was no portable stat xray available at this time, so the only other option was to send the resident out to the hospital via EMS to go get the residents xray complete. She stated that was what the family wanted and that was why the resident was sent out. She stated she has no idea why anyone would have moved the resident from the floor to the wheelchair without letting a nurse assess the resident first and she has no idea why all this information was not provided to her during shift change. She stated when it comes to a fall and the resident was on the ground they are to stay there until the resident was assessed by a nurse. She stated in this case, if a fall occurs and the resident was assessed and noted to have pain to hip or knee area, she would make the resident comfortable on the floor and call ems because she would not want to move the resident if there was a break to the knee or hip. She stated but this did not happen. During an interview on 6.20.25 at 7:15 pm CNA D he stated that this was literally his first or second day on the job. He stated that when he came into work, he noticed that the residents call light was on so he was going to answer it. He stated that CNA B joined him because she had assisted the resident to the restroom and the resident had already started to pee and got some on herself. He stated so CNA B wanted to come and help him, so he was not cleaning and doing everything by himself. He stated they went into the resident room they assisted the resident to stand from toilet using gait belt. He stated they were both cleaning the resident up when the resident stated she couldn't do it and began to go down. He stated CNA B was behind the resident at this time in which the resident was lowered down onto CNA B. He stated it was very slow. He stated around the same time CNA C had entered the room. He stated he was not sure but believe CNA C went to let the nurse know about the assessment. He stated CNA C came back to the room and he was not sure how long but maybe 10 mins and PT E came by and asked if they needed assistance. He stated he can't remember if CNA B said anything about no assessment had been done by a nurse or not, but they all assisted the resident back into the wheelchair. He stated the only thing he could remember was that the resident was stating that her knee hurt while they were waiting on the nurse to assess the resident. He stated he was not sure why they didn't wait on the assessment to be completed but they should have waited. He stated this was all new to him. During an interview on 6.5.25 at 11:15 am admin stated that before a resident was accepted into the building the assessment of the resident should be complete. He stated the administration side he may not know everything, but he knows that the information that was needed before accepting the resident was if the resident needs any devices, (walker, wheelchair, etc.), if the resident was ambulatory, needs assistance, what kind of assistance, if the resident needs oxygen or any extra equipment. He stated this should all be known before the resident was accepted into the building. He stated this information is necessary to know that the facility can provide the proper care for the resident and that the resident will have all their needs met. He stated if any of this information was not acquired then it could result in an injury to the resident. During an interview on 6.5.25 at 1:25 pm the DON she stated that the readmit screener documentation should have been filled out completely which was not done. She stated LVN A should have completed that documentation so the staff/facility would have known the assistance required by the resident. She stated overall there were a few misses here in this situation, but she started in-services on the situation to cover documentation. She stated the pain assessment and head-to-toe should have been done while Resident #1 was still on the floor. She stated this did not occur. She stated there were a lot of misses that occurred during this incident. Record review of facility policy dated December 2016 titled: Comprehensive Assessments and the Care Delivery Process indicated: Assessment and information collection includes (WHAT, WHERE and WHEN). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. This was determined to be an Immediate Jeopardy (IJ) on 6.23.25 at 4:20 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 6.23.25 at 4:20 pm. Record review of Plan of Removal accepted on 6.24.25 at 12:10 PM reflected the following: Impact Statement: On 6/23/2025 an abbreviated survey was initiated on 6/23/25 the facility was provided with notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure for 1 of 87 residents pain being recognized, properly assessed, and receiving pain management. What corrective actions have been implemented for the identified residents? a. The resident involved in the incident on 4/8/25 received immediate pain management and evaluation once identified. The resident was sent to the emergency room on 4/8/25 and diagnosed with a femoral fracture. Resident's pain was managed per physician orders and follow-up care was provided. b. Ambassador rounds were completed by the interdisciplinary team on 4/8/25 and incident reports of falls that occurred in the last 24 hours were reviewed to ensure any resident pain was properly assessed, reported, and addressed by direct care staff and no other discrepancies were identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. On 6/23/25 the Director of Nursing and/or nurse managers in-serviced direct care staff on recognizing, properly assessing, and receiving pain management. Staff educated on reporting recognized resident pain to the charge nurse, the charge nurse is to immediately assess the resident's pain, and administer pain medication in accordance to the results of the pain assessment completed. All Direct care staff employees will be in-serviced by the Director of Nursing and/or nurse managers on recognizing, properly assessing, and receiving pain management prior to their next scheduled shift. Staff members will recite understanding of the education to the educator and 5 staff interviews will be completed daily for seven days. b. The facility DON or nurse manager will in-service new hires during orientation, on recognizing, properly assessing, and receiving pain management prior to their next scheduled shift. Staff educated on reporting recognized resident pain to the charge nurse, the charge nurse is to immediately assess the resident's pain, and administer pain medication in accordance to the results of the pain assessment completed. Effectiveness of staff educated on recognizing, properly assessing, and receiving pain management will be evaluated with staff reciting information and 5 staff interviews per day for seven days to ensure information is retained. How will the system be monitored to ensure compliance? a. Starting 6/23/25 the DON or nurse manager will complete resident interviews and/or assessments daily for seven days to ensure are pain was recognized, properly assessed and received pain medication in a timely manner. Post the daily monitoring on 6/30/25 the DON/nurse manager will round on residents to ensure pain was recognized, properly assessed and received pain medication in a timely manner effectively 2x week X 6 weeks or until it is determined the metric is met. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. b. Starting 6/23/25 the DON and/or nurse manager will review the 24 hour report in electronic medical record that identifies all nurse documentation, PRN pain administration, resident assessments completed, and progress note documentation daily for 7 days and then 5x week for 3 weeks to ensure any documented pain was recognized, properly assessed and received pain medication in a timely manner. c. Administrator and/or designee will review the 24 hour report and round on residents daily for seven days and then on a weekly basis for six weeks to ensure nurse managers are following the plan of removal or until it is determined the metric is met starting 6/23/25. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/23/25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring of facilities Plan of Removal through observations, interviews, and record reviews from 06/24/2025 to 06/25/2025: During an interview on 6.24.25 at 1:10 pm CNA F stated she got in-serviced yesterday 6.23.25 at roughly late afternoon. She stated that there were so many that they molded together, but she knows she did at least 3. She stated one in-service covered falls. She stated that it covered what constitutes as a fall, what to do in case of a fall and who to call. She stated if a fall occurred assisted or not she was not allowed to touch the resident. She stated if there was another CNA with you that CNA can go and let the nurse know but if you were by yourself you need to call out for help because you do not leave the resident. She stated that nothing was to be done to the resident until the nursing assessment had been completed by the nurse. She stated the nursing assessment was to be completed by the nurse, and there was no reason for the resident to ever be moved until it was completed. She stated but if a resident did complain of pain, no associated to a fall or anything witnessed, then the CNA would ask the resident basic questions such as, how bad is the pain, how did you hurt yourself etc. She stated once that information was received she would go directly to the charge nurse to let them know the resident had pain. During an interview on 6.24.25 at 1:25 pm CNA G stated she has been doing this for many years and this was all a refresher for her. She stated that the topics discussed in the in-services were falls, nursing assessments and pain. She stated a fall is any time a resident ends up on the ground without intending to. She stated it did not matter if it was assisted or witnessed, with injury or no injury, a fall was to be reported to the charge nurse immediately. She stated she should not move the resident, sit the resident up, assist the resident in anyway. She stated the focus at that time was to make sure the resident did not move and stayed on the floor and then go and inform the charge nurse. She stated nothing at all was to be done even while waiting on the nurse to come and do the assessment. She stated ever fall in the building must have a nursing assessment completed. She stated lastly pain was discussed. She stated anytime a resident has any sort of pain, major or minor, she would repot to the charge nurse and let them know the resident was complaining of pain. During an interview on 6.24.25 at 1:35 pm CNA H stated she was in-serviced 3 different times over the past day or so. She stated pain was a big one she can remember. She stated she is not a nuse so assessing the resident for pain was not something required. She stated but inquiring about pain level and maybe how the resident hurt themselves was okay. She stated right when the resident let her know of any pain she would report it to the charge nurse. She stated the next two topics kind of went hand in hand. She stated that if a resident has a fall, assisted or not, it must be reported to the nurse and nothing should be done to the resident until the nuse has completed her assessment of the resident. She stated, essentially, if a resident falls, let charge nurse know, don't move the resident and wait for the nurse to do their assessment of the resident before any moving of the resident was allowed. During an interview on 6.24.25 at 1:45 pm CNA I stated any fall any was any change in residents plane. She stated even if it's a 3 inch movement, different plane means a fall. She stated it also doesn't matter if it was assisted, witnessed or unwitnessed it was still a fall and had to be reported to the nurse. She stated even while waiting on the nurse to get to the residents room, the resident was not to be moved or assisted in any way. She stated once the nurses assessment was complete she would be allowed to, with the help of the nurse, get the resident up. She stated the other in-service covered pain. She stated this could be any pain, in general or associated to a fall. She stated all pain should be immediately reported to the nurse and the nurse would come and do the assessment of the resident. During an interview on 6.24.25 at 2:00 pm RN J stated she has been nurse since 23. She stated she was in-serviced this morning before she was allowed to work. She stated that she went through a few in-services. She stated the first one covered falls. She stated, it covered what constitutes as a fall, with injury or no injury. She stated that the in-service covered what a CNA must do related to a fall and what a nurse must do related to a fall. She stated that a CNA was not to assist or move the resident, but only too report the fall to the nurse and wait for the nurse to come do the nursing assessment. She stated second the nursing assessment covered a head to toe assessment that checked for swelling, bruising, bleeding, how the resident was acting, etc. she stated if there were concerns the resident hit their head the resident would not be moved at all and EMS would be called to come and get the resident. She stated after assessment was completed on resident then the resident could be moved and then monitored. She stated lastly, if any resident complains of any sort of pain, to CNA, the CNA should come report to the nurse immediately, but if the pain was notated directly from resident to nurse, the nurse must do a head to toe assessment and pull meds pending level of pain or reach out to physician if pain was high. During an interview on 6.24.25 at 2:15 pm LVN K stated that this was a refresher, but it was everything that she did consistently. She stated the main topic was about falls and pain associated to falls. She stated the CNA's got a little bit different of an in-service then the nurses did. She stated for the nurses, the requirement was no matter how big of a fall, a nurse must go and assess the resident before they were allowed to be moved by anyone. She stated pain was covered and the overview was that any resident who complains of any sort of pain, associated to a fall or not should be assessed from head to toe and meds could be given associated to the level of pain and what medications were available to the resident. She stated primary focus, no moving of any resident associated to any fall could be done until the nursing assessment was completed. During an interview on 6.24.25 at 2:25 pm RN L stated that she was in-serviced and it covered 3 parts. She stated two parts went together, any fall occurs in the building a nurse must respond to the resident and do a full body head to toe assessment of the resident before the resident was allowed to be moved by anyone. She stated that CNA's were to either call for help while still being able to see the resident or have another CNA who was with them to go and let the nurse know that they had a fall and a nursing assessment must be done. She stated that all pain in the same process should be notated to the nurse at this time as well. She stated beyond a fall, any pain a resident notates to any CNA, the CNA must immediately come to the nurse and let the nurse know of the pain and the nurse must go and perform a pain assessment on the resident and provide the resident with any medication the resident may have for pain or reach out to the physician. During an interview on 6.24.25 at 2:45 pm ADON stated that he was aware of the situation going on. He stated that he has been helping/part of every in-service provided by the DON to all nursing staff. He stated that the main topic was falls and pain, which went for both CNA's and nurses. He stated that any fall in the facility must be responded to and a nurse must do a nursing assessment before the resident was allowed to be moved at all. He stated that it was imperative that any CNA does not move the resident at all until the resident was assessed by the nurse. He stated it was also imperative that a nurse do a head to toe nursing assessment on all residents who had a fall, checking for swelling, bruising, blood, etc. he stated second topic for both CNA and nurse was to communicate fully to each other when any resident complains of pain anywhere on their body. He stated the CNA just needs to inform the nurse that resident complained of pain and where on the body. He stated it was then the nurses responsibility to go and assess the resident for any pain. During an interview on 6.24.25 at 3:00 pm CNA M stated she was in serviced last night before she came on shift. Phone interview. She stated that she got in-serviced the night before. She stated it was roughly around 5:30pm. She stated there were 3 topics covered, falls, pain, and nursing assessments. She stated the main thing for the CNA's that was covered was falls. She stated the definition of a call, which was anytime a residents body went to the floor. She stated it does not matter if it was assisted or not, it was still considered a fall. She stated second the topic that was associated to the fall was that a CNA's was not to move or get the resident up after the fall unless a nurse had completed the nursing assessment of the resident. She stated lastly was pain, she stated pain does not have to be only associated to a fall but anytime a resident complains of any pain on their body they are to report it to the nurse so the nurse could come and do a pain assessment of the resident. During a phone interview on 6.24.25 at 3:10 pm CNA N stated that there were 3 topics covered. She stated pain, falls, and nursing assessment. She stated that pain can be any complaint made by the resident no matter how big or small of a complaint, the complaint should be reported to the nurse immediately. She stated she was not a nurse so she would not assess the resident for pain but may ask how it happened or level of pain. She stated the other topic that was covered, was falls and reporting falls to the nurse. She stated not only do you have to report the fall to the nurse but stay with the resident, do not move them until the nurse has physically come and done a nursing assessment. She stated that it was drilled into the CNA's that they are not to move the resident for no reason until that nursing assessment was completed. During a phone interview on 6.24.25 at 3:15 pm CNA O stated she works nights and can work both sides. she stated she got in-serviced yesterday 6.23.25 at roughly late afternoon. She stated that there were so many that they molded together, but she knows she did at least 3. She stated one in-service covered falls. She stated that it covered what constitutes as a fall, what to do in case of a fall and who to call. She stated if a fall occurred assisted or not she was not allowed to touch the resident. She stated if there was another CNA with you that CNA can go and let the nurse know but if you were by yourself you need to call out for help because you do not leave the resident. She stated that nothing was to be done to the resident until the nursing assessment had been completed by the nurse. She stated the nursing assessment was to be completed by the nurse, and there was no reason for the resident to ever be moved until it was completed. She stated but if a resident did complain of pain, no associated to a fall or anything witnessed, then the CNA would ask the resident basic questions such as, how bad is the pain, how did you hurt yourself etc. She stated once that information was received she would go directly to the charge nurse to let them know the resident had pain. Record Review of in-service presented by DON titled communication of complaints of pain-CNA's from residents, dated 6.23.25, signature page provided. Inservice covered CAN/CMA's: When a resident reports having pain, specifically after a fall, ask the resident where the pain is coming from on their body. Then tell the resident's charge nurse immediately. DO NOT MOVE RESIDENT AFTER A FALL WITHOUT A NURSE COMPLETING AN ASSESSMENT OF PAIN AND/OR INJURY. All employees interviewed were verified with signatures. During a phone interview on 6.24.25 at 3:20 pm LVN P stated she worked the north side. She stated that she got in-serviced last night. She stated that the main topic covered for the nurses was that an assessment had to be done from head to toe for each resident now matter how minor of a fall occurred. She stated there was no excuse that a resident after a fall was not assessed before the resident was moved off of the ground. She stated the second topic covered was pain in general. She stated pain associated to a fall or not, must be brought to the attention of the nurse even if it was minor. She stated once being reported that a resident complained of pain, the nurse must go to the resident and assess the resident for pain level, location, injury, etc. she stated once the pain was identified, medications could be administered if resident has prn meds or pain meds in general. Record review of in-service presented by DON titled Resident Assessment of Pain-Nurses. Do not move resident after a fall without completing an assessment of pain and/or injury. Assess: onset- Mechanism of injury or etiology of pain, if identifiable. Location/distribution. Duration. Course or temporal pattern. Character and quality of the pain. Aggravating/provoking factors. Alleviating factors. And Associated symptoms. Administer pain medication as ordered by physician. If no pain medication is previously ordered by physician, notify physician immediately of residents pain/pain assessment. Acquire orders as given by physician for pain control and/or additional orders as received. All employees interviewed were verified with signatures. Record Review of Qapi Signature Page. Quapi meeting covering PoR and topic of IJ. Attendees included administrator, Dr A, DON, ADON, RUP, and DRO. During a phone interview on 6.24.25 at 3:40 pm RN Q stated that she got in-serviced last night. She stated that the main topic covered for the nurses was that an assessment had to be done from head to toe for each resident now matter how minor of a fall occurred. She stated there was no excuse that a resident after a fall was not assessed before the resident was moved off of the ground. She stated the second topic covered was pain in general. She stated pain associated to a fall or not, must be brought to the attention of the nurse even if it was minor. She stated once being reported that a resident complained of pain, the nurse must go to the resident and assess the resident for pain level, location, injury, etc. she stated once the pain was identified, medications could be administered if resident has prn meds or pain meds in general. During a phone interview on 6.24.25 at 3:50 pm CNA R stated topics covered pain, then falls, wait for assessment before anyone is moved. She stated there were a few in-services. She stated that the topics discussed in the in-services were falls, nursing assessments and pain. She stated a fall is any time a resident ends up on the ground without intending to. She stated it did not matter if it was assisted or witnessed, with injury or no injury, a fall was to be reported to the charge nurse immediately. She stated she should not move the resident, sit the resident up, assist the resident in anyway. She stated the focus at that time was to make sure the resident did not move and stayed on the floor [TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that spoiled food items were disposed of properly. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During observation on [DATE] at 10:00 AM in the kitchen: Refrigerator 1) 2 cucumbers with a white substance on them 2) An unopened clear bag of broccoli that contained broccoli that had turned brown. 3) An unopened clear bag of lettuce that had turned brown. 4) A box that contained red bell peppers, 3 of the red bell peppers had black spots and soft spots on them. 5) A box that contained yellow bell peppers, 2 of the yellow bell peppers had black spots and soft spots on them. During an interview on [DATE] at 11:06 AM the DM stated her expectation was when food appeared to have spoiled it needed to be thrown out. The DM stated all kitchen staff were responsible to throw out food that was spoiled or expired, but she was ultimately responsible to ensure food had been discarded when it had spoiled. The DM stated that if residents were to receive spoiled food it could have caused them to become sick. The DM stated what led to failure was there had been some staff turnover and staff calling in and she had been working extra hours to cover shifts. During an interview on [DATE] at 1:13 PM the ADMN stated his expectation was that food that was spoiled or expired should be discarded. The ADMN stated the DM was responsible to ensure that spoiled food was discarded. The ADMN stated if residents received food that was spoiled it could cause food borne illness. The ADMN stated lack of oversight by the DM led to the failure of spoiled items not being discarded. Record review of facility policy titled, Receiving dated ,d+[DATE] revealed: Safe food handling procedures for time and temperature control will be in the transportation, delivery, and subsequent storage of all food items.

Based on interview and record review the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 3 of 18 Residents (Resident #1, Resident #3, and Resident #6) reviewed for assessments. The facility failed to complete a quarterly assessment for Resident #1, #3, and #6 every 3 months. This failure could place residents at risk for not getting an accurate assessment and could result in lack of care. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses to include: Urinary Tract Infection, Bladder dysfunction, and Depression. Review of Resident #1's last completed MDS assessment dated [DATE] revealed a BIMS score of 09 which indicated moderate cognitive impairment. Further review of Resident #1's MDS tracking record revealed the last completed MDS was completed on 07-11-2024. The next MDS listed was a quarterly dated 10-31-2024 that was in progress as of 11/07/2024. Resident #3 Review of Resident #3's electronic face sheet revealed a [AGE] year-old male admitted [DATE] with diagnoses to include: Bipolar Disorder, Anxiety, and Dementia. Review of Resident #3's last completed MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Further review of Resident #3's MDS tracking record revealed the last completed MDS was completed 06-22-2024. The next MDS listed was a quarterly dated 9-22-2024 that was in progress as of 11/07/2024. Resident #6 Review of Resident #6's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Dementia, Depression, and heart failure. Review of Resident #6's last completed MDS assessment dated [DATE] revealed with a BIMS score of 10 which indicated moderate cognitive impairment. Further review of Resident #6's MDS tracking record revealed the last completed MDS was an annual completed 07-05-2024. The next MDS listed was a quarterly dated 10-05-2024 that was in progress as of 11/07/24. During an interview on 11/07/24 at 10:54 AM, the ADMN stated MDS assessments were to be completed annually and quarterly. He stated he was unsure as to the timeframe requirement for submission. He stated his expectation was for MDS assessments to be completed and submitted within the required time frame. He stated he was unaware that the facility was behind on MDS assessment completions and submissions, and he was not sure as to what caused the failure. He stated this failure did not directly affect the residents but did affect the facility with reimbursement. During an interview on 11/07/24 at 11:03 AM, the DON stated she was not aware that MDS assessments were not being completed and submitted within a timely manner. She stated that it was the MDS Coordinator's responsibility to monitor MDS completions and submissions. The DON stated it was not her responsibility to ensure the completion of MDS assessments in a timely manner. During an interview on 11/07/24 at 02:09 PM, the MDS Coordinator stated that MDS assessments should have been completed and submitted within 14 days of their due date. She stated they should have been done annually and quarterly. She stated she was responsible for ensuring they are completed in a timely manner. She stated the facility had a flood at the beginning of the year and that was her reasoning for being behind. MDS nurse stated this failure did not directly impact the residents. Review of facility policy titled, Resident Assessment Instrument, revised September 2010, revealed in part: .Policy Interpretation and Implementation: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct a timely resident assessments and reviews according to the following schedule: a. Within fourteen days of resident's admission to the facility; b. Where there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve months .

Based on observation, interview, and record review, the facility failed to ensure medications were stored in locked compartments and only authorized personnel were permitted to have access to the keys for 1 cart (medication cart Hall 500) of 3 medication carts reviewed for storage. The facility failed to ensure medication cart Hall 500 was locked and secured when unattended. These failures could place all residents at risk of harm or decline in health due to lack of , medications/biologicals or misappropriation of medications, or drug diversions. Findings included: During an observation on 11/05/2024 at 11:24 AM the medication cart was unlocked and not secured and left in the middle of the 500 hallway. RN A was in a resident's room with resident's door closed. The medication cart was not within eyesight of the nurse and narcotics were under one lock, instead of two. The unlocked medication cart contained prescription and OTC medications that included eye medications, stool softeners, antipsychotics, Insulins, Blood Pressure Medications, Narcotics, antibiotics, diuretics, lidocaine cream, and nasal sprays. One resident and one visitor were observed to have walked past the unlocked medication cart while it was unattended. During an interview on 11/05/2024 at 11:24 AM RN A stated she was responsible for this medication cart and there were 8 residents' medications on the cart. RN A stated that she knew better and did not know why she left the medication cart unlocked. RN A stated someone could access the cart and take medications that were not prescribed for them. RN A stated this could have caused harmful side effects such as allergic reaction for the residents. RN A stated she had been trained on locking the medication cart when not in use. During an interview on 11/07/24 at 02:05 PM the DON stated medications carts should be locked when not in use, unattended and not in line of sight. The DON stated she believed the nurse being distracted led to this failure. The DON stated nurses are trained upon hire and with routine education on security of medication carts. The DON stated possible harm to residents would be if a resident accessed the medication cart and took a medication that was not prescribed for them. The DON stated if a resident took a medication not prescribed for them there could have been adverse side effects. The DON stated locked medication carts were monitored by the two ADON's, herself and the ADMN. Review of facility's policy titled Security of Medication Cart dated Revised April 2007: Policy statement The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parking in the hallway against the wall with doors and drawers facing the wall. Medication carts must be securely locked at all times when out of the nurse's view. 4. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 (CNA-E and LVN-F) staff observed during incontinent care and wound care. The facility failed to ensure that staff (CNA-E) performed proper peri-care (incontinent care) using improper hand hygiene for Resident #33. The facility failed to ensure that staff (LVN-F) performed proper wound care for Resident #33. These failures placed residents of the facility at risk of infections from incontinent care and wound care. Findings included: Record Review of Resident #33's Face Sheet dated 11/06/2024 revealed a [AGE] year-old male admitted on [DATE] and his original admission on 05/01/2024. Review of Resident #33's diagnoses revealed: Type 2 Diabetes, multiple Pressure Ulcer of unspecified stages, and Muscle Weakness. Record review of Resident # 33's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior a BIMS score of 08 (moderately impaired cognition). Section H-Bladder and Bowel, Indwelling catheter, and always incontinent. During observation and interview on 11/06/2024 at 10:04 AM, CNA-E had not changed her gloves or perform hand hygiene from dirty to clean during the peri care of Resident #33. CNA E was observed to touch the clean linens and to reposition the resident while wearing her soiled gloves. CNA E stated she was supposed to have done hand hygiene between dirty and clean gloves as well as not touching clean linens or the resident before taking her dirty gloves off. CNA-E stated there could have possibly been cross contamination between residents with the possibility of infections. Record Review of CNA-E's Perineal Care training dated 09/11/2024 revealed: CNA-E's performance Criteria was completed and met. During observation on 11/06/2024 at 10:41 AM, while having clean gloves on, LVN-F removed her unclean pen and unclean scissors from her scrub pant pockets and proceeded with performing wound care with dirty gloves for Resident #33. During an interview on 11/07/2024 at 2:17 PM, LVN-F stated she should have washed her hands and put on new gloves after she touched the pen and scissors from her pant pockets. She stated it could have caused crossed contamination between residents. LVN-F stated she should have had those items cleaned with other supplies needed for her wound care. Record Review of LVN-F's Wound Care Competency dated 09/09/2024 revealed: LVN-F's performance Criteria was completed and met. During an interview on 11/07/2024 at 2:20 PM the DON stated the wound care staff should not have retrieved her pen and scissors out of her pocket. The DON stated in doing so, her clean gloves became contaminated prior to dressing the wound which could have been caused the wound to have been infected. The DON also stated, she monitored the staff and observed during rounds. She stated the negative impact for residents could have possibly led to infection or bacteria with distraction and nervousness being what led to the failure. The DON stated her expectations were for staff to have washed their hands between treatments when changing their contaminated gloves between procedures. She stated staff should not touch clean linen or touch resident with contaminated gloves . Record review of the policy titled Perineal Care dated 12/2011 revealed: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident skin condition. Precedure : .12. Remove gloves and discard into designated container. Wah and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place 18. Remove gloves, and 19. Wash and dry your hands thoroughly. Record review of the policy titled Wound Care dated with 12/2011 revealed: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .6. Put on gloves. 7. Use no-touch technique 14. Be certain all clean items are on clean field

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 4 (Resident #13) Resident's rooms observed for environmental conditions. The facility failed to ensure that Resident # 13's blinds were free from dust. The facility's failure placed the residents at risk for diminished quality of life and discomfort. The findings included: Record review of Resident #13's face sheet dated 11/07/2024 revealed a [AGE] year-old female admitted on [DATE] with most recent admission on 09/23/2024 with the following diagnoses: Encephalopathy (central nervous system diseases located in brain), Hypothyroidism, Type 2 Diabetes, Hypertension, Heart failure and anxiety. Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed: Section C- Cognitive Patterns Resident #13 had a BIMS of 13, meaning she was cognitively intact. Record review of Resident #13's care plan dated revealed Resident #13 had oxygen therapy prn related to her Congestive Heart Failure. During an observation and interview on 11/06/24 at 2:51 PM Resident #13 stated she wished that her blinds were cleaned and did not have dust on them. Resident #13 stated the dust on the blinds irritated her allergies. The blinds were observed to have a layer of dust on them. During an interview on 11/07/24 at 1:44 PM the HK DM stated her expectation was resident's rooms were to have been dusted at least every other day; she stated there should not have been dust on the blinds. The HK DM stated the housekeepers were responsible to ensure that blinds were cleaned daily and ultimately it was the HK manager 's responsibility. The HK DM stated the effect on residents could have been Resident's allergies being agitated by breathing in the dust. The HK DM stated what led to the failure was staff getting in a hurry and skipping steps. During an interview on 11/07/2024 at 1:55 PM the ADMN stated his expectation was that housekeeping clean residents' room daily. The ADMN stated there should not have been dust on the blinds. The ADMN stated it was the responsibility of the housekeeper and housekeeper manager to ensure that blinds were being cleaned. The ADMN stated dust on blinds could have caused residents' allergies to be agitated by dust in the room. The ADMN sated lack of supervision of the housekeeping staff, by the housekeeping supervisor, led to the failure. Record review of facility form tilted 5- step Daily Room Cleaning revealed: Horizontal surfaces- disinfected Using a solution of properly diluted germicide, sanitize all horizontal surfaces. As you enter the room, work clockwise around the room hitting all surfaces. Use your high duster to dust hard to reach areas, such as the tops of closets, high lights, and ceilings areas as needed. Tabletops, headboards, windowsills.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 (Resident #1) of 5 residents reviewed for privacy. The facility failed to ensure Resident #1's BIMS score and medical diagnosis was not given to non-family or non-medical persons in the building. These failures could allow residents' protected HIPAA information to be shared with individuals who do not have a need or right to know which could place residents at a risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female with an initial admitted [DATE], with diagnoses which included metabolic encephalopathy (a neurological disorder that occurs when a chemical imbalance in the blood affects the brain), arthritis, dementia, and anxiety disorder. Record review of Resident #1's quarterly MDS assessment section C, cognitive patterns, dated 8/21/24 reflected a BIMS score of 10 (moderate impairment). During a phone interview on 8/19/24 at 2:35 p.m., the ombudsman stated that she had a call from Resident #1's Family Member A who stated that someone at the building on 8/5/24 gave out Resident #1's BIMS and diagnosis to someone they should not have. She stated that there is an ongoing court case involving Resident #1 and Family Member B. She stated that a notary came to the facility and attempted to get Resident #1 to sign documentation to not evict Family Member B off the property back home. She stated that there was an argument, and some medical information was given out to the notary. She stated she followed up on the incident on 8/7/24 and went to the facility and asked who in the building gave away this information. She stated that the administrator stated, she was the one who gave out this information to the notary. She stated the administrator stated, she gave out the information to calm everyone down. During a phone interview on 8/19/24 at 2:55 p.m., Family Member A stated that on august 5th 2024 around 5:30 p.m., a notary came to the facility. She stated that the notary was trying to get Resident #1 to sign documentation which she should not sign. She stated that the next day august 6th 2024 there was a court case in which the notary at the facility shared Resident #1's diagnosis and BIMS score. She stated she has no idea who gave this information to the notary, and this should never have happened. She stated that was when she decided to reach out to the ombudsman to figure out who gave this information away. During an interview on 8/19/24 at 3:15 p.m., the Administrator stated that there was an incident on August 5th, 2024, in which a notary from the court was at the facility. She stated that Resident #1's Family Member A came and banged on her door and stated that the notary in the building should not be there and is not sure why he was there. She stated that there had been an ongoing court case, and this was roughly the 4th time the case was trying to be determined. She stated that in open conversation she stated to both the notary and Family Member A that they needed to know the residents BIMS score to determine if she had the ability to make the decision on her own. She stated that once she found out Resident #1's BIMS score she stated out loud to a group of employees and the notary. She stated she was trying to help the situation. Record review of Facility Policy dated December 2006; titled Confidentiality of Information indicated: Policy statement-our facility shall treat all resident information confidentially. Policy interpretation and implementation: 1. The facility will safeguard all resident records, weather medical, financial, or social in nature, to protect the confidentiality of the information.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 2 newly admitted residents (Residents #2) reviewed for baseline care plan. The facility failed to develop a baseline care plan for Resident #2. These deficient practices could place residents at-risk for decreased quality of life, improper care, and injury. The findings were: Record review of Resident #2's face sheet dated 8/20/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included end stage renal disease, hyperlipidemia, and hypertension. Record review of Resident #2's baseline care plan reviewed 8/20/24 revealed no data available. During an interview on 8/19/24 at 4:45 p.m., MDS C stated that Resident #2 came in on a Friday 6/28/24 and left AMA early Monday 7/1/24 morning. She stated that the nurses interim plan of care was completed upon admission for Resident #2. She stated but no baseline care plan was completed for the resident. She stated that the resident was not here long enough to get the care plan completed because it was through a weekend, and she left before they started on 7/1/24. She stated a baseline care plan should be completed on every resident within 48 hours. During an interview on 8/22/24 at 11:45 a.m., the administrator stated a baseline care plan should be completed within 48 hours of being admitted into the facility. During an interview on 8/22/24 at 12:25 p.m., the DON stated that a baseline care plan should be done within 48 hours of the resident being admitted . She stated that sometimes they use the interim plan of care to get an initial care plan done for a resident. She stated however, the interim plan of care documentation is incomplete and there is no baseline care plan completed Resident #2. She stated this was a miss by the staff, even if it was a weekend, it should have been completed and it was not. Record review of Facility Policy dated December 2016; titled Care Plans-Baseline indicated: Policy statement-A baseline pan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, for 2 of 6 (Hall 600 & Hall 700) Medication Carts. 1.) The facility failed to ensure medication cart #1 was locked when unattended by nurse. 2.) The facility failed to ensure that all medications stored in Hall 600 & 700 medication carts were properly stored/labeled. These failures placed all residents at risk of harm or decline in health due to lack of potency of medications/biologicals or misappropriation of medications. The findings included: During an observation and interview on 01/26/2024 at 11:27 a.m., of 700 hall medication cart, revealed RN A stored 10 loose pills in the top drawer under one lock in a clear medication cup with no label. RN A stated she had attempted to administer the medications earlier and the resident would not take them so she stored it in the top of medication cart to attempt to give again. She stated she knew what the resident's medications were for due to it was the only medication cup with medications in the top of her cart. She stated medications were for Resident #2 which included 5 supplements, 1 thyroid medication, 1 blood thinner, 1 proton pump inhibitor, 1 constipation medication, 1 diuretic, and 1 blood pressure medication. RN 1 did not state any negative outcome when asked if there could be a negative outcome from storing medication outside of their original medication packages. During an observation and interview on 01/26/2024 at 12:04 p.m. of the 600 hall medication cart, revealed RN B stored loose medications in 3 medication cups in the top drawer under one lock 1 medication cup had Resident #3's last name written on it and one capsule in a medication cup. 2 medication cups had Resident #4's last name written on them with 7 pills in them. RN B stated the medications were for Resident #3 and Resident #4 which included: 1 antibiotic, 1 heart arrythmia medication, 4 supplements, 1 steroid, and 1 blood thinner. RN B stated she attempted to give medications earlier and both residents would not take. She stated she had stored them in the top drawer to attempt to administer the medications later and then would dispose of them if residents continued to refuse. RN B stated she did not know if the facility had a policy on medication storage regarding loose medication in cups. During an interview on 01/26/2024 at 12:08 p.m., the DON stated she was not aware if the facility had policy on medication storage. She stated she felt it was better to store medications loose in medication cups than to dispose of the medications right away when resident refused to take and not attempt to give the medications again. During an observation on 01/27/2024 at 8:12 p.m., revealed the medication cart #1 was unlocked and unsupervised on the 700 hall. Residents were observed near the medication cart and no staff were visible. On top of the medication cart there were 7 medication cups labeled with resident last name on some and room number on others for Residents #2, #5, #6, #7, #8, #9, and #10 stacked on top of each other with medications pre-popped inside of the cups. There were 2 additional medication cups that had a crushed medication inside of them. 1 medication cup has 4 pills, 2 medication cups had 5 pills, 1 medication cup had 6 pills, and 1 medication cup had 11 pills. The loose medications included: Crestor a cholesterol lowering medication; Melatonin a supplement to help induce sleep; Mirtazapine an anti-depressant; Eliquis a blood thinner (medication that interferes with blood clotting); Metoclopramide a medication that increases the speed the stomach empties into the intestines. Lyrica a medication used to treat nerve pain; Calcium / Magnesium / Zinc supplement; Atorvastatin a cholesterol lowering medication; Trazodone an antidepressant that can help with sleeplessness; Baclofen a medication that helps reduce muscle spasms; Carvedilol a medication that is used to help heart and circulation of blood; Famotidine a medication that decreases the amount of acid in the stomach; Keflex an antibiotic for infection; Seroquel an anti-psychotic medication used to treat psychosis; Senna-S a medication used to treat constipation; Buspirone an anti-anxiety medication; Sertraline an anti-depressant; Metoprolol a medication used to treat high blood pressure or elevated heart rate; Potassium chloride a supplement; Ticagrelor a medication that lowers risk for heart attack and helps lower risk of blood clots; Carisoprodol a medication to help relax muscles and reduce nerve pain; Amitriptyline a medication that helps lower depression; Metformin a medication used to help lower blood sugars in Type 2 diabetics; Gabapentin a medication used to help reduce nerve pain; Omeprazole a medication used to lower stomach acid; Donepezil a medication used to treat dementia. The medication names were gathered from the MARs of each of these residents. During an interview on 01/27/2024 at 8:17 p.m., RN C stated the medication cart was her cart and that she had not left the cart unattended for very long. RN C stated that she had pre-popped medications for resident #5, #6, #7, #8, #9, and #10 that were to be administered at nighttime. RN C stated the medication cart should have been locked and that medications should not have been on top of the cart. RN C stated it was not appropriate to pre-pop the medications, but she lived in the real world and that was the only way she would have time to administer all her medications to residents. During an interview on 01/27/2024 at 8:35 p.m., the DON stated she and the ADONs were responsible for monitoring medication storage and administration by performing rounds. She stated an in-service was performed with staff that handle medications earlier today. The DON stated pre-popping medications increases the chance of medication errors. The DON was unsure of why medications were pre-popped but felt the nurse pre-popped to make her medication pass faster. During an interview on 01/27/2024 at 8:45 PM RN C stated she had signed an in-service when she started her shift informing her about not pre-popping medications. Review of an in-Service document provided by the facility to CMAs and nurses on 01/27/2024 titled Medication Administration revealed RN C had signed the in-service document prior to observation. The in-service document revealed: It is not best practice to leave medications in the cart for any reason. If the resident won't take their medications, and you have already popped them out of the card, then you will need to waste the pills that were popped with another nurse. Record review of the facility policy titled Storage of Medications revised date of April 2007 revealed: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers .The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to: A. dispose of food items after the use by or expiration date . B. store, seal and date food items. These failures could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included : During observations on 10/02/2023 from 10:01am to 11:30am of the kitchen revealed: Dry Storage: One unsealed opened bag containing fish fry seafood breading mix in an unlabeled 25-pound box One can of cream of mushroom soup with a dent on the side of the can Refrigerator One box of individual one pound margarine sticks in a 30pound box with no arrive or open date One 32 once container labeled vanilla yogurt with no arrive or open date Freezer One fourth full unsealed opened bag containing frozen sliced carrots in an unlabeled 30-pound box One plastic bag labeled ham with ice around the ham with a date of 01/01/2023 One half full unsealed opened bag of sweet green peas in an unlabeled 30-pound box One, one fourth full unsealed opened bag of lima beans in a 30-pound box with an open date of 09/21/2023 One three fourths full unsealed opened bag containing crinkled cut potato fries in an unlabeled 30-pound box One unopened 32-ounce bag of sugar snap peas with no arrive date During an interview 10/05/2023 at 09:20 AM Dietary Manager stated that her expectation of her staff was to correctly store, seal and label all foods. The Dietary Manger stated that if foods were not stored, labeled and dated properly that it could cause residents to get food borne illnesses. She stated that everyone in the kitchen is responsible to ensure foods are stored properly. She stated that as the dietary manger she is responsible to ensure that staff are properly trained on sealing, labeling and storing of foods. The dietary manger stated that all residents eat from the kitchen. During an interview on 10/05/2023 at 9:40 AM the Cook stated that she was trained by the dietary manager on how to properly store foods. She stated that she was trained by in-services and physically shown how to properly store foods. The c ook stated that if food was not stored properly that it could make residents sick. Review of facility policy HCSG 017, 019 titled Food Storage and Receiving of Food, revised 2022, revealed: All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Review of the FDA Food Code 2022 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 1 of 1 meal reviewed for palatability and appetizing temperature. The facility failed to serve meals that were palatable and at an appetizing temperature. These failures could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. Findings included: During an observation on 10/03/2023 at 1:06 PM the facility tray was provided and consisted of a beef hamburger with cheese, tater tots, Cole slaw, fruit cocktail and peaches. The hamburger's internal temperature at the time of service was 106 degrees Fahrenheit. It was not palatable. During an interview on 10/04/2023 at 3:00 PM Resident #39 stated that food is cold . During an Interview on 10/05/2023 at 9:20 AM, the Dietary M anager stated that everyone in the kitchen from the cooks, the aides, whatever personnel that was in the kitchen was responsible to ensure that food was served at the proper temperatures of 165 degree Fahrenheit. The Dietary manager stated that the negative effects of foods not being served at the proper temperatures could make a resident sick, cause them to get salmonella, E.coli and it could cause them to have a decreased palatability. She stated that her expectations of staff are that temperatures are to be done on all food items to be served to the residents. During an interview on 10/05/2023 at 9:40 AM, the Cook stated the staff responsible for serving were responsible to ensure meals were served at the correct temperature of 165 degrees Fahrenheit. She stated that the negative effects of food not at correct temperatures could cause residents that consume the meals to get bacteria, food poisoning and sicknesses. She also stated residents would not want to eat their meals and they could lose weight. Record review of the policy for Food Quality and Palatability HCSG Policy 006 dated 05/2014, revised 09/2017, reflected Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Record review of the facility policy for Food Preparation HCSG 016 dated 05/2014, revised 09/2017, reflected All foods will be held at appropriate temperatures, greater than 135 for hot holding. 48883

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. The medication error rate was 7.41% with 2 errors in 27 opportunities involving 2 staff; RN E and LVN F and 2 of 5 residents (Resident # 125 and Resident # 31) reviewed for medication errors. 1.) The facility failed to ensure RN E administered the medication Aspirin 325mg to Resident #125 as ordered by the physician. The facility administered the wrong dose 81mg to Resident #125 instead. 2.) The facility failed to ensure LVN F administered the medication Admelog SoloStar 100 unit/ML Solution to Resident #31 as ordered by the physician. The facility administered the wrong medication insulin glargine to Resident #31 instead. The facility's failure could place residents at risk of uncontrolled pain, decreased circulation, low blood sugar readings or seizures. Findings included: 1. Review of Resident #125's Face Sheet dated 10/03/2023 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including encounter for other orthopedic aftercare, low back pain, high blood pressure, and fibromyalgia (disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue, and sleep disturbances). Review of Resident #125's admission MDS dated [DATE] revealed Resident #125 had a BIMS of 15 indicating the resident was cognitively intact. Review of Resident #125's Physician's Orders dated 10/03/2023 revealed an order with start date of 09/28/2023 for Aspirin Oral Tablet 325MG with directions to be give one tablet by mouth twice a day. Review of drugs.com accessed on 10/09/2023 at https://www.drugs.com/aspirin.html revealed that Aspirin is used to treat pain, reduce inflammation, and to treat and prevent heart attacks, strokes, and chest pain. During an observation on 10/02/2023 at 10:12 a.m., RN E administered Aspirin 81 MG one tablet by mouth to Resident #125 from OTC bottle in the top of medication cart. During an observation and interview on 10/03/2023 at 3:36 p.m., RN E said that he was just used to giving 81MG and did not realize that the resident was ordered a different dosage. He looked in the resident's records and verified that the order reflected to give 325MG Aspirin twice a day. He stated the effect on the resident getting the wrong dose could affect the resident's circulation or pain. 2. Review of Resident #31's Face Sheet dated 10/03/2023 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus with foot ulcer (an open sore or wound on the foot of a person with diabetes), and type 2 diabetes mellitus with diabetic neuropathy (nerve damage that is caused by diabetes). Review of Resident #31's Quarterly MDS dated [DATE] revealed Resident #31 had a BIMS score of 15 indicating he was cognitively intact. Review of Resident #31's Physician's Orders dated 10/03/2023 revealed an order with start date of 08/01/2023 for Insulin Glargine Solution 100units/ML with directions to give 35 units subcutaneous at bedtime. Review of Resident #31's Physician's Orders dated 10/03/2023 revealed an order with start date of 08/09/2023 for Admelog SoloStar also known as insulin lispro 100unit/ML Solution with directions to give per sliding scale (if FSBS 201-250 give 6 units). Review of drugs.com accessed on 10/09/2023 at https://www.drugs.com/mtm/insulin-glargine.html revealed that Glargine is long-acting insulin that starts to work several hours after injection to improve blood sugar control in people. Review of drugs.com accessed on 10/09/2023 at https://www.drugs.com/admelog.html revealed that Admelog is a fast-acting insulin that starts to work in about 15 minutes to improve blood sugar control in adults. During an observation on 10/03/2023 at 11:30 a.m., revealed LVN F checked Resident #31's finger stick blood sugar using the glucometer with a reading of 235 and then administered 6 units of insulin glargine 100units/ML into subcutaneous tissue. During an interview on 10/03/2023 at 3:28 p.m., LVN F stated she had verified that she had given insulin glargine thinking that it was the correct insulin as it was the only insulin in the medication cart. LVN F stated if she was not familiar with a medication, she would have to look it up on her phone. She stated she was not aware of any medication books for reference provided by the facility. She stated she did not know what the adverse effect the medication error could had been on the resident but did voice that his FSBS had been good. During an interview on 10/03/2023 at 4:16 p.m., the DON said that it was the ADONs' and pharmacy representatives' responsibility to monitor if medications were administered correctly. The DON said the pharmacy representatives would follow nurses and watch medication administration when they were in the facility. She stated the lack of education was what led to the medication error failure. She stated that RN E and LVN F had notified her of the medication errors observed by the surveyor and that the medication error process had been done including notifying the ordering physician. She stated that insulin was a high-risk medication. She stated that she did provide LVN F medication interchange guide that the pharmacy had given the facility. She stated that the effect of insulin not being administered correctly (correct dose or correct medication) would have caused the resident to have low/high blood sugars or worse. Her expectation was that medications were given correctly using the 8 rights of medication administration (right Resident, right medication, right dose, right route, right time, right documentation, right reason, and right response). She stated that correct insulin was found in medication room fridge and education given to LVN F. Review of the facility's policy for Administering Medications on 10/03/2023 at 4:32 p.m. revealed 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of [Pharmacy name] Therapeutic Interchange Form on 10/03/2023 revealed [Pharmacy name] is offering the following therapeutic interchange protocols. Original Medication Prescribed Novolog vials, pen and Therapeutic Interchange Admelog pen, vial or generic lispro pen, vial.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public reviewed for a safe and homelike environment for 3 (halls 500, 600, and 700) of 4 hallways. The facility failed to have residents' rooms, without damage: 1. hole in the drywall, 2. call lights did not connect to the light in the hallway, 3. scuffed paint with exposed sheetrock, 4. broken blind, 5. light string broken, 6. no toilet cover, and 7. toilet without a flushing handle. These failures could place residents and staff at risk of unsafe and unsanitary environment. Findings included: During observations on 10/02/2023 between 11:08 AM and 2:53 PM revealed: room [ROOM NUMBER]B-There was a hole in the drywall. room [ROOM NUMBER]A/B and room [ROOM NUMBER]A/B-The call lights did not connect to the light in the hallway when pressed. room [ROOM NUMBER]A-There was scuffed paint with exposed sheetrock. room [ROOM NUMBER]A/B- The window blind was broken and with resident unable to easily open, and the resident light string was broken and out of reach. room [ROOM NUMBER]A/B-There was a hole in the drywall at the resident's head of bed; in the bathroom there was no toilet cover, and no handle for easy access to flush the toilet. During an observation and interview on 10/02/2023 at 02:53 PM, revealed the call light did not light in the hallway when resident pushed her call light button. LVN G stated sometimes she had to jiggle and reset the restroom lights in order for the light in the hallway to work. During an interview on 10/05/2023 at 10:42 AM, LVN H, stated there should have been maintenance in the facility. She stated once they changed the overhead light chords out, they worked fine. She stated when the residents broke them, the staff would have placed the work order in the facility computer program for maintenance to review and repair. LVN H stated she had not ever followed up on how long it took for maintenance to repair the orders she had previously placed; she would resubmit the order if she saw that it had not been corrected. She stated, the staff, including herself had to troubleshoot the call light systems in a few rooms. She stated the scuffs and holes in the residents' walls were related to the beds rubbing on them and had been there at least a couple of months. An interview on 10/05/2023 at 11:08 AM, the ADM stated the staff had discussed why the call system was not fully engaging with the lights in the hallway outside the residents' rooms. She stated, when the residents told the staff their lights outside of their rooms had not worked, the staff would know to go troubleshoot and jiggle the wires where it was connected into the wall. The ADM stated that it was a random occurrence but was always fixable. She stated, when the facility had maintenance, the staff notified them. The ADM stated if it happened at night, their upper management was notified in a group message. She stated it was the CNAs and nurses that worked those hallways during the times the call light would not function correctly. She stated staff used a program on the computer to report issues that needed to be maintained, but the facility had been without maintenance for almost a month. The ADM stated once the incidents were reported and logged into their maintenance repair program, it should have been maintenance to follow up with those, with her as the ADM to monitor maintenance. She stated the facility protocols were for staff to have reported the repairs needed with maintenance prioritizing the needed repairs. The ADM stated she would not have liked living in those situations as it was not homelike. The ADM stated the negative impact to the residents was that the environment was not conducive and not beneficial to them. She stated if the call lights were not working, they could then have a possible behavior issue. She stated the failure for not having maintenance led to the failure, which delayed the process of not getting the repairs done. She stated she was not sure if the call lights could be repaired, as she believed it to be a wiring issue between the bathroom call light when used and the room call light. The ADM stated her expectations were for the facility to look nice for the residents with them feeling like it was their home and being felt taken care of. Record review of the facility's Open & In Progress work orders dated 10/04/2023 revealed: #1566 Pull string for light in room is missing-Medium priority-Room/Area 808A-Not Assigned #1509 Overhead bed light needs string-Low priority-Room/Area 803A-Not Assigned #1521 wall damage-Low priority-Room/Area 706A-Not Assigned #1496 Large hole in wall where recliner use to be-Low priority-Room/Area 501B-Not Assigned #1564 Family states light over the bed is not managed by the cord but by switch-Medium priority-Room/Area 508B-not assigned Record review of the facility policy statement and procedures for Maintenance Service revised December 2009 revealed: Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building and compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazard . d. plumbing fixtures, . In good working order. e. Maintaining lighting levels that are comfortable, and assuring that exit lots are in good working order. f. Establishing priorities in providing repair service i. Providing routinely scheduled maintenance service to all areas. j. Others that may be become necessary or appropriate. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the building, grounds, and equipment are maintained in a safe and operable manner. 4. A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to residents. 5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule. 6. Changes in maintenance schedules must be approved by the maintenance director 8. The maintenance director is responsible for maintaining the following record/reports. a. Inspection of building; b. Work order request; c. Maintenance schedule; d. Authorized vendor listing; and e. Warranties and guarantees 9. Records shall be maintained in the maintenance directors office. 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Record review of facility policy Answering the Call Light dated with the revised date of March 2012 revealed: Purpose: The purpose of this procedure is to respond to the resident's requests and needs . .7. Report all defective call lights to the Nurse Supervisor promptly. 47775

Based on interviews, and record reviews, the facility failed to assure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, for 1 of 1 (Resident #71), resident reviewed for accuracy of assessments. The facility failed to include accurate discharge for Resident #71 on MDS. This failure placed residents at risk of not receiving an accurate assessment, reflective of the resident's status. Findings included: Review of resident #71's face sheet revealed resident was admitted to facility 05/17/2023 and discharged on [DATE]. Review of r esident #71's MDS dated [DATE] revealed resident #71 was discharged to a local community hospital. Review of resident #71's progress notes on 07/13/2023 at 12:23 PM by SW A revealed that resident #71 was transferred to a skilled nursing facility. During an Interview on 10/05/2023 at 3:45 pm the MDS coordinator stated that it was her responsibility to ensure that the MDS was accurate. She stated that she received the information on the resident by reading the resident's chart in the electronic health record. She stated that she reviewed the resident's progress notes, assessments, discharge summary as well as interviewed staff regarding the resident. The MDS coordinator demonstrated in the electronic health record that Resident #71 had no discharge summary. The MDS coordinator then showed in the resident's progress notes of the electronic health record a note reflected Resident #71 was discharged on [DATE] from the facility to another skilled nursing facility with medications. She then showed in the MDS section of the electronic health record where Resident #71 entered to be discharged to an acute hospital. The MDS coordinator stated that it was her error. She stated that she entered the incorrect code and information on Resident #71's discharge status in the Minimum Data Set. She stated that it should have been entered as 02 another nursing home and instead she entered 03 acute hospital. During an interview on 10/05/2023 at 4:40 PM, DON D stated that she was the person responsible to sign off on MDS assessments . Record review of policy for Resident Assessment Instrument dated revised September 2010, reflected All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent residents from abuse, neglect, exploitation, and misappropriation of resident property for 1 of 15 employees (CNA-P) reviewed for criminal history checks and EMR/NAR's. The facility failed to perform an initial criminal and EMR/NAR checks for CNA-P. These failures placed residents at risk of abuse, neglect, exploitation and misappropriation of property. Findings included: Record review of facility policy titled Abuse Prevention Program last revised 08/2006 revealed: Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: a. Protocols for conducting employment background checks. Record review of facility policy titled Personnel Records last revised 04/2008 revealed: a. Criminal History Check (completed prior to hire) . d. Misconduct Registry Check (completed prior to hire and annually) Record review of Personnel Files revealed: CNA-P had a hire date of 1/23/23 with an initial criminal history ran on 1/25/23 and an initial EMR/NAR ran on 1/30/23. During an interview on 10/04/23 at 02:48 PM with ADM- C, she said the facility had a computer virus that took away their access to get the EMR/NAR and criminal histories during the months of August and September of 2023 so new employees or employees that needed annual history checks in the months of August and September 2023 did not get them done timely. She said if the employee was hired or their annual was in the months prior to August and September or after September then they should have been completed timely. During an interview on 10/05/23 at 04:17 PM with HR-T and HRA-V, HR-T said she had been working as HR for about a month. HRA-V said he had been working about 8 months. HR-T said she did a criminal history and EMR/NAR check before the employee was hired, but only did a criminal hx annually after that. HR-T said she could just do them all in January each year, not on their anniversary date. She said she was unaware that the criminal history and the EMR/NAR was to be ran annually on the employee's anniversary date. They both said they got a few days training by former HR personnel. HR-T said the criminal history and EMR/NAR check was to ensure that the facility did not hire someone that had committed certain crimes like abuse, assault, felony theft. HR-T said she understood that some things might not come through when someone was first hired or that they may have had a conviction after they are working. HRA-V said the criminal history and the EMR/NAR should have been ran before an employee was hired, not days after they were hired .

Based on interviews and record reviews, the facility failed to preserve the resident right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 6 (Resident #31) reviewed for Resident Rights. The facility failed to respect the rights of Resident #31 regarding smokeless chewing tobacco. These failures placed residents at risk of their rights to make choices about their life being disregarded. Findings included: Record review of Resident #31's Facesheet dated 10/05/23 revealed a [AGE] year-old male that admitted to the facility on [DATE]. He had a diagnosis list that included Acute respiratory failure with hypoxia (low oxygen saturation), (Primary), Cognitive communication deficit, Morbid obesity due to excess calories, Type II diabetes with foot ulcer, Hypertension. Record review of Resident #31's MDS dated [DATE] revealed a BIMS of 15 meaning he had no cognitive deficits. Record review of Resident #31's Careplan last revised 09/25/23 did not address that resident utilized chewing tobacco or snuff. Record review of Resident #31's Admission Consent labeled A Comprehensive Form of Authorizations, Consents, Releases, and Acknowledgements signed 04/01/22 revealed: I hereby acknowledge that the facility is a non-smoking facility. Residents may not use or keep cigarettes, cigars, matches, or any smoking paraphernalia in their room or on their person at any time during their stay at the facility. Failure to adhere to this policy may result in immediate discharge. During an interview on 10/03/23 at 10:53 AM with Resident #31, he said he would like to be able to have dip in and out of the building. Resident #31 said he had snuff, and the facility kept taking it from him. He said he did not mind that he might have to go outside to dip but said there was staff that smoked out back of the facility and there was staff that dipped, and they did it in the building. Resident #31 said it was not fair that the staff was able to smoke or dip and he was not. He said he would like the facility to let him come and go outside to dip and keep his tobacco himself. During an interview on 10/04/23 at 10:56 AM with MR-R, she said the facility had an admissions coordinator that ensured residents completed the entire admission packet and she uploaded it to the electronic health record. She said she thought a smoking policy might be in the packet but didn't know. She reviewed resident uploaded documents and did not see the file; she was going to speak to the admissions coordinator. During an interview on 10/04/23 at 11:23 AM with ADM-C, she said she considered snuff to be a smoking paraphernalia, per say, but that she would find their smoking policy to see what it had to say. CNS-S said that it would probably be just the same as E cigarettes, and they would look at their policy, it might just need some updating. During an interview on 10/04/23 at 02:29 PM with Resident #31, he was again adamant that he wanted his tobacco/snuff back. He said his snuff was not smoking paraphernalia. Resident #31 said he was fine if they could not do it but felt the staff should not be able to do it either. Record review of ADM-C email sent on 10/04/23 at 11:53 AM that stated: has smoking policy, but we are non-smoking, so admission packet is what we follow for smoking-free facility. Paraphernalia includes tobacco, but mgmt. office has agreed to expand on the paraphernalia working on admission packet. Record review of facility policy labeled Resident Rights revised 10/2009 revealed: Federal and state laws guarantee certain basic rights to all residents of this facility Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on interview and record review, the facility failed to Incorporate Level II Recommendations from the PASRR level II determination and the PASRR (Pre-admission screening and resident review) evaluation for 1 of 2 residents (Resident #13) reviewed for PASRR in that: The facility failed to follow up with the LA for PASRR Level II determination when Resident #13's PASRR Level 1 Screening reflected she was positive for mental illness. This failure could place the residents with a documented mental illness, intellectual and/or developmental disability at risk for not receiving needed services. The findings are: Record review of Resident #13's Face Sheet dated 10/03/2023 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: major depressive disorder, recurrent severe without psychotic features; and post-traumatic stress disorder. Record review of Resident #13's PASRR Level 1 Screening dated 08/16/2023 revealed the resident was positive for mental illness. Record review of Resident #13's admission MDS dated [DATE] revealed the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Record review of Care Plan dated 08/16/2023 revealed Resident #13 had focus that included taking antidepressant, mood problem, and psychosocial wellbeing problem. Record review of Behavioral Health progress note by the behavioral therapist dated 09/15/2023 revealed that patient would be receiving therapy for major depressive disorder, recurrent severe without psychotic features, post-traumatic stress disorder, chronic, and Insomnia due to other mental disorder. Current Psychotropic Medications included: Clonazepam 0.5mg quantity 1 twice a day, Cymbalta 90mg quantity 1 at bedtime, Gabapentin 100mg quantity 1 at bedtime, and Gabapentin 800mg quantity 1 three times a day. During an interview on 10/04/2023 at 3:12 p.m., SW A stated that the MDS coordinator was responsible for completing the MDS PASRR section . During an interview on 10/04/2023 at 3:13 p.m., MDS coordinator B stated that the PASRR 1 form was submitted to the local authority on 08/23/2023. She provided that PASRR 1 submitted on 08/23/2023 at 9:39a.m. On 08/23/2023 at 9:39 AM the resident was placed in nursing facility Exempted Hospital Discharge. On 08/23/2023 at 9:39 a.m., the resident had been admitted to the nursing facility and required less than 30 days of nursing facility services. On 09/15/2023 at 9:19 a.m. status was awaiting PE. MDS coordinator B stated that Resident #13 planned to reside in facility longer than 30 days and information was inputted wrong. MDS coordinator B could not provide information on when the PE (was to be performed. After surveyor requested information, she voiced that she would follow up with local authority today on the status of the PE. During an interview on 10/05/2023 at 10:50 a.m., the ADMN stated the facility was in the process of having a PE scheduled for Resident #13. She stated that she had spoken to MDS coordinator B, and that the local authority voiced they would perform the PE but was unsure of the time. She stated she would provide the policy and procedure. During an interview on 10/05/2023 at 11:06 a.m., MDS coordinator B stated that she spoke to local authority on the telephone, and the facility had Resident #13's PE scheduled. She could not state the effect on the resident for failing to have completed PASRR II assessment. Review of the PASRR clinical policy on 10/05/23 01:55 p.m. revealed If documentation entered on the PL1 Indicates MI/ID/DD, a PE must be completed. The PL1 must be completed and submitted via the LTC Online Portal for every individual seeking admission to a Medicaid certified nursing facility prior to admission, regardless of funding source. The Referring Entity (RE) will perform the PL1 Screening Form for individuals admitted to the HMG Facility under the Preadmission process. Only a Local Authority (LA) or HMG Facility can submit a PL1 on the LTC online portal .The PL1 submission procedure: 1. Enter the data from the had written PL1 Screening paper form into the online version of the PL1. 2. Retain a copy of the handwritten PL1 Screening paper form, with the appropriate original signatures, in the resident's record in the Business Office. The handwritten PL1 Screening paper form with the appropriate original signatures will be kept as a part of the resident's record for 5 years after resident's discharge or death. 3. The PL1 Screening must include the address of the individual, or LAR or the address where the individual or LAE can be contacted. 4. The PL1 Screening must include at least 1 nursing facility choice entered in Section D regardless of PASRR eligibility .Section C; PASRR Screen (Screener) INTENT: This section to be completed for resident's suspected of having Mental Illness .A mental disorder is defined as the following: a schizophrenic, mood, paranoid, panic or other severe anxiety disorder, somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability Nursing Responsibilities 5. The MDS/DON and/or designee will monitor the LTC Online Portal daily for submitted PE's.

Based on observation, interview, and record review the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers that were avoidable and failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 6 of 8 residents (Resident #4, Resident #1, Resident #2, Resident #6, Resident #7, Resident #8) reviewed for skin integrity. 1. The facility failed to follow physician's orders to prevent Resident #4's Deep Tissue Injury to right medial heel to deteriorate to a stage 4 pressure ulcer. 2. The facility failed to follow physician's orders to prevent Resident #1's Right Ischium(hip) pressure ulcer to deteriorate from a stage 2 to a stage 3. 3. The facility failed to obtain physician orders for treatment of Resident #2's stage 4 pressure ulcer on right posterior calf. Resident #2 went 12 days without treatment to wound. 4. The facility failed to obtain physician orders for treatment of Resident #6's left heel Deep Tissue Injury. Resident #6 went 5 days without treatment to wound. 5. The facility failed to complete skin assessments of Resident #7 which led to the development of a stage 2 pressure ulcer to the right upper buttocks and stage 2 to the right lower buttocks. 6. The facility failed to complete weekly skin assessments which led to Resident #8 developing stage 2 pressure ulcer to left buttock and stage 2 pressure ulcer to right buttock. 7. The facility failed to ensure Resident #2 and Resident #4's skin assessments were completed, assessed accurately and accurately documented by the DON. 8. The facility failed to ensure Resident #1, Resident #4 and Resident #5's wound treatments were completed and accurately documented by DON and ADON E. 9. The facility failed to maintain accurate list of residents with pressure ulcers. The facility did a skin sweep and found Resident #7's and Resident #8's wounds after surveyor intervention requesting accurate lists of residents with pressure ulcers. An Immediate Jeopardy (IJ) was identified on 08/03/23. While the IJ was lowered on 08/07/23, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of wound deterioration, wound development, and infection. Findings include: 1.Resident #4 Record review of Resident # 4's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Sepsis (primary) and need for assistance with personal care. Record Review of Resident #4's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed Resident #4 had physical help limited to transfer only (mostly setup help or one person physical assist); Section H- Bowel and Bladder revealed always continent for bowel and bladder; Section M-Skin Conditions revealed Resident #4 was at risk of developing pressure ulcers/injuries and that Resident #4 had stage 4 pressure ulcer. Record review of Resident #4's care plan dated 05/15/2023 revealed: Focus: The resident has the potential for pressure ulcer development r/t impaired mobility, incontinence, obesity. Date Initiated: 08/23/2022. Revision on: 08/23/2022. Interventions: Notify nurse immediately of any signs of skin breakdown: redness, blisters, bruises, and discoloration noted during bath or daily care. Date Initiated: 08/23/2022. Provide assist with turning and repositioning during rounds. Date Initiated: 08/23/2022; Focus: The resident has (DTI) pressure injury to Rt medial heel r/t Reduced Mobility. Date Initiated: 03/29/2023. Revision on: 03/29/2023. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/29/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/29/2023. Assess/record/and monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 03/29/2023. Revision on: 06/05/2023. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition, and frequent repositioning. Date Initiated: 03/29/2023. Record review of Resident #4's physician order revealed start date 03/14/2023 Location of wound: Plantar right heel with order to be performed topically one time a day for Apply betadine to plantar right heel unstageable ulcer daily apply betadine until healed. Offloading @ all times. F/U with wound care and end date 04/13/2023. Record Review of Resident #4's TAR dated 04/01/2023 - 04/30/2023 revealed no evidence of treatment being completed on: 04/08/2023 and 04/09/2023. Record review of Resident #4's physician order revealed the order start date 04/13/2023 Location of wound: Right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Leptospermum honey in to wound bed cover with border dressing. and end date 05/04/2023. Record Review of Resident #4's TAR dated on 04/01/2023 - 04/30/2023 revealed no evidence of treatment for order with being completed on: 04/14/2023, 04/15/2023 and 04/23/2023. Record review of Resident #4's physician order revealed the following order start date 05/04/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date 06/27/2023. Record Review of Resident #4's TAR dated on 05/01/2023 - 05/31/2023 revealed no evidence of treatment for order with being completed on: 05/08/2023, 05/15/2023, 05/16/2023, 05/22/2023, 05/29/2023, 05/30/2023 and 05/31/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/02/2023, 06/03/2023, 06/04/2023, 06/12/2023, 06/19/2023, 06/20/2023, 06/21/2023 and 06/24/2023. Record review of Resident #4's physician order revealed the following order start date 06/27/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen powder and sodium hypochlorite get (anapest) cover with border dressing. And end date 06/29/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/28/2023. Record review of Resident #4's physician order revealed the following order start date on 06/29/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift every Tue, Thu, Sat Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/10/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/01/2023. Record review of Resident #4's physician order dated 07/29/2023 revealed the following order start date on 07/10/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/20/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/14/2023, 07/15/2023, and 07/23/2023. Record review of Resident #4's Medication Administration Audit Report generated by CSD revealed: -Scheduled for 07/14/2023 at 06:00AM and charted as completed on 07/29/2023 8:58PM by DON. -Scheduled for 07/15/2023 at 06:00AM was charted as completed on 07/29/2023 9:06PM by DON. -Scheduled for 07/23/23 at 6:00AM was charted as completed on 7/29/23 at 9:53PM by DON. Record review of Resident #4's nurse's skin assessment dated [DATE] revealed DTI (deep tissue injury) to right medial heel. Record review of Resident #4's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #4's WCS physician note dated 05/18/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #4's WCS physician note dated 05/25/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Treatment options - risks - benefits and the possible need for subsequent additional procedures on this wound were explained on 04/13/2023 to the patient. Record review of Resident #4's WCS physician note titled dated 07/27/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.4cm in length by 2.2cm in width by 0.2cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. During an observation and interview on 08/01/2023 at 4:30PM Resident #4 was sitting up in wheelchair with offloading boot to right foot and elevated with extended wheelchair footrest. Resident #4 stated she gave permission to observe foot and take a photograph of wound. Resident #4's right foot pressure ulcer had thick green tinged skin surrounding a circular wound with beefy red granulation tissue observed to wound bed. Observation of small amount of drainage observed to bandage and no odor. Resident #4 stated she had no concerns with her wound. 2. Resident # 1 Record review of Resident # 1's closed record face sheet dated 07/29/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent hospital readmitted [DATE], with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease. Record review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Record review of Resident #1's closed record care plan dated 05/15/2022 (revised on 06/04/2023) revealed: Focus: The resident is at risk for pressure injury r/t History of Pressure Injuries, Poor nutrition, Reduced Mobility, Sheering/friction problems. Date Initiated: 08/20/2020 Revision on: 02/21/2022; Perform and document weekly assessment form of skin for changes or observations. Date Initiated: 08/20/2020 Protect elbows and heels from friction. Date Initiated: 08/20/2020 Protect heels-offload when in bed. Administer medication as ordered. Date Initiated 11/29/2022. Follow facility policy and procedures for line listing, summarizing infections. Focus The resident has a stage 1 pressure injury to his R buttocks r/t Reduced Mobility, Incontinence, Sheering/Friction. Date Initiated: 08/18/2022 Revision on: 10/24/2022. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/18/2022. Administer treatments as ordered and monitor for effectiveness. Date Initiated 08/18/2022 Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD. Date Initiated: 08/18/2022. Revision on: 08/23/2022. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Date Initiated: 08/18/2022. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated 08/18/2022. Provide low air loss mattress to bed. Date Initiated: 08/18/2022. Provide pressure relieving cushion to wheelchair. Monitor for placement and condition. Notify supervisor if cushion needs to be replaced. Date Initiated: 08/18/2022. Record review of Resident #1's closed record Admission Summary Progress Note dated 06/03/2023 revealed stage 2 pressure wound on coccyx. Record review of Resident #1's closed record progress note titled Skin/Wound Note dated 06/15/2023 revealed WCS here this am to see resident. Stage 3 on rt ischium measures3x4.5x0.3. Light serous drainage with45% slough 5% granulation, 50% skin. Deterioration noted. Green tinge to drainage concerning for Pseudomonas. No signs of infection. WCS preformed surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #1's closed record nurses progress note dated 06/21/2023 revealed Resident return from OS per physician progress notes: 1) Please do NOT change the patients dressing 2) RTC on June 25 @ 1130AM. Transportation notified of f/u appt. and Info updated on 24 hour report. Record review of Resident #1's nurses progress note dated 06/30/2023 revealed Resident return from OS office per physician progress notes Please change Resident #1's foot wound dressing daily. No further need for ACE wrap. Please see that patient gets his augmentin as ordered. Call placed to OS office for clarification on orders what does provider want for dressing orders and orders for augmentin. Per [NAME] nurse at OS office to cleanse wound then swab with betadine cover with 4x4 and secure. Augmentin 875mg q12 hours x10days. Orders updated in chart and placed on24 hr{hour} report. Record review of Resident #1's closed record nurses progress note dated 07/07/2023 revealed Resident return from OS appointment per physician's progress notes: Continue daily dressing changes with betadine to wound base . Return in 1 week appt of 7/14/23 @ 1045am Transportation notified. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 4 pressure ulcer to R Ischium with wound care and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 05/18/2023 revealed diabetic wound of the left, distal, plantar, lateral foot full thickness. Surgical excisional debridement procedure indicated for removal of necrotic tissue and establish the margins of viable tissue. No mention of R Ischium wound. Record review of Resident #1's closed record WCS physician notes dated 06/08/2023 revealed R Ischium wound measuring 2.3cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/15/2023 revealed R Ischium wound measuring 3.0cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/22/2023 revealed R Ischium wound measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/29/2023 revealed R Ischium wound measuring 3.5cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 07/06/2023 revealed R Ischium wound measuring 4.0cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record hospital records dated 05/16/2023 revealed Stage 2 coccygeal & gluteal PI-POA. Record review of Resident #1's closed record physician orders revealed start date 06/05/2023 stating Location of wound: right Ischium with order to be performed every day shift Treatment order: Cleanse with NS/wound cleanser. Pat dry Apply Triad cream and cover with silicone dressing with end date 06/09/2023. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for order being completed on: 06/07/2023, 06/08/2023, 06/09/2023. Record review of Resident #1's closed record physician orders revealed start date 06/09/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Anasept and TAO to wound bed cover bordered gauze dressing with end date 06/27/2023 written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for completed on: 06/09/2023, 06/14/2023, 06/19/2023, 06/20/2023, 06/21/2023, 06/24/2023, 06/25/2023 and 06/26/2023. Record review of Resident #1's closed record physician orders revealed start date 06/27/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of being completed on: Record Review of Resident #1's closed record TAR dated June 1, 2023 - July 31, 2023, reviewed on 07/29/2023 at 1:17 pm, revealed no evidence of treatment for order being completed on: 06/27/2023, 06/30/2023, 07/01/2023, 07/03/2023, 07/05/2023, 07/07/2023 and 07/12/2023. Record review of Resident #1's closed Medication Administration Audit Report for July 2023 revealed Instructions were: Location of wound: Unstageable Rt Ischium every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to pen wound. Apply Leptospermum honey to wound bed cover border gauze dressing. Record review of Resident #1's closed Medication Administration Audit Report generated by CSD revealed: -Scheduled date of 7/1/23 at 6:00AM charted as N/A for assessment of wound bed and completed on 7/29/23 at 9:11PM by ADON E. -Scheduled date of 7/3/23 at 6:00AM charted as N/A for assessment of wound bed and completed on 7/29/23 at 9:09PM by ADON E. -Scheduled date of 7/12/23 at 6:00AM charted as N/A for assessment of wound bed and completed on 7/29/23 at 9:27PM by ADON E. During an interview on 07/29/2023 at 12: 59 PM Resident # 1's family member stated he/she had concerns about Resident 1's care while at the facility. Resident #1's family member stated he/she felt Resident #1 was neglected by the facility which led to his death. Resident #1's family member stated his room always smelled like urine and that Resident #1's dressing on his wounds were never changed timely. 3. Resident #2 Review of Resident #2's face sheet dated 08/03/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis unspecified dementia (primary), need for assistance with personal care, flaccid hemiplegia affecting right dominant side. Review of Resident #2's annual MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 8 (moderate); Section G- Functional Status revealed Resident #2 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bowel and Bladder revealed always incontinent for bowel; Section M-Skin Conditions revealed Resident #2 was at risk of developing pressure ulcers/injuries. Review of Resident #2's care plan dated 07/04/2022 revealed: Focus: The resident is at risk for pressure ulcer development r/t disease process and immobility. Date Initiated: 06/26/2018 Revision on: 04/15/2021; Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 06/26/2018. Administer treatments as ordered and monitor for effectiveness. Date initiated 06/26/2018. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiate initiated: 06/26/2018. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: 06/26/2018. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, S/SX of infection, wound size (length X width X depth), stage. Date Initiated: 06/26/2018. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments. Date initiated: 06/26/2018. Revision on: 03/03/2023; Focus: patient has a stage 4 pressure injury to right posterior calf with potential for further skin breakdown R/T: disease process, immobility, impaired mobility, lack of sensation, non-compliance with therapeutic regimen. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 07/29/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 07/29/2023. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 07/29/1013. Review of Resident #2's nurses notes dated 07/15/2023 at 11:00 PM written by LVN T revealed: Aide has brought to my attention that [Resident #2] has open area on back of right ankle area. When this nurse assessed, I found wound that is denuded, partial thickness and has black eschar in wound bed. I cleansed wound with wound cleanser, applied hydrophilic ointment and covered with bordered gauze. Entire leg and foot have severe outward rotation. It is stroke effected side. Heel is elevated off bed and wound area is hanging free with no pressure. Review of Resident #2's nurses note dated 07/17/2023 at 1:37 PM written by LVN A revealed: Resident noted to have a DTI per night nurse to his right lower calf area cleaned Review of Resident #2's physician orders revealed no evidence of pressure ulcer treatment between 07/15/2023 and 07/27/2023. Review of Resident #2's physician orders revealed: Order date 07/27/2023 at 2:15 PM Cleanse right lower posterior calf with dermal wound cleaner apply Triad Debriding Cream to wound bed and cover with boarder dressing. Every day shift every Mon, Wed, Fri for promote Wound healing and every 1 hour as needed for skin irritation. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed Right lower leg stage 3 pressure ulcer measuring 2.5cm in length by 2.7cm in width by 0.5cm in depth. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed right lower leg unstageable pressure ulcer measuring 2.5cm in length by 2.0cm in width by 0.5cm in depth. During an observation on 07/29/2023 at 4:10PM of Resident #2 revealed Resident #2 lying in bed with right leg on pillow. Resident #2's right lower leg was covered by gauze and secured with tape. The dressing did not have a date on the outside. During an observation on 7/30/2023 at 3:30 PM of Resident #2 revealed Resident #2's lower right leg had a wound that had red tissue present, surrounding skin within normal limits for race, no tendon or bone observed, no necrosis observed, measurements were not taken appeared to be a Stage 3. During an interview on 07/30/2023 at 5:35 PM, the DON stated she had completed skin assessment on 7/20/2023 for Resident #2. The DON stated that she should have looked at the nurses notes to verify that Resident #2 did have a pressure ulcer. The DON stated the system was new to her, and she must have gotten confused between patients. The DON stated she had not completed a thorough assessment and that her assessment did not give an accurate assessment of Resident # 2, because if nurses note on 07/13 and 7/15 stated he had a pressure ulcer then her assessment on 7/20 should have reflected that. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. 4. Resident # 6 Review of Resident #6's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Type 2 diabetes (primary), age-related physical debility, cognitive communication deficit, and unspecified dementia. Review of Resident #6's significant change in status MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 99 (Unable to complete interview); Section G- Functional Status revealed patient had extensive dependence with most activities (1 physical assist); Section F- Bowel and Bladder revealed always incontinent to bowel and bladder. Section M-Skin Conditions revealed Resident #6 had a risk of developing pressure ulcers/injuries. Review of Resident #6's care plan dated 5/15/2023 revealed no intervention related to Deep Tissue Injury prevention or care. Review of Resident #6's Weekly Skin Integrity Review dated 07/25/2023 completed TX D revealed; Suspected Deep Tissue Injury to left heel measuring 4cm in length by 3cm in width. Review of Resident #6's physician orders dated 07/29/2023 revealed no evidence of wound treatment order for Deep Tissue Injury between 07/25/2023 and 07/29/2023. Review of Resident #6's physician orders dated 07/30/2023 revealed Skin prep to left heel every day and prn every day shift for wound care related to weakness. During an observation and interview on 08/01/2023 at 4:25 PM revealed Resident #6 laying on her back not wearing her offloading boot, the boot was to the left side of her foot. Resident #6's wound was located on left heel, the wound was circular and purple in color, there was no drainage and skin appeared firm. ADON C voiced that facility treatment nurse applying skin prep daily. ADON C placed offloading boot to left foot that was lying to the left of her left leg when surveyor entered room. During an interview on 08/01/2023 at 4:25 PM ADON C stated Resident #6 should have been wearing the offloading boot while in laying bed. ADON C stated that Resident #6's wound was not healed and needed further treatment. 5. Resident #7 Review of Resident #7's face sheet dated 08/02/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis cerebral infarction (primary), muscle weakness, need for assistance with personal care, and Type 2 diabetes. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed limited to extensive assist needing 1 - 2+ persons for assistance; Section- H Bowel and Bladder revealed occasionally incontinent to bladder and frequently incontinent to bowel. Section M- Skin Conditions revealed resident is at risk for developing pressure ulcers/injuries. Review of Resident #7's care plan dated 05/31/2023 revealed: Focus: The resident has pressure injury to Rt buttock stage 3 with potential for further skin breakdown r/t: chronic progressive disease, impaired mobility, obesity. Date Initiated: 03/02/2023. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 03/02/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 03/02/2023. Check for incontinence during rounds and provide care as needed. Keep resident clean and dry. Date Initiated: 03/02/2023. Document wound appearance, color, wound healing, s/sx of infection, wound size (length X width X depth) and stage, and report to MD PRN any changes in skin status. Date Initiated: 03/02/2023. Notify Nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 03/02/2023. Provide pressure relieving device in bed. Date Initiated: 03/02/2023. Refer to dietician and follow recommendation. Date Initiated: 03/02/2023. Serve diet as ordered. Date Initiated: 03/02/2023. Review of Resident #7's Weekly Skin Integrity Review dated 07/28/2023 completed by TX D revealed redness to right buttock. Review of Resident #7's Skin Note dated 07/31/2023 completed by TX D revealed Wounds to bilateral gluteal ischium tuberosities are healed, discontinue wound care to these areas, will continue to monitor. Review of Resident #7's Weekly Skin Integrity Review dated 08/02/2023 completed by TX D revealed new stage 2 right upper gluteal fold pressure ulcer measured 2cm in length by 2cm in width and 0.1cm in depth and stage 2 right lower gluteal fold pressure ulcer measured 1cm in length by 0.3cm in width and 0.1cm in depth. During an interview on 08/02/2023 at 9:40 AM, Resident #7 stated he wished the facility was more proactive and would have prescribed antibiotics for his possible wound infection. 6. Resident #8 Review of Resident # 8's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Chronic Obstructive Pulmonary Disease (primary), type 2 diabetes mellitus, mild cognitive impairment, muscle weakness, and need for assistance with personal care. Review of Resident # 8's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 11 (moderately impaired); Section G- Functional Status revealed patient had extensive dependence with most activities (1-to-2-person assistance with physical assist); Section H- Bowel and Bladder revealed Resident #8 Frequently incontinent to bowel and bladder M-Skin Conditions revealed Resident #8 had a risk of developing pressure ulcers/injuries. Review of Resident #8's care plan on 08/02/2023 revealed: Focus: The resident has the potential for pressure ulcer development r/t disease process, impaired mobility. Date Initiated: 02/08/2022. Revision on: 02/08/2022. Goal: Will have intact skin, free of redness, blisters, or discoloration by/through review date. Date Initiated: 02/08/2022. Revision on: 04/04/2022. Target Date: 08/13/2023. Interventions: Check for incontinence during rounds, provide care as needed. Keep skin clean and dry. Date Initiated: 02/05/2022. [TRUNCATED]

Based on observation, interview, and record review, the facility failed to notify the physician when there was a significant change of condition for 4 (Resident #4, Resident #1, Resident #2, Resident #6) of 8 residents reviewed for notification of changes. 1. The facility failed to notify physician of Resident #4's missed treatments to wounds. 2. The facility failed to notify physician of Resident #1's missed treatments to wounds. 3. The facility failed to notify physician of Resident #2's newly acquired pressure ulcer. Resident #2 went 12 days without treatment to wound. 4. The facility failed to notify physician of Resident #6's left heel Deep Tissue Injury. Resident #6 went 5 days without treatment to wound. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for not receiving care and services to meet their needs. Findings include: 1.Resident #4 Review of Resident # 4's face sheet dated [DATE] revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Sepsis (primary) and need for assistance with personal care. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed Resident #4 had physical help limited to transfer only (mostly setup help or one person physical assist); Section H- Bowel and Bladder revealed always continent for bowel and bladder; Section M-Skin Conditions revealed Resident #4 was at risk of developing pressure ulcers/injuries and that Resident #4 had stage 4 pressure ulcer. Review of Resident #4's care plan dated [DATE] revealed: Focus: The resident has the potential for pressure ulcer development r/t impaired mobility, incontinence, obesity. Date Initiated: [DATE]. Revision on: [DATE]. Interventions: Notify nurse immediately of any signs of skin breakdown: redness, blisters, bruises and discoloration noted during bath or daily care. Date Initiated: [DATE]. Provide assist with turning and repositioning during rounds. Date Initiated: [DATE]; Focus: The resident has (DTI) pressure injury to Rt medial heel r/t Reduced Mobility. Date Initiated: [DATE]. Revision on: [DATE]. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: [DATE]. Administer treatments as ordered and monitor for effectiveness. Date Initiated: [DATE]. Assess/record/and monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: [DATE]. Revision on: [DATE]. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. Date Initiated: [DATE]. Record review of Resident #4's physician order revealed the following orders start date [DATE] Location of wound: Plantar right heel with order to be performed topically one time a day for Apply betadine to plantar right heel unstageable ulcer daily apply betadine until healed. Offloading @ all times. F/U with wound care and end date [DATE]. Record Review of Resident #4's TAR dated [DATE] - [DATE] revealed no evidence of treatment being completed on: [DATE] and [DATE]. Record review of Resident #4's physician order revealed the following order start date [DATE] Location of wound: Right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Leptospermum honey in to wound bed cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE], [DATE] and [DATE]. Record review of Resident #4 physician order revealed the following order start date [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #4's physician order revealed the following order start date [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #4's physician order revealed the following order start date [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen powder and sodium hypochlorite get (anapest) cover with border dressing. And end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE]. Record review of Resident #4 physician order revealed the following order start date on [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift every Tue, Thu, Sat Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE]. Record review of Resident #4 physician order revealed the following order start date on [DATE] Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date [DATE]. Record Review of Resident #4's TAR dated on [DATE] - [DATE] revealed no evidence of treatment for order with being completed on: [DATE], and [DATE]. During interview on [DATE] at 10: 50 AM, the WCS stated he was not made aware of missed treatments or treatment refusals. WCS stated missing treatments and/or delay in treatment would have interfered with improvement of wound. 2. Resident # 1 Review of Resident # 1's closed record face sheet dated [DATE] revealed, [AGE] year-old male originally admitted on [DATE] with most recent hospital readmitted [DATE], with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease. Review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Review of Resident #1's closed record care plan dated [DATE] (revised on [DATE]) revealed: Focus: The resident is at risk for pressure injury r/t History of Pressure Injuries, Poor nutrition, Reduced Mobility, Sheering/friction problems. Date Initiated: [DATE] Revision on: [DATE]; Perform and document weekly assessment form of skin for changes or observations. Date Initiated: [DATE] Protect elbows and heels from friction. Date Initiated: [DATE] Protect heels-offload when in bed. Administer medication as ordered. Date Initiated [DATE]. Follow facility policy and procedures for line listing, summarizing infections. Focus The resident has a stage 1 pressure injury to his R buttocks r/t Reduced Mobility, Incontinence, Sheering/Friction. Date Initiated: [DATE] Revision on: [DATE]. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: [DATE]. Administer treatments as ordered and monitor for effectiveness. Date Initiated [DATE] Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: [DATE]. Revision on: [DATE]. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: [DATE]. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated [DATE]. Provide low air loss mattress to bed. Date Initiated: [DATE]. Provide pressure relieving cushion to wheelchair. Monitor for placement and condition. Notify supervisor if cushion needs to be replaced. Date Initiated: [DATE]. Record review of Resident #1's closed record physician orders revealed start date [DATE] stating Location of wound: left foot with order to be performed every day shift Treatment order: Cleanse with NS or Wound Cleanser and pat dry. Swab with betadine swab. Cover with 4x4 and secure with tape. and no end date written. Record Review of Resident #1's closed record TAR dated [DATE] - [DATE], revealed no evidence of treatment for order being completed on: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #1's closed record physician orders revealed start date [DATE] Location of wound: Unstageable Rt Ischium (hip) with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated [DATE] - [DATE], revealed no evidence of treatment for order being completed on: [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #1's closed record physician orders revealed start date [DATE] stating Location of wound: right Ischium with order to be performed every day shift Treatment order: Cleanse with NS/wound cleanser. Pat dry Apply Triad cream and cover with silicone dressing with end date [DATE]. Record Review of Resident #1's TAR dated [DATE] - [DATE], revealed no evidence of treatment for order being completed on: [DATE], [DATE], [DATE]. Record review of Resident #1's closed record physician orders revealed order with start date [DATE] stating Location of wound: Unstageable right Ischium with order to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Anasept and TAO to wound bed cover bordered gauze dressing with end date [DATE] written. Record Review of Resident #1's closed record TAR dated [DATE] - [DATE], revealed no evidence of treatment for completed on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review of Resident #1's closed record physician orders dated [DATE] revealed start date [DATE] stating Location of wound: Unstageable right Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated [DATE] - [DATE], revealed no evidence of being completed on: [DATE] and [DATE]. During an interview on [DATE] at 4:30 PM, RN OS stated OS had concerns with facility not showing up for appointments or calling to reschedule. RN OS stated Resident #1 was scheduled for one week follow up on [DATE] after surgery and missed appointment. RN OS stated the facility never called to clarify treatment orders, or to called to reschedule appointment. RN OS stated when she called to reschedule, facility stated visits were missed because another resident had an appointment. RN OS stated Resident #1 did not make it to the office for 3 weeks. The bandage had not been changed in 3 weeks and had to be soaked to remove dressing and Resident #1 received bandage burns to his skin. During an interview on [DATE] at 11:50 AM, the OS stated he had concerns Resident #1 was a no call/no show for his first scheduled post-operation visit on [DATE]. The OS stated the facility never called to reschedule visit or to clarify orders. The OS stated Resident #1 went over 3 weeks without bandage being changed, which led to the bandage had to be soaked to be removed and Resident #1 had bandage burns. The OS stated he was never notified of missed wound treatments. The OS stated Resident #1 missing wound care treatments postponed his foot healing. During an interview on [DATE] at 4:46 PM, MR stated she is responsible for making transportation arrangements. She stated she doesn't make the doctor's appointments and when residents are discharged from hospital with a card, the nurse is responsible to make the appointments. MR stated she did not have documentation to why Resident #1 missed appointment on [DATE]. MR stated there were days when the transportation van was not working in order to take residents to appointments; however, it was functioning and working properly on [DATE]. 3. Resident #2 Review of Resident # 2's face sheet dated [DATE] revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis unspecified dementia (primary), need for assistance with personal care, flaccid hemiplegia (inability to move without assistance) affecting right dominant side. Review of Resident # 2's annual MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 8 (moderate); Section G- Functional Status revealed Resident #2 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bowel and Bladder revealed always incontinent for bowel; Section M-Skin Conditions revealed Resident #2 was at risk of developing pressure ulcers/injuries. Review of Resident #2's care plan dated [DATE] revealed: Focus: The resident is at risk for pressure ulcer development r/t disease process and immobility. Date Initiated: [DATE] Revision on: [DATE]; Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated [DATE]. Administer treatments as ordered and monitor for effectiveness. Date initiated [DATE]. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiate initiated: [DATE]. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: [DATE]. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, S/SX of infection, wound size (length X width X depth), stage. Date Initiated: [DATE]. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments. Date initiated: [DATE]. Revision on: [DATE]; Focus: patient has a stage 4 pressure injury to right posterior calf with potential for further skin breakdown R/T: disease process, immobility, impaired mobility, lack of sensation, non-compliance with therapeutic regimen. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: [DATE]. Assist resident with turning/repositioning during rounds. Date Initiated: [DATE]. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: [DATE]. Review of Resident # 2's nurses notes dated [DATE] at 11:00 PM written by LVN T revealed: Aide has brought to my attention that [Resident #2] has open area on back of right ankle area. When this nurse assessed, I found wound that is denuded, partial thickness and has black eschar in wound bed. I cleansed wound with wound cleanser, applied hydrophilic ointment and covered with bordered gauze. Entire leg and foot have severe outward rotation. It is stroke effected side. Heel is elevated off bed and wound area is hanging free with no pressure. Review of Resident # 2's nurses note dated [DATE] at 1:37 PM written by LVN A revealed: Resident noted to have a DTI per night nurse to his right lower calf area cleaned Review of Resident #2's physician orders revealed no evidence of pressure ulcer treatment between [DATE] and [DATE]. Review of Resident #2's physician orders revealed: Order date [DATE] at 2:15 PM Cleanse right lower posterior calf with dermal wound cleaner apply Triad Debriding Cream to wound bed and cover with boarder dressing. Every day shift every Mon, Wed, Fri for promote Wound healing and every 1 hour as needed for skin irritation. During an interview on [DATE] at 5:35 PM, the DON stated she had completed skin assessment on [DATE] for Resident #2. The DON stated the system was new to her, and she must have gotten confused between patients. The DON stated she had not completed a thorough assessment and that her assessment did not give an accurate assessment of Resident # 2. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. During interview on [DATE] at 10: 50 AM, the WCS stated he was not made aware of missed treatments or treatment refusals. WCS stated missing treatments and/or delay in treatment would have interfered with improvement of wound. 4. Resident # 6 Review of Resident # 6's face sheet dated [DATE] revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Type 2 diabetes (primary), age-related physical debility, cognitive communication deficit, and unspecified dementia. Review of Resident # 6's significant change in status MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 99 (Unable to complete interview); Section G- Functional Status revealed patient had extensive dependence with most activities (1 physical assist); Section F- Bowel and Bladder revealed always incontinent to bowel and bladder. Section M-Skin Conditions revealed Resident #6 had a risk of developing pressure ulcers/injuries. Review of Resident #6's care plan dated [DATE] revealed no intervention related to Deep Tissue Injury prevention or care. Review of Resident #6's Weekly Skin Integrity Review dated [DATE] completed TX D revealed; Suspected Deep Tissue Injury to left heel measuring 4cm in length by 3cm in width. Review of Resident #6's physician orders revealed no evidence of wound treatment order for Deep Tissue Injury between [DATE] and [DATE]. Review of Resident #6's physician orders dated [DATE] revealed Skin prep to left heel every day and prn every day shift for wound care related to weakness. During an interview on [DATE] at 5:35 PM, the DON stated orders for new skin issues should be obtained within the shift but not later than 24 hours after identified. During interview on [DATE] at 10: 50 AM, the WCS stated he was not made aware of missed treatments or treatment refusals. WCS stated missing treatments and/or delay in treatment would have interfered with improvement of wound. During an interview on [DATE] at 8:19 AM TX G stated she had been the treatment nurse until mid-July. TX G stated she documented when she performed wound care. TX G stated if there were blanks in the TAR treatments were not done. TX G stated she had to work the floor on day or night shifts on several occasions and was not able to complete her duties as treatment nurse. TX G stated when she worked the floor, if she was am not the treatment nurse that day or not working, the charge nurses were responsible for wound care of their patients. During an interview on [DATE] at 9:38 AM, the ADM stated her expectation was that treatments were followed per physician's order. The ADM stated if treatment orders were missed it should have been documented why the treatment was missed and notify the physician that treatments were missed. The ADM stated missed treatments could have caused wounds to worsen. The DON was to monitor that treatments were completed. The ADM stated missing treatment could have put the residents at risk of neglect. The ADMN stated what led to the failure of physician not being contacted for orders and/or updating the physician was that staff got busy with other tasks or assumed that another shift had contacted physician. During an interview on [DATE] at 11:08 AM TX D stated neglect was not contacting a doctor when new issues were identified, not following doctor and/or performing a doctor's order. TX D stated the doctor should be contacted immediately when resident had a change of condition. TX D stated there was not any reason that a resident should have to wait for over 24 hours for orders. TX D stated missed wound treatments could have resulted in poor wound healing or worsening of wound. Record Review of Facility policy titled, Pressure Ulcer/Injury Risk assessment dated [DATE] revealed: If the resident refuses the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification. Notify attending MD {Medical Director} if new skin alteration noted. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:15pm. The Administration was informed of the IJ. The Administrator was provided with the IJ template on [DATE] at 5:15pm. Record review of the Plan of Removal accepted on [DATE] at 2:35 PM reflected the following: What corrective actions have been implemented for the identified residents? A. Resident # 1 was unable to be assessed (expired ,d+[DATE]). B. Resident # 2 was assessed by Director of Nursing on [DATE] at the time the concern was identified. No new concerns were identified. Wound Care physician also assessed patient on ,d+[DATE]. No new concerns were identified C. Resident # 4 was assessed by Director of Nursing on [DATE] at the time the concern was identified. No new concerns were identified. Wound Care physician also assess patient on ,d+[DATE]. No new concerns were identified. D. Resident # 6 was assessed by Director of Nursing on [DATE] at the time the concern was identified. No new concerns were identified. E. Facility nurse management (Assistant Directors of Nursing) completed a skin audit on residents residing in the facility on [DATE], [DATE] and [DATE]. Skins audits were reviewed by DON and Nurse management team. Two residents were identified that had open areas. Physician was notified and orders received by facility for treatment. F. Residents physician will be notified upon the identification of a new wound, any wounds that have progressively worsened and any missed treatment or treatments that were refused by the resident. This notification will be documented in the resident's chart. G.DON and/or designee will review and ensure that orders, treatments and notification to the physician are completed through the facilities daily clinical meeting. Any concerns identified will be addressed immediately. How were other residents at risk to be affected by this deficient practice identified? A. All residents residing in the facility have the potential to be affected by this proposed deficient practice. B. Facility nurse management (Assistant Directors of Nursing) completed a skin audit on residents residing in the facility on [DATE], [DATE] and [DATE]. Skins audits were reviewed by DON and Nurse management team. Two residents were identified that had open areas. Physician was notified and orders received by facility for treatment. The facility has 15 total residents with skin issues. The physician has been notified of all issues. The two additional residents were identified on the ,d+[DATE] skin round. Resident A had two areas (irritant dermatitis from body fluid) on this scrotum/anterior thigh. Resident B had one area on each buttock. Hospice and physician were notified on both patients. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. During the facilities morning clinical meeting the DON and/or designee will review any new wounds, any new treatments, wounds that have progressively worsened and any treatments that were missed or refused and ensure physician notification was completed and documented appropriately in the residents chart. B. On [DATE] Corporate Clinical Services Director in-serviced the DON and nurse managers on properly and accurately assessing resident's skin, monitoring for change of condition, wound care documentation, clinical records documentations, and any omissions of treatments in the treatment record. This in-service included MD notification. DON, ADONs and Treatment Nurse will verbalize teach back of education provided to them. Any staff not available will be required to receive in-service prior to their next schedule shift. C. Facility direct care staff was in-serviced by the Clinical Management team on [DATE] regarding pressure ulcer prevention. This in-service included MD notification. Any staff not available will be required to receive in-service prior to their next schedule shift. D. An in-service was initiated on [DATE] by Director of Nursing and ADONs with the licensed nursing staff on properly assessing resident's skin, monitoring for change of condition, wound care documentation, clinical records documentation, and omissions of treatments in the treatment record. Licensed staff will verbalize teach back of education provided to them. This in-service included MD notification. Any staff not available will be required to receive in-service prior to their next schedule shift. E. Newly hired nurses and contract staff will be in-serviced by the Director of Nursing or ADON on properly assessing resident's skin, monitoring for change of condition, wound care documentation, clinical records documentation, and omissions of treatments in the treatment record. This in-service included MD notification. Licensed staff will verbalize teach back of education provided to them. F. Facility has implemented/re-implemented the following procedure to ensure How will the system be monitored to ensure compliance? Facility Director of Nursing and/or designee will review skin assessments, treatment administration records, documentation and physician notification through facilities clinical morning meeting. Any identified concerns will be address immediately. Facility Administrator and/or designee will attend the clinical morning meeting and ensure system is being followed. Any concerns identified will be addressed immediately. This process began immediately on [DATE] and will continue weekly DON will Monitor and the Administrator will oversee Clinical documentation review upon admission/readmission noting pressure injury/skin and that physician was notified, orders were received, and area treated. Any identified concerns will be addressed immediately with staff and physician. Monitoring will continue 5x weekly for the next 8 weeks. DON will monitor and the Administrator will oversee that upon admission/readmission that the charge nurse on duty has completed the full body skin assessment - intentionally assessing the resident head to toe for evidence of any pressure injury or skin concerns. DON and facility treatment nurse will review to ensure accuracy and to ensure the physician was notified of any identified concerns. Monitoring will continue 5x weekly for the next 8 weeks. DON will monitor and Administrator will oversee conducting weekly skin assessments shall be completed upon admission/readmit at least every 7 days thereafter. This will be monitored through the facility's clinical morning meeting. Monitoring will continue 5x weekly for the next 8 weeks. DON will monitor and Administrator will oversee the signing out for weekly skin assessments on the MAR and signing out the treatments as ordered and administered by licensed nurse a minimum of 5x weekly for three months during the morning clinical meeting. If there is an omission in the TAR or an assessment showing not completed the assigned nurse will be called immediately to verify if there was a reason for the omission. If truly missed the resident will be assessed immediately and the physician notified of the missed treatment/assessment. DON will monitor and Administrator will oversee that the Charge Nurse / Wound Care Nurse conducts a head - to - toe skin assessment upon admission / readmission and that physician is notified and orders received and that this is documented in the resident chart. Charge nurses will perform a complete skin assessment for each admission/re-admission including notifying the physician, receiving orders and documenting such. DON, ADONs or Treatment Nurse will conduct post admission skin assessments within 24 -72 hours after the initial admission/readmission skin assessment to validate accuracy of documentation of skin condition. Any remedial education or reprimand will occur at this time. DON will monitor and the Administrator will oversee weekly for the next 8 weeks that the IDT will review the plan of care to ensure appropriate interventions are in place to address the prevention of or minimizing the risks associated with skin injury in relation to the identified resident's clinical complexity and resident care needs. When physician is notified of skin integrity concerns any recommendations will be documented in resident's chart. In-service education provided on [DATE] by nurse management for licenses nurses on the 24hr report process to identify new or worsening skin injures updating caregivers at shift change. The treatment nurse, trained by wound physician on staging and measuring, will document wound site and staging and will be reviewed weekly during rounds with wound physician. DON and/or designee will review weekly for the next 8 weeks the documentation of site, staging as indicated and measurement note in PCC. DON and/or designee will oversee Tx ord [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 6 of 8 residents (Resident #4, Resident #1, Resident #2, Resident #6, Resident #7, Resident #8) reviewed for neglect. 1. The facility failed to follow physician's orders to prevent Resident #4's Deep Tissue Injury to right medial heel to deteriorate to a stage 4 pressure ulcer. 2. The facility failed to follow physician's orders to prevent Resident #1's Right Ischium(hip) pressure ulcer to deteriorate from a stage 2 to a stage 3. 3. The facility failed to obtain orders from Resident #1's Podiatrist when appointments were missed status post amputation of 5th digit of left foot. 4. The facility failed to obtain physician orders for treatment of Resident #2's pressure ulcer on right posterior calf. Resident #2 went 12 days without treatment to wound. Resident #2 was assessed on 08/03/2023 with Stage IV. 5. The facility failed to obtain physician orders for treatment of Resident #6's left heel Deep Tissue Injury. Resident #6 went 5 days without treatment to wound. 6. The facility failed to complete skin assessments of Resident #7 which led to the development of a stage 2 pressure ulcer to the right upper buttocks and stage 2 to the right lower buttocks. 7. The facility failed to complete weekly skin assessments which led to Resident #8 developing stage 2 pressure ulcer to left buttock and stage 2 pressure ulcer to right buttock. 8. The facility failed to ensure Resident # 2 and Resident #4 ' s skin assessments were completed, assessed accurately and accurately documented by the DON. 9. The facility failed to ensure Resident #1, Resident #4 and Resident #5 ' s wound treatments were completed and accurately documented by DON and ADON E. 10. The facility failed to maintain accurate list of residents with pressure ulcers. The facility did a skin sweep and found Resident #7's and Resident #8's wounds after surveyor intervention requesting accurate lists of residents with pressure ulcers. An Immediate Jeopardy (IJ) was identified on 08/03/23. While the IJ was lowered on 08/07/23, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death. Findings included: 1.Resident #4 Record review of Resident # 4's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Sepsis (primary) and need for assistance with personal care. Record Review of Resident #4's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed Resident #4 had physical help limited to transfer only (mostly setup help or one person physical assist); Section H- Bowel and Bladder revealed always continent for bowel and bladder; Section M-Skin Conditions revealed Resident #4 was at risk of developing pressure ulcers/injuries and that Resident #4 had stage 4 pressure ulcer. Record review of Resident #4's care plan dated 05/15/2023 revealed: Focus: The resident has the potential for pressure ulcer development r/t impaired mobility, incontinence, obesity. Date Initiated: 08/23/2022. Revision on: 08/23/2022. Interventions: Notify nurse immediately of any signs of skin breakdown: redness, blisters, bruises and discoloration noted during bath or daily care. Date Initiated: 08/23/2022. Provide assist with turning and repositioning during rounds. Date Initiated: 08/23/2022; Focus: The resident has (DTI) pressure injury to Rt medial heel r/t Reduced Mobility. Date Initiated: 03/29/2023. Revision on: 03/29/2023. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/29/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/29/2023. Assess/record/and monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 03/29/2023. Revision on: 06/05/2023. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. Date Initiated: 03/29/2023. Record review of Resident #4's physician order revealed start date 03/14/2023 Location of wound: Plantar right heel with order to be performed topically one time a day for Apply betadine to plantar right heel unstageable ulcer daily apply betadine until healed. Offloading @ all times. F/U with wound care and end date 04/13/2023. Record Review of Resident #4's TAR dated 04/01/2023 - 04/30/2023 revealed no evidence of treatment being completed on: 04/08/2023 and 04/09/2023. Record review of Resident #4's physician order revealed the order start date 04/13/2023 Location of wound: Right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Leptospermum honey in to wound bed cover with border dressing. and end date 05/04/2023. Record Review of Resident #4's TAR dated on 04/01/2023 - 04/30/2023 revealed no evidence of treatment for order with being completed on: 04/14/2023, 04/15/2023 and 04/23/2023. Record review of Resident #4's physician order revealed the following order start date 05/04/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date 06/27/2023. Record Review of Resident #4's TAR dated on 05/01/2023 - 05/31/2023 revealed no evidence of treatment for order with being completed on: 05/08/2023, 05/15/2023, 05/16/2023, 05/22/2023, 05/29/2023, 05/30/2023 and 05/31/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/02/2023, 06/03/2023, 06/04/2023, 06/12/2023, 06/19/2023, 06/20/2023, 06/21/2023 and 06/24/2023. Record review of Resident #4's physician order revealed the following order start date 06/27/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen powder and sodium hypochlorite get (anapest) cover with border dressing. And end date 06/29/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/28/2023. Record review of Resident #4's physician order revealed the following order start date on 06/29/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift every Tue, Thu, Sat Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/10/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/01/2023. Record review of Resident #4's physician order dated 07/29/2023 revealed the following order start date on 07/10/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/20/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/14/2023, 07/15/2023, and 07/23/2023. Record review of Resident #4's Medication Administration Audit Report generated by CSD revealed: -Scheduled for 07/14/2023 at 06:00AM and charted as completed on 07/29/2023 8:58PM by DON. -Scheduled for 07/15/2023 at 06:00AM was charted as completed on 07/29/2023 9:06PM by DON. -Scheduled for 07/23/23 at 6:00AM was charted as completed on 7/29/23 at 9:53PM by DON. Record review of Resident #4's nurse's skin assessment dated [DATE] revealed DTI (deep tissue injury) to right medial heel. Record review of Resident #4's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #4's WCS physician note dated 05/18/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #4's WCS physician note dated 05/25/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Treatment options - risks - benefits and the possible need for subsequent additional procedures on this wound were explained on 04/13/2023 to the patient. Record review of Resident #4's WCS physician note titled dated 07/27/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.4cm in length by 2.2cm in width by 0.2cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. During an observation and interview on 08/01/2023 at 4:30PM Resident #4 was sitting up in wheelchair with offloading boot to right foot and elevated with extended wheelchair footrest. Resident #4 stated she gave permission to observe foot and take a photograph of wound. Resident #4's right foot pressure ulcer had thick green tinged skin surrounding a circular wound with beefy red granulation tissue observed to wound bed. Observation of small amount of drainage observed to bandage and no odor. Resident #4 stated she had no concerns with her wound. 2. Resident # 1 Record review of Resident # 1's closed record face sheet dated 07/29/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent hospital readmitted [DATE], with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease. Record review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Record review of Resident #1's closed record care plan dated 05/15/2022 (revised on 06/04/2023) revealed: Focus: The resident is at risk for pressure injury r/t History of Pressure Injuries, Poor nutrition, Reduced Mobility, Sheering/friction problems. Date Initiated: 08/20/2020 Revision on: 02/21/2022; Perform and document weekly assessment form of skin for changes or observations. Date Initiated: 08/20/2020 Protect elbows and heels from friction. Date Initiated: 08/20/2020 Protect heels-offload when in bed. Administer medication as ordered. Date Initiated 11/29/2022. Follow facility policy and procedures for line listing, summarizing infections. Focus The resident has a stage 1 pressure injury to his R buttocks r/t Reduced Mobility, Incontinence, Sheering/Friction. Date Initiated: 08/18/2022 Revision on: 10/24/2022. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/18/2022. Administer treatments as ordered and monitor for effectiveness. Date Initiated 08/18/2022 Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 08/18/2022. Revision on: 08/23/2022. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 08/18/2022. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated 08/18/2022. Provide low air loss mattress to bed. Date Initiated: 08/18/2022. Provide pressure relieving cushion to wheelchair. Monitor for placement and condition. Notify supervisor if cushion needs to be replaced. Date Initiated: 08/18/2022. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed no new areas, continue tx{treatment} to diabetic ulcer to lt{left} foot. Record review of Resident #1's closed record Admission Summary Progress Note dated 06/03/2023 revealed stage 2 pressure wound on coccyx. Record review of Resident #1's closed record progress note titled Skin/Wound Note dated 06/15/2023 revealed WCS here this am to see resident. Stage 3 on rt ischium measures3x4.5x0.3. Light serous drainage with45% slough 5% granulation, 50% skin. Deterioration noted. Green tinge to drainage concerning for Pseudomonas. No signs of infection. WCS preformed surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #1's closed record nurses progress note dated 06/21/2023 revealed Resident return from OS per physician progress notes: 1) Please do NOT change the patients dressing 2)RTC on June 25 @ 1130AM. Transportation notified of f/u appt. and Info updated on 24 hour report. Record review of Resident #1's closed record nurses progress note dated 06/30/2023 revealed Resident return from OS office per physician progress notes Please change Resident #1's foot wound dressing daily. No further need for ACE wrap. Please see that patient gets his augmentin as ordered. Call placed to OS office for clarification on orders what does provider want for dressing orders and orders for augmentin. Per [NAME] nurse at OS office to cleanse wound then swab with betadine cover with 4x4 and secure. Augmentin 875mg q12 hours x10days. Orders updated in chart and placed on24 hr{hour} report. Record review of Resident #1's closed record nurses progress note dated 07/07/2023 revealed Resident return from OS appointment per physician's progress notes: Continue daily dressing changes with betadine to wound base . Return in 1 week appt of 7/14/23 @ 1045am Transportation notified. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 4 pressure ulcer to R Ischium with wound care and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 05/18/2023 revealed diabetic wound of the left, distal, plantar, lateral foot full thickness. Surgical excisional debridement procedure indicated for removal of necrotic tissue and establish the margins of viable tissue. No mention of R Ischium wound. Record review of Resident #1's closed record WCS physician notes dated 06/08/2023 revealed R Ischium wound measuring 2.3cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/15/2023 revealed R Ischium wound measuring 3.0cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/22/2023 revealed R Ischium wound measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/29/2023 revealed R Ischium wound measuring 3.5cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 07/06/2023 revealed R Ischium wound measuring 4.0cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record hospital records dated 05/16/2023 revealed Stage 2 coccygeal & gluteal PI-POA. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/27/2023 Location of wound: Unstageable Rt Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on: 07/01/202, 07/03/2023, 07/05/2023, 07/07/2023 and 07/12/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/05/2023 stating Location of wound: right Ischium with order to be performed every day shift Treatment order: Cleanse with NS/wound cleanser. Pat dry Apply Triad cream and cover with silicone dressing with end date 06/09/2023. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for order being completed on: 06/07/2023, 06/08/2023, 06/09/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed order with start date 06/09/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Anasept and TAO to wound bed cover bordered gauze dressing with end date 06/27/2023 written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for completed on: 06/09/2023, 06/14/2023, 06/19/2023, 06/20/2023, 06/21/2023, 06/24/2023, 06/25/2023 and 06/26/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/27/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of being completed on: 06/27/2023 and 06/30/2023. Record review of Resident #1's physician orders dated 7/29/23 revealed no evidence of treatment orders for Resident #1 left foot from 06/01/2023 to 06/30/2023. Record review of Resident # 1 physician orders revealed start date 06/30/2023 Location of wound: left foot with order to be performed every day shift Treatment order: Cleanse with NS or Wound Cleanser and pat dry. Swab with betadine swab. Cover with 4x4 and secure with tape. and no end date. Record Review of Resident #1's TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on: 07/01/2023, 07/03/2023, 07/05/2023, 07/07/2023, 07/09/2023 and 07/12/2023. Record review of Resident #2's Progress note dated 08/03/23 revealed: DON performed skin assessment of this resident who has stage 4 pressure wound to right posterior, lower extremity, measures 3.2 x 1.8 x 1.0cm with minimal serous drainage noted, peri wound of normal skin color for resident. 70% granulation tissue noted, no slough, and tendon and bone noted. Suprapubic cath site to mid-lower abdomen area, no drainage or leakage to area noted. No sis of infection or further abnormalities noted. Signed DON 8/3/23 at 7:40PM Record review of Resident #2's Wound Care Physician Assessment Note dated 08/03/23 revealed: Focused Wound Exam (Site 1) STAGE 4 PRESSURE WOUND OF THE RIGHT, LATERAL CALF FULL THICKNESS. Etiology (quality), Pressure. Stage. 4. Duration > 1 days During an interview on 07/29/2023 at 12: 59 PM Resident # 1's family member stated he/she had concerns about Resident 1's care while at the facility. Resident #1's family member stated he/she felt Resident #1 was neglected by the facility which led to his death. Resident #1's family member stated his room always smelled like urine and that Resident #1's dressing on his wounds were never changed timely. During an interview on 08/03/2023 at 11:50 AM the OS stated he had concerns Resident #1 was a no call/no show for his first scheduled post-operation visit. The OS stated the facility never called to reschedule visit or to clarify orders. The OS stated Resident #1 went over 3 weeks without bandage being changed, which led to the bandage had to be soaked to be removed and Resident #1 had bandage burns. The OS stated he was never notified of missed treatments. The OS stated Resident #1 missing wound care treatments postponed his foot healing. 3. Resident #2 Review of Resident #2's face sheet dated 08/03/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis unspecified dementia (primary), need for assistance with personal care, flaccid hemiplegia affecting right dominant side. Review of Resident #2's annual MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 8 (moderate); Section G- Functional Status revealed Resident #2 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bowel and Bladder revealed always incontinent for bowel; Section M-Skin Conditions revealed Resident #2 was at risk of developing pressure ulcers/injuries. Review of Resident #2's care plan dated 07/04/2022 revealed: Focus: The resident is at risk for pressure ulcer development r/t disease process and immobility. Date Initiated: 06/26/2018 Revision on: 04/15/2021; Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 06/26/2018. Administer treatments as ordered and monitor for effectiveness. Date initiated 06/26/2018. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiate initiated: 06/26/2018. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: 06/26/2018. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, S/SX of infection, wound size (length X width X depth), stage. Date Initiated: 06/26/2018. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments. Date initiated: 06/26/2018. Revision on: 03/03/2023; Focus: patient has a stage 4 pressure injury to right posterior calf with potential for further skin breakdown R/T: disease process, immobility, impaired mobility, lack of sensation, non-compliance with therapeutic regimen. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 07/29/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 07/29/2023. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 07/29/1013. Review of Resident #2's nurses notes dated 07/15/2023 at 11:00 PM written by LVN T revealed: Aide has brought to my attention that [Resident #2] has open area on back of right ankle area. When this nurse assessed, I found wound that is denuded, partial thickness and has black eschar in wound bed. I cleansed wound with wound cleanser, applied hydrophilic ointment and covered with bordered gauze. Entire leg and foot have severe outward rotation. It is stroke effected side. Heel is elevated off bed and wound area is hanging free with no pressure. Review of Resident #2's nurses note dated 07/17/2023 at 1:37 PM written by LVN A revealed: Resident noted to have a DTI per night nurse to his right lower calf area cleaned Review of Resident #2's physician orders revealed no evidence of pressure ulcer treatment between 07/15/2023 and 07/27/2023. Review of Resident #2's physician orders revealed: Order date 07/27/2023 at 2:15 PM Cleanse right lower posterior calf with dermal wound cleaner apply Triad Debriding Cream to wound bed and cover with boarder dressing. Every day shift every Mon, Wed, Fri for promote Wound healing and every 1 hour as needed for skin irritation. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed Right lower leg stage 3 pressure ulcer measuring 2.5cm in length by 2.7cm in width by 0.5cm in depth. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed right lower leg unstageable pressure ulcer measuring 2.5cm in length by 2.0cm in width by 0.5cm in depth. During an observation on 07/29/2023 at 4:10PM of Resident #2 revealed Resident #2 lying in bed with right leg on pillow. Resident #2's right lower leg was covered by gauze and secured with tape. The dressing did not have a date on the outside. During an observation on 7/30/2023 at 3:30 PM of Resident #2 revealed Resident #2's lower right leg had a wound that had red tissue present, surrounding skin within normal limits for race, no tendon or bone observed, no necrosis observed, measurements were not taken appeared to be a Stage 3. During an interview on 07/30/2023 at 5:35 PM, the DON stated she had completed skin assessment on 7/20/2023 for Resident #2. The DON stated that she should have looked at the nurses notes to verify that Resident #2 did have a pressure ulcer. The DON stated the system was new to her, and she must have gotten confused between patients. The DON stated she had not completed a thorough assessment and that her assessment did not give an accurate assessment of Resident # 2, because if nurses note on 07/13 and 7/15 stated he had a pressure ulcer then her assessment on 7/20 should have reflected that. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. 4. Resident # 6 Review of Resident #6's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Type 2 diabetes (primary), age-related physical debility, cognitive communication deficit, and unspecified dementia. Review of Resident #6's significant change in status MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 99 (Unable to complete interview); Section G- Functional Status revealed patient had extensive dependence with most activities (1 physical assist); Section F- Bowel and Bladder revealed always incontinent to bowel and bladder. Section M-Skin Conditions revealed Resident #6 had a risk of developing pressure ulcers/injuries. Review of Resident #6's care plan dated 5/15/2023 revealed no intervention related to Deep Tissue Injury prevention or care. Review of Resident #6's Weekly Skin Integrity Review dated 07/25/2023 completed TX D revealed; Suspected Deep Tissue Injury to left heel measuring 4cm in length by 3cm in width. Review of Resident #6's physician orders dated 07/29/2023 revealed no evidence of wound treatment order for Deep Tissue Injury between 07/25/2023 and 07/29/2023. Review of Resident #6's physician orders dated 07/30/2023 revealed Skin prep to left heel every day and prn everyday shift for wound care related to weakness. During an observation and interview on 08/01/2023 at 4:25 PM revealed Resident #6 laying on her back not wearing her offloading boot, the boot was to the left side of her foot. Resident #6's wound was located on left heel, the wound was circular and purple in color, there was no drainage and skin appeared. During an interview on 08/01/2023 at 4:25 PM ADON C stated Resident #6 should have been wearing the offloading boot while in laying bed. ADON C stated that Resident #6's wound was not healed and needed further treatment. 5. Resident #7 Review of Resident #7's face sheet dated 08/02/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis cerebral infarction (primary), muscle weakness, need for assistance with personal care, and Type 2 diabetes. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed limited to extensive assist needing 1 - 2+ persons for assistance; Section- H Bowel and Bladder revealed occasionally incontinent to bladder and frequently incontinent to bowel. Section M- Skin Conditions revealed resident is at risk for developing pressure ulcers/injuries. Review of Resident #7's care plan dated 05/31/2023 revealed: Focus: The resident has pressure injury to Rt buttock stage 3 with potential for further skin breakdown r/t: chronic progressive disease, impaired mobility, obesity. Date Initiated: 03/02/2023. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 03/02/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 03/02/2023. Check for incontinence during rounds and provide care as needed. Keep resident clean and dry. Date Initiated: 03/02/2023. Document wound appearance, color, wound healing, s/sx of infection, wound size (length X width X depth) and stage, and report to MD PRN any changes in skin status. Date Initiated: 03/02/2023. Notify Nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 03/02/2023. Provide pressure relieving device in bed. Date Initiated: 03/02/2023. Refer to dietician and follow recommendation. Date Initiated: 03/02/2023. Serve diet as ordered. Date Initiated: 03/02/2023. Review of Resident #7's Weekly Skin Integrity Review dated 07/28/2023 completed by TX D revealed redness to right buttock. Review of Resident #7's Skin Note dated 07/31/2023 completed by TX D revealed Wounds to bilateral gluteal ischium tuberosities are healed, discontinue wound care to these areas, will continue to monitor. Review of Resident #7's Weekly Skin Integrity Review dated 08/02/2023 completed by TX D revealed new stage 2 right upper gluteal fold pressure ulcer measured 2cm in length by 2cm in width and 0.1cm in depth and stage 2 right lower gluteal fold pressure ulcer measured 1cm in length by 0.3cm in width and 0.1cm in depth During and interview on 08/02/2023 at 9:40 AM, Resident # 7 stated he wished the facili [TRUNCATED]

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibited and prevented abuse and neglect for 6 of 8 residents (Resident #4, Resident #1, Resident #2, Resident #6, Resident #7, Resident #8) reviewed for neglect. 1. The facility failed to follow physician's orders to prevent Resident #4's Deep Tissue Injury to right medial heel to deteriorate to a stage 4 pressure ulcer. 2. The facility failed to follow physician's orders to prevent Resident #1's Right Ischium(hip) pressure ulcer to deteriorate from a stage 2 to a stage 3. 3. The facility failed to obtain orders from Resident #1's Podiatrist when appointments were missed status post amputation of 5th digit of left foot. 4. The facility failed to obtain physician orders for treatment of Resident #2's pressure ulcer on right posterior calf. Resident #2 went 12 days without treatment to wound. Resident #2 was assessed on 08/03/2023 with Stage IV. 5. The facility failed to obtain physician orders for treatment of Resident #6's left heel Deep Tissue Injury. Resident #6 went 5 days without treatment to wound. 6. The facility failed to complete skin assessments of Resident #7 which led to the development of a stage 2 pressure ulcer to the right upper buttocks and stage 2 to the right lower buttocks. 7. The facility failed to complete weekly skin assessments which led to Resident #8 developing stage 2 pressure ulcer to left buttock and stage 2 pressure ulcer to right buttock. 8. The facility failed to ensure Resident # 2 and Resident #4 ' s skin assessments were completed, assessed accurately and accurately documented by the DON. 9. The facility failed to ensure Resident #1, Resident #4 and Resident #5 ' s wound treatments were completed and accurately documented by DON and ADON E. 10. The facility failed to maintain accurate list of residents with pressure ulcers. The facility did a skin sweep and found Resident #7's and Resident #8's wounds after surveyor intervention requesting accurate lists of residents with pressure ulcers. An Immediate Jeopardy (IJ) was identified on 08/03/23. While the IJ was lowered on 08/07/23, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death. Findings included: 1.Resident #4 Record review of Resident # 4's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Sepsis (primary) and need for assistance with personal care. Record Review of Resident #4's quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed Resident #4 had physical help limited to transfer only (mostly setup help or one person physical assist); Section H- Bowel and Bladder revealed always continent for bowel and bladder; Section M-Skin Conditions revealed Resident #4 was at risk of developing pressure ulcers/injuries and that Resident #4 had stage 4 pressure ulcer. Record review of Resident #4's care plan dated 05/15/2023 revealed: Focus: The resident has the potential for pressure ulcer development r/t impaired mobility, incontinence, obesity. Date Initiated: 08/23/2022. Revision on: 08/23/2022. Interventions: Notify nurse immediately of any signs of skin breakdown: redness, blisters, bruises and discoloration noted during bath or daily care. Date Initiated: 08/23/2022. Provide assist with turning and repositioning during rounds. Date Initiated: 08/23/2022; Focus: The resident has (DTI) pressure injury to Rt medial heel r/t Reduced Mobility. Date Initiated: 03/29/2023. Revision on: 03/29/2023. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/29/2023. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/29/2023. Assess/record/and monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 03/29/2023. Revision on: 06/05/2023. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. Date Initiated: 03/29/2023. Record review of Resident #4's physician order revealed start date 03/14/2023 Location of wound: Plantar right heel with order to be performed topically one time a day for Apply betadine to plantar right heel unstageable ulcer daily apply betadine until healed. Offloading @ all times. F/U with wound care and end date 04/13/2023. Record Review of Resident #4's TAR dated 04/01/2023 - 04/30/2023 revealed no evidence of treatment being completed on: 04/08/2023 and 04/09/2023. Record review of Resident #4's physician order revealed the order start date 04/13/2023 Location of wound: Right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Leptospermum honey in to wound bed cover with border dressing. and end date 05/04/2023. Record Review of Resident #4's TAR dated on 04/01/2023 - 04/30/2023 revealed no evidence of treatment for order with being completed on: 04/14/2023, 04/15/2023 and 04/23/2023. Record review of Resident #4's physician order revealed the following order start date 05/04/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound area. Apply Collagen powder and Calcium alginate with silver cover with border dressing. and end date 06/27/2023. Record Review of Resident #4's TAR dated on 05/01/2023 - 05/31/2023 revealed no evidence of treatment for order with being completed on: 05/08/2023, 05/15/2023, 05/16/2023, 05/22/2023, 05/29/2023, 05/30/2023 and 05/31/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/02/2023, 06/03/2023, 06/04/2023, 06/12/2023, 06/19/2023, 06/20/2023, 06/21/2023 and 06/24/2023. Record review of Resident #4's physician order revealed the following order start date 06/27/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen powder and sodium hypochlorite get (anapest) cover with border dressing. And end date 06/29/2023. Record Review of Resident #4's TAR dated on 06/01/2023 - 06/30/2023 revealed no evidence of treatment for order with being completed on: 06/28/2023. Record review of Resident #4's physician order revealed the following order start date on 06/29/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift every Tue, Thu, Sat Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/10/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/01/2023. Record review of Resident #4's physician order dated 07/29/2023 revealed the following order start date on 07/10/2023 Location of wound: Stage 4 right posterior medial heel to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep around peri wound. Apply Collagen power cover with border dressing. and end date 07/20/2023. Record Review of Resident #4's TAR dated on 07/01/2023 - 07/31/2023 revealed no evidence of treatment for order with being completed on: 07/14/2023, 07/15/2023, and 07/23/2023. Record review of Resident #4's Medication Administration Audit Report generated by CSD revealed: -Scheduled for 07/14/2023 at 06:00AM and charted as completed on 07/29/2023 8:58PM by DON. -Scheduled for 07/15/2023 at 06:00AM was charted as completed on 07/29/2023 9:06PM by DON. -Scheduled for 07/23/23 at 6:00AM was charted as completed on 7/29/23 at 9:53PM by DON. Record review of Resident #4's nurse's skin assessment dated [DATE] revealed DTI (deep tissue injury) to right medial heel. Record review of Resident #4's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #4's WCS physician note dated 05/18/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #4's WCS physician note dated 05/25/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.8cm in length by 2.4cm in width by 0.3cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. Treatment options - risks - benefits and the possible need for subsequent additional procedures on this wound were explained on 04/13/2023 to the patient. Record review of Resident #4's WCS physician note titled dated 07/27/2023 revealed stage 4 pressure wound of the right, posterior, medial heel full thickness measuring 1.4cm in length by 2.2cm in width by 0.2cm in depth. Surgical excisional debridement procedure indicated to remove necrotic tissue and establish the margins of viable tissue. During an observation and interview on 08/01/2023 at 4:30PM Resident #4 was sitting up in wheelchair with offloading boot to right foot and elevated with extended wheelchair footrest. Resident #4 stated she gave permission to observe foot and take a photograph of wound. Resident #4's right foot pressure ulcer had thick green tinged skin surrounding a circular wound with beefy red granulation tissue observed to wound bed. Observation of small amount of drainage observed to bandage and no odor. Resident #4 stated she had no concerns with her wound. 2. Resident # 1 Record review of Resident # 1's closed record face sheet dated 07/29/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent hospital readmitted [DATE], with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease. Record review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Record review of Resident #1's closed record care plan dated 05/15/2022 (revised on 06/04/2023) revealed: Focus: The resident is at risk for pressure injury r/t History of Pressure Injuries, Poor nutrition, Reduced Mobility, Sheering/friction problems. Date Initiated: 08/20/2020 Revision on: 02/21/2022; Perform and document weekly assessment form of skin for changes or observations. Date Initiated: 08/20/2020 Protect elbows and heels from friction. Date Initiated: 08/20/2020 Protect heels-offload when in bed. Administer medication as ordered. Date Initiated 11/29/2022. Follow facility policy and procedures for line listing, summarizing infections. Focus The resident has a stage 1 pressure injury to his R buttocks r/t Reduced Mobility, Incontinence, Sheering/Friction. Date Initiated: 08/18/2022 Revision on: 10/24/2022. Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/18/2022. Administer treatments as ordered and monitor for effectiveness. Date Initiated 08/18/2022 Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 08/18/2022. Revision on: 08/23/2022. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 08/18/2022. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated 08/18/2022. Provide low air loss mattress to bed. Date Initiated: 08/18/2022. Provide pressure relieving cushion to wheelchair. Monitor for placement and condition. Notify supervisor if cushion needs to be replaced. Date Initiated: 08/18/2022. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed no new areas, continue tx{treatment} to diabetic ulcer to lt{left} foot. Record review of Resident #1's closed record Admission Summary Progress Note dated 06/03/2023 revealed stage 2 pressure wound on coccyx. Record review of Resident #1's closed record progress note titled Skin/Wound Note dated 06/15/2023 revealed WCS here this am to see resident. Stage 3 on rt ischium measures3x4.5x0.3. Light serous drainage with45% slough 5% granulation, 50% skin. Deterioration noted. Green tinge to drainage concerning for Pseudomonas. No signs of infection. WCS preformed surgical excisional debridement to remove necrotic tissue and establish the margins of viable tissue. Record review of Resident #1's closed record nurses progress note dated 06/21/2023 revealed Resident return from OS per physician progress notes: 1) Please do NOT change the patients dressing 2)RTC on June 25 @ 1130AM. Transportation notified of f/u appt. and Info updated on 24 hour report. Record review of Resident #1's closed record nurses progress note dated 06/30/2023 revealed Resident return from OS office per physician progress notes Please change Resident #1's foot wound dressing daily. No further need for ACE wrap. Please see that patient gets his augmentin as ordered. Call placed to OS office for clarification on orders what does provider want for dressing orders and orders for augmentin. Per [NAME] nurse at OS office to cleanse wound then swab with betadine cover with 4x4 and secure. Augmentin 875mg q12 hours x10days. Orders updated in chart and placed on24 hr{hour} report. Record review of Resident #1's closed record nurses progress note dated 07/07/2023 revealed Resident return from OS appointment per physician's progress notes: Continue daily dressing changes with betadine to wound base . Return in 1 week appt of 7/14/23 @ 1045am Transportation notified. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 4 pressure ulcer to R Ischium with wound care and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth and left leg dressing intact. Record review of Resident #1's closed record nurse's skin assessment dated [DATE] revealed stage 3 pressure ulcer to R Ischium measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 05/18/2023 revealed diabetic wound of the left, distal, plantar, lateral foot full thickness. Surgical excisional debridement procedure indicated for removal of necrotic tissue and establish the margins of viable tissue. No mention of R Ischium wound. Record review of Resident #1's closed record WCS physician notes dated 06/08/2023 revealed R Ischium wound measuring 2.3cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/15/2023 revealed R Ischium wound measuring 3.0cm in length by 4.5cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/22/2023 revealed R Ischium wound measuring 2.2cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 06/29/2023 revealed R Ischium wound measuring 3.5cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record WCS physician notes dated 07/06/2023 revealed R Ischium wound measuring 4.0cm in length by 5.0cm in width by 0.3cm in depth. Record review of Resident #1's closed record hospital records dated 05/16/2023 revealed Stage 2 coccygeal & gluteal PI-POA. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/27/2023 Location of wound: Unstageable Rt Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on: 07/01/202, 07/03/2023, 07/05/2023, 07/07/2023 and 07/12/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/05/2023 stating Location of wound: right Ischium with order to be performed every day shift Treatment order: Cleanse with NS/wound cleanser. Pat dry Apply Triad cream and cover with silicone dressing with end date 06/09/2023. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for order being completed on: 06/07/2023, 06/08/2023, 06/09/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed order with start date 06/09/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift Treatment order: Cleanse area with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Anasept and TAO to wound bed cover bordered gauze dressing with end date 06/27/2023 written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of treatment for completed on: 06/09/2023, 06/14/2023, 06/19/2023, 06/20/2023, 06/21/2023, 06/24/2023, 06/25/2023 and 06/26/2023. Record review of Resident #1's closed record physician orders dated 7/29/23 revealed start date 06/27/2023 stating Location of wound: Unstageable right Ischium with order to be performed every day shift: Treatment order: Cleanse with NS/wound cleanser. Pat dry. Apply skin prep to peri wound. Apply Leptospermum honey to wound bed cover border gauze dressing and no end date written. Record Review of Resident #1's closed record TAR dated June 1, 2023 - June 30, 2023, revealed no evidence of being completed on: 06/27/2023 and 06/30/2023. Record review of Resident #1's physician orders dated 7/29/23 revealed no evidence of treatment orders for Resident #1 left foot from 06/01/2023 to 06/30/2023. Record review of Resident # 1 physician orders revealed start date 06/30/2023 Location of wound: left foot with order to be performed every day shift Treatment order: Cleanse with NS or Wound Cleanser and pat dry. Swab with betadine swab. Cover with 4x4 and secure with tape. and no end date. Record Review of Resident #1's TAR dated July 1, 2023 - July 31, 2023, revealed no evidence of treatment for order being completed on: 07/01/2023, 07/03/2023, 07/05/2023, 07/07/2023, 07/09/2023 and 07/12/2023. Record review of Resident #2's Progress note dated 08/03/23 revealed: DON performed skin assessment of this resident who has stage 4 pressure wound to right posterior, lower extremity, measures 3.2 x 1.8 x 1.0cm with minimal serous drainage noted, peri wound of normal skin color for resident. 70% granulation tissue noted, no slough, and tendon and bone noted. Suprapubic cath site to mid-lower abdomen area, no drainage or leakage to area noted. No sis of infection or further abnormalities noted. Signed DON 8/3/23 at 7:40PM Record review of Resident #2's Wound Care Physician Assessment Note dated 08/03/23 revealed: Focused Wound Exam (Site 1) STAGE 4 PRESSURE WOUND OF THE RIGHT, LATERAL CALF FULL THICKNESS. Etiology (quality), Pressure. Stage. 4. Duration > 1 days During an interview on 07/29/2023 at 12: 59 PM Resident # 1's family member stated he/she had concerns about Resident 1's care while at the facility. Resident #1's family member stated he/she felt Resident #1 was neglected by the facility which led to his death. Resident #1's family member stated his room always smelled like urine and that Resident #1's dressing on his wounds were never changed timely. During an interview on 08/03/2023 at 11:50 AM the OS stated he had concerns Resident #1 was a no call/no show for his first scheduled post-operation visit. The OS stated the facility never called to reschedule visit or to clarify orders. The OS stated Resident #1 went over 3 weeks without bandage being changed, which led to the bandage had to be soaked to be removed and Resident #1 had bandage burns. The OS stated he was never notified of missed treatments. The OS stated Resident #1 missing wound care treatments postponed his foot healing. 3. Resident #2 Review of Resident #2's face sheet dated 08/03/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis unspecified dementia (primary), need for assistance with personal care, flaccid hemiplegia affecting right dominant side. Review of Resident #2's annual MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 8 (moderate); Section G- Functional Status revealed Resident #2 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bowel and Bladder revealed always incontinent for bowel; Section M-Skin Conditions revealed Resident #2 was at risk of developing pressure ulcers/injuries. Review of Resident #2's care plan dated 07/04/2022 revealed: Focus: The resident is at risk for pressure ulcer development r/t disease process and immobility. Date Initiated: 06/26/2018 Revision on: 04/15/2021; Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 06/26/2018. Administer treatments as ordered and monitor for effectiveness. Date initiated 06/26/2018. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiate initiated: 06/26/2018. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: 06/26/2018. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, S/SX of infection, wound size (length X width X depth), stage. Date Initiated: 06/26/2018. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Weekly skin assessments. Date initiated: 06/26/2018. Revision on: 03/03/2023; Focus: patient has a stage 4 pressure injury to right posterior calf with potential for further skin breakdown R/T: disease process, immobility, impaired mobility, lack of sensation, non-compliance with therapeutic regimen. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 07/29/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 07/29/2023. Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 07/29/1013. Review of Resident #2's nurses notes dated 07/15/2023 at 11:00 PM written by LVN T revealed: Aide has brought to my attention that [Resident #2] has open area on back of right ankle area. When this nurse assessed, I found wound that is denuded, partial thickness and has black eschar in wound bed. I cleansed wound with wound cleanser, applied hydrophilic ointment and covered with bordered gauze. Entire leg and foot have severe outward rotation. It is stroke effected side. Heel is elevated off bed and wound area is hanging free with no pressure. Review of Resident #2's nurses note dated 07/17/2023 at 1:37 PM written by LVN A revealed: Resident noted to have a DTI per night nurse to his right lower calf area cleaned Review of Resident #2's physician orders revealed no evidence of pressure ulcer treatment between 07/15/2023 and 07/27/2023. Review of Resident #2's physician orders revealed: Order date 07/27/2023 at 2:15 PM Cleanse right lower posterior calf with dermal wound cleaner apply Triad Debriding Cream to wound bed and cover with boarder dressing. Every day shift every Mon, Wed, Fri for promote Wound healing and every 1 hour as needed for skin irritation. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by DON revealed Skin Intact. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed Right lower leg stage 3 pressure ulcer measuring 2.5cm in length by 2.7cm in width by 0.5cm in depth. Record review of Resident #2's nurse's skin assessment dated [DATE] completed by TX D revealed right lower leg unstageable pressure ulcer measuring 2.5cm in length by 2.0cm in width by 0.5cm in depth. During an observation on 07/29/2023 at 4:10PM of Resident #2 revealed Resident #2 lying in bed with right leg on pillow. Resident #2's right lower leg was covered by gauze and secured with tape. The dressing did not have a date on the outside. During an observation on 7/30/2023 at 3:30 PM of Resident #2 revealed Resident #2's lower right leg had a wound that had red tissue present, surrounding skin within normal limits for race, no tendon or bone observed, no necrosis observed, measurements were not taken appeared to be a Stage 3. During an interview on 07/30/2023 at 5:35 PM, the DON stated she had completed skin assessment on 7/20/2023 for Resident #2. The DON stated that she should have looked at the nurses notes to verify that Resident #2 did have a pressure ulcer. The DON stated the system was new to her, and she must have gotten confused between patients. The DON stated she had not completed a thorough assessment and that her assessment did not give an accurate assessment of Resident # 2, because if nurses note on 07/13 and 7/15 stated he had a pressure ulcer then her assessment on 7/20 should have reflected that. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. 4. Resident # 6 Review of Resident #6's face sheet dated 08/02/2023 revealed, [AGE] year-old female originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis Type 2 diabetes (primary), age-related physical debility, cognitive communication deficit, and unspecified dementia. Review of Resident #6's significant change in status MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 99 (Unable to complete interview); Section G- Functional Status revealed patient had extensive dependence with most activities (1 physical assist); Section F- Bowel and Bladder revealed always incontinent to bowel and bladder. Section M-Skin Conditions revealed Resident #6 had a risk of developing pressure ulcers/injuries. Review of Resident #6's care plan dated 5/15/2023 revealed no intervention related to Deep Tissue Injury prevention or care. Review of Resident #6's Weekly Skin Integrity Review dated 07/25/2023 completed TX D revealed; Suspected Deep Tissue Injury to left heel measuring 4cm in length by 3cm in width. Review of Resident #6's physician orders dated 07/29/2023 revealed no evidence of wound treatment order for Deep Tissue Injury between 07/25/2023 and 07/29/2023. Review of Resident #6's physician orders dated 07/30/2023 revealed Skin prep to left heel every day and prn everyday shift for wound care related to weakness. During an observation and interview on 08/01/2023 at 4:25 PM revealed Resident #6 laying on her back not wearing her offloading boot, the boot was to the left side of her foot. Resident #6's wound was located on left heel, the wound was circular and purple in color, there was no drainage and skin appeared. During an interview on 08/01/2023 at 4:25 PM ADON C stated Resident #6 should have been wearing the offloading boot while in laying bed. ADON C stated that Resident #6's wound was not healed and needed further treatment. 5. Resident #7 Review of Resident #7's face sheet dated 08/02/2023 revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmitted [DATE], with the following diagnosis cerebral infarction (primary), muscle weakness, need for assistance with personal care, and Type 2 diabetes. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed, Section C-Cognitive Behavior revealed a BIMS score of 15 (cognitively intact); Section G- Functional Status revealed limited to extensive assist needing 1 - 2+ persons for assistance; Section- H Bowel and Bladder revealed occasionally incontinent to bladder and frequently incontinent to bowel. Section M- Skin Conditions revealed resident is at risk for developing pressure ulcers/injuries. Review of Resident #7's care plan dated 05/31/2023 revealed: Focus: The resident has pressure injury to Rt buttock stage 3 with potential for further skin breakdown r/t: chronic progressive disease, impaired mobility, obesity. Date Initiated: 03/02/2023. Interventions: Administer treatments as ordered and monitor effectiveness. Date Initiated: 03/02/2023. Assist resident with turning/repositioning during rounds. Date Initiated: 03/02/2023. Check for incontinence during rounds and provide care as needed. Keep resident clean and dry. Date Initiated: 03/02/2023. Document wound appearance, color, wound healing, s/sx of infection, wound size (length X width X depth) and stage, and report to MD PRN any changes in skin status. Date Initiated: 03/02/2023. Notify Nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. Date Initiated: 03/02/2023. Provide pressure relieving device in bed. Date Initiated: 03/02/2023. Refer to dietician and follow recommendation. Date Initiated: 03/02/2023. Serve diet as ordered. Date Initiated: 03/02/2023. Review of Resident #7's Weekly Skin Integrity Review dated 07/28/2023 completed by TX D revealed redness to right buttock. Review of Resident #7's Skin Note dated 07/31/2023 completed by TX D revealed Wounds to bilateral gluteal ischium tuberosities are healed, discontinue wound care to these areas, will continue to monitor. Review of Resident #7's Weekly Skin Integrity Review dated 08/02/2023 completed by TX D revealed new stage 2 right upper gluteal fold pressure ulcer measured 2cm in length by 2cm in width and 0.1cm in depth and stage 2 right lower gluteal fold pressure ulcer measured 1cm in length by 0.3cm in width and 0.1cm in depth During and interview on 08/02/2023 at 9:40 AM, [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment in accordance with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1 was making appointments with the Podiatrist/Orthopedic Surgeon (OS) post amputation of 5th digit of left foot. 2. The facility failed to obtain orders from Resident #1's Podiatrist/Orthopedic Surgeon (OS) Podiatrist when appointments were missed status post amputation of 5th digit of left foot. 3. The facility failed to follow Podiatrist/Orthopedic Surgeon (OS)'s orders for daily dressing changes. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of infections, worsening of wounds, injuries, emotional distress, and even death due to missed appointments, lack of follow-up, dressing changes, and lack of monitoring of amputations Findings include: Resident # 1 Review of Resident # 1's closed record face sheet dated [DATE] revealed, [AGE] year-old male originally admitted on [DATE] with most recent readmitted [DATE] and discharge date of [DATE] with the following diagnosis metabolic encephalopathy (primary), encounter for orthopedic aftercare following surgical amputation, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, need assistance with personal care, dependence on renal dialysis and end stage renal disease Review of Resident #1's hospital records dated [DATE] revealed Resident #1 was admitted to local hospital on [DATE] with stroke like symptoms, diabetes, and end stage renal disease requiring dialysis. Further review of hospital records revealed metatarsal resection (amputation of toe) on [DATE]. Further review of hospital record revealed resident Resident #1 was discharged from local hospital on [DATE] at 4:30pm with diagnosis of ulcer of left foot due to necrosis (death of tissues) of bone because of chronic osteomyelitis (inflammation of bone due to infection) of left foot with orders to follow up with Podiatrist/Orthopedic Surgeon in two weeks ([DATE]). Review of Resident # 1's closed record admission MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 10 (moderate cognitive impairment); Section G- Functional Status revealed Resident #1 had mostly total dependence (needed one to two + persons physical assist with most ADLs); Section H- Bladder and Bowel revealed Resident # 1 always incontinent for bowel and bladder; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. Review of Resident #1's closed record care plan dated on [DATE] revised on [DATE] revealed: Focus The resident has infection of the left foot r/t candidiasis. Date Initiated: [DATE] Revision on: [DATE]. Interventions: Administer medication as ordered. Date Initiated [DATE]. Follow facility policy and procedures for line listing, summarizing infections. Date Initiated: [DATE]. Maintain universal precautions when providing resident care. Date Initiated: [DATE]. Perform and document weekly assessment of skin for changes or observations. Record review of Resident #1's closed record progress note on [DATE] written by NP revealed Patient was admitted for sepsis of multi sourced infection sites. Patient was started on empiric antibiotics and blood cultures were negative. Patient underwent a left fifth metatarsal head resection on [DATE]. Patient was medically stabilized and subsequently discharged to facility on [DATE] . Patient to have follow-up with OS on [DATE] at10:30 a.m. Dressing is to remain on the left foot until he is seen by the orthopedic surgeon. Further review of Resident #1's closed record revealed no evidence of documentation of missing Resident #1's appointment with OS on [DATE]. Record review of Resident #1's closed record nurses progress note dated [DATE] revealed Resident return from OS per physician progress notes: 1) Please do NOT change the patients dressing 2)RTC on [DATE] @ 1130AM. Transportation notified of f/u appt. and Info updated on 24 hour report. Record review of Resident #1's closed record nurses progress note dated [DATE] revealed Resident return from OS office per physician progress notes Please change Resident #1's foot wound dressing daily. No further need for ACE wrap. Please see that patient gets his augmentin as ordered. Call placed to OS office for clarification on orders what does provider want for dressing orders and orders for augmentin. Per nurse at OS office to cleanse wound then swab with betadine cover with 4x4 and secure. Augmentin 875mg q12 hours x10days. Orders updated in chart and placed on24 hr{hour} report. Record review of Resident #1's closed record nurses progress note dated [DATE] revealed Resident return from OS appointment per physician's progress notes: Continue daily dressing changes with betadine to wound base . Return in 1 week appt of [DATE] @ 1045am Transportation notified. Record review of Resident # 1 physician orders revealed start date [DATE] Location of wound: left foot with order to be performed every day shift Treatment order: Cleanse with NS or Wound Cleanser and pat dry. Swab with betadine swab. Cover with 4x4 and secure with tape. and no end date. Record Review of Resident #1's TAR dated [DATE] - [DATE], revealed no evidence of treatment for order being completed on: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #1's hospital records dated [DATE] revealed Resident #1 was readmitted to local community hospital on [DATE] due to complications related to End Stage Renal Disease requiring dialysis. Further review of Resident #1's hospital records revealed resident was discharged [DATE] to in house hospital hospice. During an interview on [DATE] at 12: 59 PM, Resident # 1's family member stated he/she had concerns about Resident 1's care while at the facility. Resident #1's family member stated he/she felt Resident #1 was neglected by the facility which led to his death. Resident #1's dressing on his wounds were never changed timely. During an interview on [DATE] at 5:35 PM, the DON stated documentation for wound care should have been on the TAR. The DON stated if there were no initials of nursing staff then it meant that the wound treatment was not provided. The DON stated her expectation was that wound care orders be followed and need to be completed, and if resident refused the refusal should have been documented that resident refused wound care. The DON stated she was not aware of missed treatments, she stated she thought treatments were done because she saw TX G's pushing treatment cart up and down the hall. The DON stated that was why she went in and initiated some of the treatment dates. The DON stated that missed treatments could have caused resident decline in wounds. The DON stated if nurse did not document there was no way to prove treatments were done. The DON stated the negative affect on residents, if wound care treatments were not completed, could have caused skin breakdown, and could have caused the wounds to worsen in various ways. The DON stated that RNWS J and LVN F should have provided wound care on the blank entry dates for missed wound care for Resident #1. During an interview on [DATE] at 6:13 PM, RNSW J stated he had never heard of Resident #1. RNWS J stated if wound care was not done it could have caused infection, or resident to become septic. RNWS J stated he had never not documented work, if you do not document it did not happen. During an interview on [DATE] at 6:32 PM, LVN F stated she had never done wound care on Resident #1. LVN F state skin assessments were completed by treatment nurse, and for new admissions the nurse on unit would complete skin assessments. During an interview on [DATE] at 12:05 CSD stated thru her audits she discovered issues with TX G documentation and reeducated TX G. CSD stated she continued to see missed documentation and TX G was removed from treatment nurse about the [DATE]th. TX G stated if someone were to document late then there should be a progress note that explained the late documentation. CSD stated NA was not appropriate entry into TAR, that documentation needed to reflect what was assessed and observed during treatment. CSD stated skin assessments needed to be completed weekly. CSD stated she could run a report that would identify who documented and the date and time they completed the documentation. During an interview on [DATE] at 4:00 PM CSD stated she had ran a report, Medication Admin Audit Report. CSD stated the report showed that DON and ADON E had completed documentation after surveyors had entered the building. During an interview on [DATE] at 4:30 PM, RN OS stated OS had concerns with facility not showing up for appointments or calling to reschedule. RN OS stated Resident #1 was scheduled for one week follow up o [DATE] after surgery and missed appointment. RN OS stated the facility never called to clarify treatment orders, or to called to reschedule appointment. RN OS stated when she called to reschedule, facility stated visits were missed because another resident had an appointment. RN OS stated Resident #1 did not make it to the office for 3 weeks. The bandage had not been changed in 3 weeks and had to be soaked to remove dressing and Resident #1 received bandage burns to his skin. During an interview on [DATE] at 11:50 AM, the OS stated he had concerns Resident #1 was a no call/no show for his first scheduled post-operation visit on [DATE]. The OS stated the facility never called to reschedule visit or to clarify orders. The OS stated Resident #1 went over 3 weeks without bandage being changed, which led to the bandage had to be soaked to be removed and Resident #1 had bandage burns. The OS stated he was never notified of missed wound treatments. The OS stated Resident #1 missing wound care treatments postponed his foot healing. During an interview on [DATE] at 4:46 PM, MR stated she is responsible for making transportation arrangements. She stated she doesn't make the doctor's appointments and when residents are discharged from hospital with a card, the nurse is responsible to make the appointments. MR stated she did not have documentation to why Resident #1 missed appointment on [DATE]. MR stated there were days when the transportation van was not working in order to take residents to appointments; however, it was functioning and working properly on [DATE]. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:15pm. The Administration was informed of the IJ. The Administrator was provided with the IJ template on [DATE] at 5:15pm. Record review of Plan of Removal accepted on [DATE] at 2:35 PM reflected the following: What corrective actions have been implemented for the identified residents? A. Resident # 1 was unable to be assessed (expired ,d+[DATE]). B. Transportation Log, Hospital Discharge Paperwork and Nurses notes will be reviewed during clinical morning meeting - appointments will be placed in log for Medical Records and Appointments will be reviewed with Administrator/Designee to ensure transportation for residents is provided. C. Transportation barriers will be communicated to Administrator/Designee to ensure appointments are followed. In event of transportation barrier facility will utilize outside resources (ie local transportation company, rental companies) to provide transportation for residents. D. Clinical Staff will notify Medical Records (via appointment sheets) of resident's MD appointments of cancelations or requests for rescheduling of appointment by family members. Medical Records will coordinate with MD office for appointment changes, cancelations or rescheduling of appointments. Clinical Staff will confirm with MD if current orders will remain in place or change any orders until next appointment. Clinical Staff will document changes in appointments in EHR. E. Medical Records / Designee with call family members and resident MD office to verify appointments, place on transportation log, upon return from MD appointment new appointment sheet will be made to reflect next appointment if necessary. How were other residents at risk to be affected by this deficient practice identified? All residents residing in the facility have the potential to be affected by this proposed deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. On [DATE] Administrator in-serviced the DON, Medical Records and ADONs on reviewing hospital discharge records and nursing documentation in clinical records for any MD appointments, place appointments on appointment sheet for medical records to coordinate transportation. DON and ADONs verbalized teach back of education provided to them. B. An in-service was initiated on [DATE] by Medical Records with clinical staff on appointment sheets for hospital discharge appointments, and MD appointment follow ups. Licensed staff verbalized teach back of education provided to them. C. Newly hired nurses and contract staff will be in-serviced by the Director of Nursing or ADON on appointment sheets for hospital discharge appointments, and MD appointment follow ups. Licensed staff will verbalized teach back of education provided to them. How will the system be monitored to ensure compliance? A. Medical Records / Designee will review during morning clinical meeting any clinical notes, hospital discharge records for MD appointments, will place on Transportation log, verify appointments. B. Medical Records / Designee will communicate with family prior to appointments, if family is unable to attend Medical Records will communicate with MD office on reschedule, will notify Charge Nurse and document in nurses note reason for change of MD appointment. C. Medical Records and Administrator will communicate regarding any appointment conflicts or families who are unable to attend appointments to ensure staff able to attend if needed. Quality Assurance Administrator / Designee will conduct 3 random transportation calendar audits a week for 2 months. Findings of audits and system management will be reported to the QAPI committee during the monthly meetings for the next 2 months, identifying system compliance or need for further education and clinical oversight. Administrator / Medical Records / IDT will conduct on [DATE] Ad Hoc QAPI meeting to review issue and response plan as indicated. An impromptu Quality Assurance and Performance Improvement review of the plan of removal will be completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from [DATE] at 8:00 am to [DATE] at 2:35pm as follows: During an interview on [DATE] at 11:08AM with TX D, she said neglect was not performing a doctor order, not documenting a doctor order, and not changing a resident's wound care dressings. She said the nurse aides were to notify the nurse about any new skin issue and at that time the nurse was supposed to go and do a skin assessment on the resident and notify the resident's physician and family. TX D said that would be the time to get an order from the physician and document the work in the resident's record. She said orders needed to be instant and should never take longer than an hour much less days from the physician and they needed to be implemented immediately as well. She said the treatment nurse was responsible for completed weekly skin assessments and they should reflect the actual picture of resident and their skin. TX D said progress notes and the TAR were supposed to be completed daily with an assessment of the wounds on the TAR and that NA was not an appropriate answer for the assessment of the wound, as it was not an accurate finding. During an interview on [DATE] at 11:25AM with CNA N, she said neglect from an aide would be to not report a skin issue to a nurse and not turning or repositioning a resident so not to put pressure on their wounds or causing pressure sores. CNA N said that the aides did not have an area to document issues, only that they were supposed to report abnormal things to their nurses. is report Nurse first, Skin issue get nurse to look at the skin issue, does not have a place to document. During an interview on [DATE] at 11:33AM with CNA P, she said that neglect from the aides would be not turning and repositioning a resident at least every 2 hours or not telling the nurse about a new skin problem when it was first seen. She said that the residents ran the risk of developing sores or their sores getting worse if the aides didn't frequently reposition the residents. During an observation and interview on [DATE] at 3:30PM with CNA R and Resident #8. Residnet #8 had a pillow behind her right shoulder, and she was inclined approx 45 degrees in the bed wearing oxygen. Resident #8 said the pillow was uncomfortable. While talking with Resident #8, CNA R came into her room, and told her that she wanted to be repositioned. CNA R said she would get help. While waiting for help to arrive, CNA R said the nurse aides were supposed to notify the charge nurses for any change in residents. For residents that had incontinence, the facility had barrier cream they could use for each change, but if they noticed reddened or open sores they were to call the charge nurse immediately. The residents were supposed to be repositioned at least every 2 hours. Resident #8 had an additional mattress overlay on her bed. CNA R said Resident #8 was on hospice, and they must have brought that overlay that morning. Resident #8 said the overlay was fine and she liked it, just didn't like the pillow at her shoulder. CNA R reminded Resident #8 that she had a sore on her lower back and bottom that they needed to try and take some pressure off to help it heal. During an interview on [DATE] at 12:06PM with ADON M, she said she had not been the RN that has been monitoring the skin of the residents of the facility. She said she became the ADON as of [DATE] and started at facility at the very end of May as an RN. she said CSD went over information regarding treatments, skin assessments, documenting in a timely manner, notifying the Dr of changes or if a resident had a refusal of treatment, and scheduling appointments. She said, if you did treatment and didn't sign the MAR, make a late entry to show that it was completed and forgot the documentation but do not go back and fill in the hole after the shift. She said the nurses were supposed to place any and all information on the 24-hour report sheets to help with continuity of care. ADON M said the treatment nurse was supposed to do the treatments and skin assessments, but if not, then the nurse for each resident should do them. She said at least 1 nurse key set has the treatment cart key to access supplies. ADON M said when she did treatments she would date and initial the bandage on the resident so anyone else could see when it was done last. She said, Personally, as a nurse if I see that it wasn't done, or the dates are old I would do a treatment myself. She said with the EHR you can go and change the date in the computer and lookback at the MAR and TAR to see the holes and back date for an assessment. She said, she would not see that as a competent nurse that it would be as a standard of nurse practice to, sign for another person or write something that you had not done yourself. She said she wouldn't want someone to fill in her own work. ADON M said she didn't think that could be a 28-day gap of knowing what I had done at work. I work 2 jobs, so it would definitely be hard to think back more than a couple of days what I had done. She said she would talk to the person that worked previously and ask them then to make a late entry if she seen that documentation had been missed. ADON M said she felt like the window of time that the information was not in the resident's records did not make them an accurate record for the resident. During an interview on [DATE] at 12:49PM with ADON E, he said he had been an LVN for [AGE] years and he had been working at the facility since May of 2023. ADON E said he started training as a floor nurse first with the expectation as he was going to be the ADON. He said as he was an LVN, he was not managing or monitoring wounds in the facility. He said TX G was managing wounds then TX D was and starting [DATE] it would be ADON C, all of those which were LVN's, so there were no RNs overall who were managing the wounds. ADON E said it had been himself and ADON C that had performed the skin sweep on [DATE] using a resident roster and the full body sheets to mark any skin issue a resident had. He said they did not do an assessment on the residents named in the allegations, as that was the responsibility of DON. He said after they completed the skin sweep, they took their paperwork to DON, but did not do new individual skin assessments in any of the resident's EHR's. ADON E said, So, I learned my lesson, will leave it red and put in a progress note, regarding filling in holes in the MAR and TAR. He said he would do treatment, or an assessment and just didn't get the documentation done, stating, days have just run together. He said, No it is not a standard of practice to go back in and back date or fill in holes in the MAR, TAR or assessments. It's the wrong thing to do. He said you do not chart the next date or later that something was done in a timely manner and never chart for someone else's work or lack of work. I wouldn't know how to defend that in court. He said he would not feel comfortable if someone else did his charting because you never know if you have an enemy. ADON E said he did inservice staff on wounds, charting, just make a note if it was wrong or late, aide to notify the nurse and the nurse needed to notify the doctor that there was a new skin issue. He said they had the 24-hour clip board for the writing of issues. ADON E said Have your shift to document your work. He said the nurses should make a note that the something was not done. He said for any changes, or refusals, the nurses should notify the dr sometime in the shift. During an interview on [DATE] at 1:28PM with MR, she said now they had 2 binders for appointments so each nurses station had 1. She said she was to look at the binders each day and transfer them to the appointment logs. MR said she was in-serviced on the doctor's notes to follow up about an appointment. She said ADM was her manager and if an appointment needed to be rescheduled, then she was to tell ADM and give an explanation. MR said she would be part of the clinical meetings each morning so she could also find out about resident issues and possible appointments, then further check on the binders. She said the facility had their own van and could use local van services or a taxi if needed to get residents to the doctor. MR said, if a family wanted to be with the resident, they did their best to accommodate. She said she a new change would be that they had to follow-up within the day with the family and the doctor's office to confirm appointments and rescheduling of appointments. She said the nurse looked through the admission paperwork for needed appts, and she would as well. During an interview on [DATE] at 1:45PM with ADON C she said, she had been an LVN for 16 yrs and had been working at the facility for 2 yrs. and 2 months. She said yesterday ([DATE]) she became the treatment nurse and before that she was an ADON. The weekend supervisor was the treatment nurse for the weekends. She said new admissions had to have a skin assessment and if they had any types of wounds they needed to have something as far as treatment orders in place within 24 hrs even on weekends. ADON C said every resident had a weekly skin assessment and they were able to run a report for the list of residents with skin assessments to see if they were done. She said, If you didn't document, it wasn't done. Regarding skin assessments and holes in MAR and TAR. She said she wouldn't feel comfortable to have another nurse document for her or doing so for another nurse. She said, That would be false documentation. ADON C said, There is no way I can even remember what I ate for supper last night. There is no way I would remember what I did last week or even further than that, regarding documentation that was days and weeks later. She said CSD was monitoring and managing the skin assessment reports and TAR's to make sure the nurses were getting their work done. She said herself and ADON E did the skin sweep on [DATE] and took skin sweep sheets to DON that had her notes on them. She said they used a skin sheet with the body, if there was nothing on the residents skin, they just put an x or line over body, if there was an area then they circled it with quick description, like redness or sore. ADON C said they didn't do any measurements, just noted any issue. She said CSD in-serviced them to document as you go and at latest the end of the shift, if its after the shift then have to write a progress note indicating it's a late entry and the reason documentation might have been missed or if it wasn't completed. Do not back date or fill in holes. Do not strike out an inaccurate assessment, just do a progress not to indicate the inaccuracy. ADON C said not doing a treatment or a skin assessment was a neglectful action. She said that was how skin issues were identified past a redness or stage 1 and why some wounds got worse. The intact then open sore or intact then DTI within days proved to be inaccurate representation of the resident's skin. She said the admission nurse had to look at new resident's paperwork to see if a resident either had an appointment or needed a follow up appointment and it was the admission nurse's responsibility to call and make the appointment and to put the information in the appointment book at the nurses station. ADON C said she worked with other orthopedic doctors in the past that at times would have orders not to touch the surgical dressing until follow-up appointments and it would sometimes be 2 weeks before a resident could be seen. She said that after the incident with Resident #1, they would now have to make follow-up calls for clarification of the treatment orders with those situations as well as follow up calls to the dr if the dressings were becoming dirty or heavy drainage through the dressing. ADON C said the biggest fix that she could do herself was to step down as an ADON and go back to being the treatment nurse herself. It had been several months since it was her responsibility so she would have to take some time to familiarize herself with wounds again. During an interview on [DATE] at 3:00PM with LVN B, she said she had been an LVN since 2005 and had been working at the facility since December of 2022. She said she had been in serviced regarding wound care in that the nurses needed to complete documentation on wounds either through the skin assessment sheets or the TAR when they were due and to make sure to notify doctor if something was new or a treatment was not completed due to a refusal. She said the nurse that admitted the resident had a skin assessment as a part of the admission paperwork. LVN B said the assessment would include what the skin looked like and if there were any wounds then should describe what the wound looked like, the approximate the size and the location of the wound. She said if there were wounds already present on the resident, they were to review the resident's paperwork for treatment orders and if there were not any orders then the nurses were supposed to notify the doctor to get treatment orders. In the case of resident doctors appointments, most especially if a resident had wounds, LVN B said the nurses reviewed the resident's paperwork for an already scheduled follow-up appointment or if an appointment needed to be scheduled for a resident. She said the nurses were responsible for calling the doctors office to confirm or set up an appointment and to clarify if a treatment was supposed to stay in place, or due to the extended period that it would be before the resident would be seen by the doctor, if the doctor would like to make an order for wound care treatments until the resident could be seen by the doctor. LVN B said each nurses station had an appointment book that the nurses were supposed to either place the appointment card in or write down the resident's name, date of appointment, which doctor and their address in the book. During an interview on [DATE] at 3:20PM with DON, she said she had been a nurse since 2008. She said she had been the DON since [DATE]th of 23. DON said there had been a big learning curve on the change of EHR system from what she had been used to in other facilities in the past. She said she is just very overwhelmed. DON said her orientation was really just a welcoming to the company not a EHR orientation. She said she did not really know how to pull reports to see what the nurses were completing or not. The CSD had been at the facility 3 times since DON came to facility. DON said the CSD has been available by phone has only recently showed her how to run reports. She said the CSD brought it to her attention that skin assessments had not been completed several times for several residents. DON said nursing management started with audits and was having daily all-day meetings checking on the nurses work, and TX G (former tx nurse) didn't want to participate, was not doing her work, would not communicate with DON that she could not get her work done. DON said the CSD said that there was a lot of issues with no documentation regarding treatments and said there was an issue back in March and April of 23 with TX G not getting her work done or her documentation done. She did not know the full description of which nurses did skin assessments for which residents but thought that the floor nurses split odd rooms day shift and even rooms night shift maybe. She said the treatment nurse should be the person that did residents skin assessments that had wounds. DON said she just got hyper focused on catching up the skin assessments and was just so overwhelmed that I was on auto pilot trying to get the documentation caught up. DON said, knows that you should not fill in holes in the MAR and TAR. Said she had never just maliciously done something like that before. She said, I know I have made mistakes, if someone will just tell me it is a mistake, I can fix it, but if you don't tell me whats wrong, I can't fix it. She said the last few days CSD had been going through the system showing her how to run different reports. She said she did a skin sweep when she first came to the facility with the other ADON's s and TX, and over the last week the ADON's s and TX had been doing them almost daily. She said Thursday ([DATE]) she went to the residents that had wounds and had the wound care doctor's notes from that morning and just made sure that there were no new areas. She said she used his measurements from that morning because they had just been done and there was no reason to believe that measurements would have changed that much. She said, I don't feel that my documentation was false just that I made a mistake and was just overwhelmed with the need to catch everything up in the residents' records. During an interview on [DATE] at 12:50PM with R [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessments and plan of care for 6 (Resident #1, #2, #5, #10, #11, and #13) of fifteen residents reviewed for change of condition, admission/transfer discharge, diabetes, medication errors and medication administration. A. The facility failed to ensure that upon being admitted to the facility on [DATE] Resident #1's physician's orders [REDACTED]. This failure resulted in Resident #1 receiving [MEDICATION NAME] 40mg once a day rather than twice a day as ordered for a period of 7 days. In addition, Resident #1 did not receive daily skilled assessments for 9 out 32 days she was in the facility, including not being assessed for [MEDICAL CONDITION] or lung sounds. The facility also failed to ensure Resident #1, who was diabetic, received routine monitoring of her blood sugar levels for at least 14 days after being admitted to the facility. On 8/26/17 Resident #1 had elevated vital signs and asked to be sent to the emergency room where she was admitted and treated for [REDACTED]. B. On 09/12/17 Resident #5 complained of chest pain to LVN K who obtained an order for [REDACTED].#5 continued to have chest pains. Approximately 7 hours after Resident #5 initially complained of chest pain he was sent to the emergency room . Resident #5 remained in the hospital for three days and a cardiac angioplasty and stent were performed. C. The facility staff failed to assess and monitor Resident #2 on 09/20/17 and 09/21/17 when she experienced an altered level of consciousness and would only arouse with painful stimuli. Resident #2 was sent out to the hospital on [DATE] at 7:00 AM, approximately 12 hours after her change in condition was initially identified. Resident #2 remained in the hospital for six days. D. On 09/26/17 RN A failed to ensure Resident #13 took her 8:00 AM medications that included medications to help address Resident #13's chronic issues with anxiety and shortness of breath. Resident #13 was asleep when RN A attempted to administer the medications so RN A left the medications at Resident #13's bedside. When she awoke Resident #13 realized she had not received her medications and begun to experience anxiety and shortness of breath. RN A, after being notified by a Hospice provider of Resident #13's change of condition, failed to promptly assess the resident or provide immediate interventions. E. The facility failed to ensure Resident #11 received [MEDICATION NAME] 40mg Injections following admission from 09/14/17 through 09/26/17. F. The facility failed to ensure Resident #10's [MEDICATION NAME] 240mg was administered for six days after being readmitted to the facility on [DATE]. The facility also failed to ensure Resident #10's blood sugar was routinely monitored or that parameters were established as to when Resident #10's insulin should be held for 11 days after he was readmitted . This deficient practice resulted in an Immediate Jeopardy (IJ) on 09/21/17. While the IJ was removed on 10/01/17, the facility remained out of compliance at a level of Actual Harm at a pattern, that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. This failure could place the entire census of 90 residents at risk for delay in treatment, receiving medications as ordered, receiving adequate assessments and serious complications and /or death. The findings included: Resident #1 Review of Resident #1's closed record Facesheet dated 09/19/17 revealed she was a [AGE] year old female, who was admitted to the facility on [DATE] under Physician A's care from 7-26-17 through 8-12-17 and Physician B followed her care from 8-13-17 to 8-26-17 for the following Diagnoses: [REDACTED]. The facesheet also identified the following: Date of Discharge: 08/26/17 Time: 9:30 AM. Review of Resident #1's history and physical from Hospital A, dated 07/22/17, prior to her admission to the facility, performed by Physician A revealed the following: This is a very pleasant [AGE] year old female with a past history of [MEDICAL CONDITION] and chronic combined systolic and diastolic heart failure, who unfortunately suffered a fall earlier this evening.She has a history of combined diastolic and systolic heart failure. She just visited the [MEDICAL CONDITIONS] clinic yesterday where she was at her normal weight and did not require any additional [MEDICATION NAME] Past Medical History: Chronic [MEDICAL CONDITION] Fibrillation, currently anticoagulated with [MEDICATION NAME], Chronic combined systolic and diastolic heart failure, Diabetes Mellitus, Plan: We will hold her diuretics at least preoperatively . Record review of Resident #1's Initial Assessment, dated 07/27/17 revealed swelling in her left leg and her lungs were clear. Signed RN A Review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE], revealed that she was admitted to the facility from an acute hospital, her Brief Interview for Mental Status (BIMS) revealed a score of 14, which indicated she was cognitively intact. Further review of the MDS showed Resident #1 had the following active [DIAGNOSES REDACTED]. Resident #1 had the following health conditions: Shortness of breath with exertion (e.g., walking, bathing, transferring) and Shortness of Breath when lying flat. Weight 148 pounds. The MDS did not indicate Resident #1 was on a diuretic. Special Treatments indicated Resident #1 received oxygen therapy while a resident in the facility. Review of Resident #1's Care Plan dated 08/03/17, revealed .I have a history of Hypertension .My B/P (blood pressure) will stay in their normal limits, will not have hyper/[MEDICAL CONDITION] over the next 90 days Approaches: Monitor B/P, increased [MEDICAL CONDITION], dizziness, headache, chest pain, and report to MD .I am a Diabetic and I am at risk for : frequent infections .hyper/[DIAGNOSES REDACTED] Ways to control diabetes: Insulin, oral hypoglycemic and diet .Goal: Diabetic status will remain stable as evidenced by residents normal limits over the next 90 days Approaches: Give resident meds as ordered, monitor labs and report abnormals to MD . Review of Resident #1's care plan did not address Resident #1's [DIAGNOSES REDACTED]. According to the US National Library of Medicine, Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. The weakening of the heart's pumping ability causes: Blood and fluid to back up into the lungs; The buildup of fluid in the feet, ankles and legs - called [MEDICAL CONDITION]; Tiredness and shortness of breath. Common causes of heart failure are [MEDICAL CONDITION], high blood pressure and diabetes. Accessed on 09/24/17. https://medlineplus.gov/heartfailure.html According to the American Heart Association, Symptoms of heart failure are: Buildup of excess fluid in body tissues ([MEDICAL CONDITION]) .swelling in the feet, ankles, legs or abdomen or weight gain. You may find that your shoes feel tight. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention in the tissues. Tiredness, fatigue .a tired feeling all the time and difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries or walking Increased heart rate .heart palpitations, which feel like your heart is racing or throbbing. Accessed on 09/24/17 http://www.heart.org/HEARTORG/Conditions/HeartFailure/WarningSignsforHeartFailure/Warning-Signs-of-Heart-Failure_UCM_ 5_Article.jsp#.Wcac7suWzIU Review of Resident #1's Physician order [REDACTED].); Aspirin [MEDICATION NAME] Coated 81mg PO once a day; Losartan Potassium 25mg Give 1 Tab PO once a day; [MEDICATION NAME] 0.125mg tablet give one tablet PO every other day, Hold if Pulse <60; [MEDICATION NAME] 6.25mg tablet, Give ½ Tablet PO BID (twice a day), [MEDICATION NAME] 100mg Tablet Give 1 tab PO (by mouth) once a day, [MEDICATION NAME] HCL 1,000 MG Tablet Give 1 Tab PO BID (twice a day) . Review of Resident #1's Physician order [REDACTED].#1. According to the U.S. National Library of Medicine, [MEDICATION NAME] ([MEDICATION NAME]) is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a [MEDICAL CONDITION]. [MEDICATION NAME] is also used to treat or prevent venous [MEDICAL CONDITION] (swelling and blood clot in a vein) and [MEDICAL CONDITION] embolism (a blood clot in the lung). [MEDICATION NAME] is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. Accessed on 10/03/17. https://medlineplus.gov/druginfo/meds/a 7.html#why According to the U.S. National Library of Medicine, The [MEDICATION NAME] time (PT) is used, often along with a partial [MEDICAL CONDITION] time (PTT), to help diagnose the cause of unexplained bleeding or inappropriate blood clots. The international normalized ratio (INR) is a calculation based on results of a PT and is used to monitor individuals who are being treated with the blood-thinning medication (anticoagulant) [MEDICATION NAME] ([MEDICATION NAME]®) The PT and INR are used to monitor the effectiveness of the anticoagulant [MEDICATION NAME]. This drug affects the function of the coagulation cascade and helps inhibit the formation of blood clots. It is prescribed on a long-term basis to people who have experienced recurrent inappropriate blood clotting. The goal of [MEDICATION NAME] therapy is to maintain a balance between preventing clots and causing excessive bleeding. This balance requires careful monitoring A PT and INR are ordered on a regular basis when a person is taking the anticoagulant drug [MEDICATION NAME] to ensure that the prescription is working properly and that the PT/INR is appropriately prolonged. There is no set frequency for doing the test. A health practitioner will order them often enough to make sure that the drug is producing the desired effect - that it is increasing the person's clotting time to a therapeutic level without significant risk of excessive bleeding or bruising. Accessed on 10/03/17 https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=PT%2FINR&_ga=2XXX 977XXX 8570XXX - XXX According to the American Heart Association, Aspirin reduces the risk of [MEDICAL CONDITION] and [MEDICAL CONDITION] by preventing blood clots from forming on the surface of ruptured [MEDICAL CONDITION] plaques. Accessed on 10/03/17 http://circ.ahajournals.org/content/125/10/e439.full According to the U.S. National Library of Medicine, [MEDICATION NAME] (Sitagliptin) is used along with diet and exercise and sometimes with other medications to lower blood sugar levels in patients with type 2 diabetes (condition in which blood sugar is too high because the body does not produce or use insulin normally). Accessed on 09/24/17 https://medlineplus.gov/druginfo/meds/a 3.html According to the U.S. National Library of Medicine, [MEDICATION NAME] is used alone or with other medications, including insulin, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood). [MEDICATION NAME] is in a class of drugs called biguanides. [MEDICATION NAME] helps to control the amount of glucose (sugar) in your blood. It decreases the amount of glucose you absorb from your food and the amount of glucose made by your liver. Accessed on 09/24/17 https://medlineplus.gov/druginfo/meds/a 5.html#why Record review of a Telephone Order dated 7/28/17 written by RN A revealed PT/INR 7/31/17, Signed by Physician A on 08/10/17. In an interview on 09/21/17 at 10:40 AM, RN A said that she recalled the family of Resident #1 asking about her PT/INR laboratory orders and I looked in the chart and saw that she was on [MEDICATION NAME] and did not have an order to check it so I wrote a telephone order to have it checked Monday 07/31/17. RN A said she did not speak with Physician A to obtain an actual order from the physician prior to writing the telephone order for the PT/INTR. She said that A lot of times with Physician A you automatically know they want it so I just wrote that order and did not contact Physician A. In an interview on 09/18/17 at 4:25 PM, the DON said that on 08/08/17, Family Member A and Family Member B complained during the care plan meeting about Resident #1's overall care at the facility and had multiple concerns, specifically when her [MEDICAL CONDITION] symptoms getting worse. The DON said that she explained to the family that she would go and assess Resident #1 immediately following the care plan meeting (08/08/17) and find out for them what was going on. The DON said that she assessed Resident #1 and it seemed as though she needed some labs, a chest x-ray and Physician A to assess her regarding her [MEDICAL CONDITION], however the DON said that she did not document her assessment and could not recall what Resident #1's specific symptoms were but she knew she needed attention. She said that she spoke with Physician A and he came to the facility that day (8/8/17) to see the resident. The DON did recall looking at her chart and finding labs that were lacking follow up on, specifically a [MEDICATION NAME] level, [MEDICAL CONDITION] Stimulating Hormone Level, PT/INR. The DON said that she had no knowledge of Resident #1's medical history until the family expressed concerns on 8/8/17. In an interview on 09/19/17 at 4:56 PM with Family Member A and Family Member B, they said that from the time of admission until their mother was discharged from the facility on 08/26/17 numerous care issues were addressed with facility staff, specifically Family Member A and Family Member B had expressed concern to the DON on 08/08/17 regarding Resident #1's care since being admitted to the facility, they both said that they had addressed concerns regarding heart failure and cardiac history from the beginning of her admission; specifically her diuretic medication [MEDICATION NAME] and laboratory values for [MEDICATION NAME], both family members said they would discuss her care with the nurses at the nurses station and it seemed like it just went right over their heads and they didn't have time to check on our mother (Resident #1). Specifically, Family Member B asked RN A directly after Resident #1 was admitted about her PT/INR laboratory monitoring and RN A said that there was an order to have it drawn. Family Member A and Family Member B both said that they entrusted the nurses to be clarifying and looking into their concerns. On 08/08/17, a care plan meeting was held and at that time the DON profusely apologized for how things had been going with our mother and at that time we felt that the DON would address our concerns. Family Member B was unaware that her mother had had her diuretic medication [MEDICATION NAME] discontinued while in the hospital and it was not resumed after discharge. Family Member B said that she had informed the admissions coordinator and several nurses, which she identified as LVN A and RN A of her mother's cardiac history with anticoagulant therapy and diuretic medications. She said that after the issues were addressed on 8/8/17, their mother (Resident #1) continued to show signs and symptoms of heart failure, specifically shortness of breath and [MEDICAL CONDITION]. Family Member B said that she had asked the nurses about lung sounds and if they had checked her mother and they indicated she was fine. Family Member B said that she inquired about her mother being on a diuretic and was told by LVN A oh yeah, she is now on [MEDICATION NAME]. Family Member B said that after expressing concerns with Physician A's care to RN A, she was encouraged by RN A to change care to Physician B. On 08/13/17, she said that Physician B saw Resident #1. Family Member B said that her mother had in the past attended the [MEDICAL CONDITION] clinic and she took it upon herself to make her mother an appointment to have her evaluated there after visiting her mother on 08/14/17 and finding her with symptoms of [MEDICAL CONDITION] and shortness of breath. She said that she was seen at the [MEDICAL CONDITION] clinic on 8/15/17 and received IntraVenous [MEDICATION NAME] to pull the fluid off and was to return weekly for follow up care on 08/24/17. Family Member B said that on the morning of 8/26/17, she received a phone call from her mother (Resident #1), she said that Resident #1 sounded upset and frightened and explained that she had had a difficult night due to shortness of breath and had been hot. Family Member B said that Resident #1 said she had told staff but that they were not paying attention to her and asked her to come to the facility. Family Member B said that when she arrived at the facility, LVN A was at her mother's bedside taking her vitals and Resident #1 was noted to have elevated blood pressure, heart rate and was short of breath. Family Member B said at that time she asked LVN A, Do I need to call 911 or are you? Family Member B said that 911 was called by the facility and her mother went to the emergency room and subsequently had an 11 day hospital stay due to her [MEDICAL CONDITION]. Family Member A said that she had received a phone call from the DON on 09/15/17 to inform her that while a resident at the facility there had been several medication errors identified with her mother's (Resident #1's) [MEDICATION NAME] medication. Overall, Family Member A and Family Member B expressed concerns that Resident #1 from admission did not receive adequate care and treatment from the facility and subsequently had to endure an 11 day hospital stay for gross negligence of Resident #1's signs and symptoms of heart failure. Review of Physician A's Progress Notes dated 8/8/17 revealed the following: 8/8/17 Patient has been here x 2 weeks. She was admitted to (Hospital A) on 7/22/17 from (assisted living facility) after she fell and fractured her left hip. She is status [REDACTED]. She has not done well since admission. 1. Pain in hip affecting her sleep 2. She's getting very [MEDICAL CONDITION] in legs, gained 15 pounds in the last two weeks .PMH (past medical history) Diabetes Mellitus Type II, Bilateral Total Knee Arthroplasty, [MEDICAL CONDITION] Fibrillation, PPM (Permanent PaceMaker), .Lungs: Clear no wheezes; Cardiac: [MEDICAL CONDITION] Fibrillation Slow 80bpm (beats per minute) Legs: + (positive) pitting .1. Debility: need to get her up or she will deteriorate PT/OT (Physical Therapy/Occupational Therapy) to work with her. 2. DM2 (Diabetes Mellitus Type 2) Accucheck fasting and HS (at bedtime), goal 100-160, meds reviewed .4.[MEDICAL CONDITION] Legs: [MEDICATION NAME] to resume 40mg BID (twice a day) .7. Hypertension 140/90 Goal 8. Get her out of bed!!!! Signed Physician A. (There were no parameters on when to notify the physician regarding low or high blood sugar levels.) According to the U.S. National Library of Medicine, [MEDICAL CONDITION] is described as pitting or non-pitting. Pitting [MEDICAL CONDITION] leaves a dent in the skin after you press the area with a finger for about 5 seconds. The dent will slowly fill back in. Non-[MEDICAL CONDITION] does not leave this type of dent when pressing on the swollen area. Accessed on 09/23/17 https://medlineplus.gov/ency/article/ 3.htm Record review of Physician A's signed Telephone Order dated 8/8/17 revealed the following orders: [MEDICATION NAME] 40mg one PO (by mouth) BID x 2 weeks then down to [MEDICATION NAME] 20mg QD (once daily) .Accucheck AM fasting BS (blood sugar) and nighttime blood sugar. Signed Physician A. (There were no parameters on when to notify the physician regarding low or high blood sugar levels.) Record review of both the Med Aide Medication Administration Record and Nurse Medication Administration Record (MAR) for August 2017 revealed the following: Med Aide MAR: Description: 8/8/17 [MEDICATION NAME] 40mg PO QD (once a day) for 2 weeks then 20 QD; Administration time 8:00 AM Unsigned. Review of the administration record revealed Resident #1 received [MEDICATION NAME] 40mg only once a day from 08/08/17 through 8/14/17 (7 days total). Another handwritten entry was found on 08/15/17 that revealed: [MEDICATION NAME] 40mg PO BID; Administration time 8:00 AM and 6:00 PM for 2 wks then 20mg QD. 8/8/17 Signed LVN A. The MAR revealed Resident #1 still continued to only receive [MEDICATION NAME] 40mg once a day on 08/15/17 and 08/16/17 (even when the order had been corrected to BID), there were not initials indicated for the 6:00 PM dose on either 8/15/17 or 08/16/17 to indicate Resident #1 received her [MEDICATION NAME] 40mg. In an interview on 09/15/17 at 4:40 PM, LVN A said that she had received the written telephone order from Physician A on 08/08/17 to order [MEDICATION NAME] 40mg PO BID for two weeks then 20mg PO QD. During this interview, LVN A reviewed the August MAR for Resident #1 and verified her handwriting for the entry of 8/8/17 [MEDICATION NAME] 40mg PO QD (once a day) for 2 weeks then 20 QD. She said that the order was incorrect and that she had transcribed the order incorrectly, it should have been BID. In an interview on 09/18/17 at 3:18 PM, Med Aide B said that she worked on 08/15/17 and 08/16/17 but did not recall if she administered Resident #1's 6:00 PM dose of [MEDICATION NAME] 40mg. She said that she could have possibly just forgot to initial the MAR but could not say for sure. She did not recall any issues with Resident #1's [MEDICATION NAME] order and thought she had received it correctly. In an interview on 09/18/17 at 3:30 PM, RN A said that she did not recall administering Resident #1's [MEDICATION NAME] on 08/15/17 or 08/16/17, however it had been a while since that date and she just couldn't recall for certain. Record review of Physician A's signed Telephone Order dated 8/10/17 revealed the following: [MEDICATION NAME] 40mg PO BID x 10 days. Signed Physician A. Record review of the Med Aid/Nurse Mar for August 2017 revealed the following handwritten entries: Description: [MEDICATION NAME] 40mg PO BID x 10days ordered 8/10/17 Unsigned. The MAR revealed that Resident #1 received [MEDICATION NAME] 40mg BID by Med Aide A for the following dates: August 10, 11, 15, 16th 2017. The MAR for [MEDICATION NAME] 40mg BID on August 12, 13, 14, 17, 18, and 19th 2017 did not reveal any initials on these dates, which would have indicated Resident #1 received the [MEDICATION NAME] 40mg BID. On 8/22/17, Resident #1 began receiving [MEDICATION NAME] 20mg QD. Review of the initialed boxes for August 22, 23,24 and 25th revealed Resident #1 had received [MEDICATION NAME] 20mg QD. There was handwritten documentation on this specific entry of [MEDICATION NAME] 20mg to have changed on 8/24/17. In an interview and record review on 9/18/17 at 3:45 PM, Med Aid A said she had handwritten the entry onto the August MAR for Resident #1's [MEDICATION NAME] order on 08/10/17. She verified she hand wrote Description: [MEDICATION NAME] 40mg PO BID x 10days ordered 8/10/17. Med Aide A said that no one had instructed her to transcribe the order onto the MAR , and that it was not in her scope of practice to transcribe orders onto the MAR. She said I just did it myself, I know that (transcribing orders) was out of my scope of practice. At this time, Med Aide A was asked to review Resident #1's August MAR. Med Aide A verified that it was her initials and handwriting on 08/10, 11, 15 and 16th 2017 of the August MAR. She said she would not have initialed the MAR if she had not administered the medication. At this time, Med Aid A was given her time card report for August 10, 11, 15 and 16th 2017 and said it looks correct. Med Aid A said she was not sure now why her initials were documented on those dates for Resident #1's [MEDICATION NAME] 40mg to have been administered if she was not clocked in and was unsure why her initials were not on the dates that she had worked. She said she did not know and could not remember now. Record review of Med Aid A's Time Card Report revealed Med Aid A did not work on August 10, 11, 15 and 16th, 2017 but did work on August 12, 13, 14, 17, and 18th, 2017. Med Aid A said she recalled Resident #1 and that she never refused her medications and was good about taking them. She said that during the time Resident #1 was a resident at the facility she did notice swelling in her feet. She said that she had informed the nurses regarding the swelling but could not recall exactly who and what dates. She said Resident #1 was short of breath when she exerted herself and mostly wanted to stay in bed. In an interview and record review on 09/18/17 at 3:18 PM, Med Aide B said that she remembered the family, specifically the daughters of Resident #1 constantly asking the nurses questions regarding Resident #1's care. She said that she did not ever check for [MEDICAL CONDITION] on Resident #1 and said that the nurse's usually are the ones to assess for [MEDICAL CONDITION]. During the interview Med Aide B was given her time card report to review and indicated that she had worked on August 10th, 11th and 15th, 2017. During the interview, Med Aide B was given page 5 of the August MAR to review that had the entries for [MEDICATION NAME] 40mg BID and stated None of the open boxes on the MAR with the [MEDICATION NAME] ordered twice per day are days that I worked, she said the days she worked had (Med Aide A's) initials in the boxes. Med Aide B said she did not recall this page of the MAR, I have not initialed it nor signed it. Record review of Med Aide B's Time Card Report revealed Med Aid B was clocked in and worked a full shift on August 10, 11, and 15th, 2017. Med Aid B was not clocked in for dates August 12, 13, 14, 16, 17, 18 or 19th, 2017. In an interview on 09/19/17 at 8:08 AM, Physician A said that he recalled seeing Resident #1 a couple of times. He said that he was contacted by the DON, unsure of date, and was asked to come and see Resident #1. He said that he had followed her in the hospital but had not been contacted by the nursing facility when she was admitted on [DATE]. He said that he was aware of her history of [MEDICAL CONDITION] and when he went to see her he felt that her [MEDICAL CONDITION] was exacerbated and she was noted to be short of breath, swollen and had some weight gain. He said he ordered labs at that time and wrote an order for [REDACTED]. He said that his goal for her blood sugar was to be in a range of 100-160mg/dl. Physician A said that he was not asked to clarify at anytime parameters for Resident #1's blood sugar levels. Attempted phone interviews with LVN A were made on 09/18, 19 and 20th, 2017 with LVN A regarding Resident #1's care. The Administrator informed the surveyor on 09/19/17 that LVN A had been terminated. Record review of Resident #1's laboratory values on 08/09/17 that Physician A had ordered revealed: Comprehensive Metabolic Panel BUN (Blood Urea Nitrogen) High at 33 (reference range 8-25) NT-proBNP high at 7,660.0; normal reference range <450.0. According to the U.S. National Library of Medicine, A metabolic panel is a group of tests that measures different chemicals in the blood. These tests are usually done on the fluid (plasma) part of blood. The tests provide information about your body's chemical balance and metabolism. They can give doctors information about your muscles (including the heart), bones, and organs, such as the kidneys and liver. There are two types: basic metabolic panel (BMP) and comprehensive metabolic panel (CMP). The BMP checks your blood sugar, calcium, and electrolytes. The BMP also has tests such as creatinine to check your kidney function. The CMP includes all of those tests, as well as tests of your cholesterol, protein levels, and liver function. Accessed on 10/03/17. https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=CMP According to the Mayo Clinic, A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys and liver are working. A BUN test measures the amount of urea nitrogen that's in your blood. Accessed on 10/03/17. http://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/home/ovc- 239 According to the Mayo Clink, B-type natriuretic peptide (brain natriuretic peptide: BNP) is a small, ringed peptide secreted by the heart to regulate blood pressure and fluid balance . Studies have demonstrated that the measured concentrations of circulating BNP and NT-proBNP increase with the severity of [MEDICAL CONDITION] based on the NYHA classification. Accessed on 10/03/17 https://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/ Record review of Telephone Order signed by Physician B dated 08/23/17 revealed CMP (complete metabolic profile) . Record review of Resident #1's laboratory values dated 08/24/17 revealed the following abnormal results: .BUN 47 (Reference Range 8-25) .BUN/Creatinine Ratio 50.00 (H) (normal reference range 6-25) Record review of Physician A's signed Physician order [REDACTED].#1, did not reveal blood sugar level parameters to give specific orders as to when to notify the physician for low or high blood sugar levels and blood sugar level checks were not initiated until 08/09/17. Record review of Physician B's signed Telephone Order dated 08/11/17 revealed the following: Transfer services to (Physician B) from (Physician A) per family request. Signed Physician B and written by RN A. Record review of Resident #1's physician progress notes [REDACTED]. History of [MEDICAL CONDITION] Fibrillation, Hypertension, [MEDICAL CONDITION] and Diabetes Mellitus Type II .Lungs: Coarse Bilaterally CV (Cardiovascular) Irregular Extremities: Left Leg 2 plus [MEDICAL CONDITION] .Plan: Continue Current Care, Needs Incentive Spirometer to bedside, expect her to attain independent status in 2-4 weeks. Signed Physician B. Record review of Resident #1's physician progress notes [REDACTED]. status [REDACTED]. Signed Physician Assistant B [MEDICAL CONDITION] Clinic. Record review of Resident #1's Physicians Progress Notes dated 08/24/17 from the [MEDICAL CONDITION] Clinic revealed the following: Weight down 5 pounds, legs still swollen, crackles in both lungs .I am going to continue her on [MEDICATION NAME] 40mg twice a day since she is still swollen in her legs. Follow up [MEDICAL CONDITION] clinic 08/31/17. Signed Physician Assistant B. Record review of Physician Assistant B's signed Telephone Order dated 08/24/17 revealed the following: [MEDICATION NAME] 40mg by mouth twice a day, follow up at [MEDICAL CONDITION] Clinic Thursday August 31st at 9:30 AM. Signed by Physician A and RN A. Record review of the Med Aid/Nurse MAR for August 2017 revealed an order that started on 08/24/17; it revealed: Description: [MEDICATION NAME] 40mg PO twice daily (8:00 AM and 2:00 PM) dated 08/24/17 Follow up with [MEDICAL CONDITION] clinic on 08/31/17 Unsigned. Review of 8/24/17 revealed Resident #1 did not receive her two o'clock dose of [MEDICATION NAME] 40mg. The box was blank. In addition the box was blank (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 5 (Residents #1, #10, #11, #13, and #15) of 15 residents reviewed for pharmacy services. A. LVN A failed to transcribe an order for [REDACTED].#1 received Lasix 40mg once a day rather than twice a day as ordered for a period of 7 days. In addition, after the order was corrected on the MAR to twice a day, Resident #1 still did not receive her Lasix on 8/15/17 and 8/16/17. Resident #1 was found on 8/26/17 to have elevated vital signs and asked LVN A to have her sent to the emergency room where Resident #1 subsequently had an 11 day hospitalization due to pulmonary edema and other complications related to an exacerbation of her congestive heart failure. B. Medication Aide A transcribed onto Resident #1's MAR an additional order for Lasix 40mg by mouth twice day which was outside the scope of practice for a medication aide. Medication Aide A also initialed on the MAR that she administered medication to Resident #1 on days when she did not work. C. The facility failed to ensure Resident #11 received Enoxaparin 40mg Injections following admission from 09/14/17 through 09/26/17. D. On 9/26/17, RN A failed to ensure Resident #13 took her 8:00 AM medications and placed them on Resident #13's bedside table and left the room, subsequently Resident #13 awoke and had increased anxiety and shortness of breath and was upset that her medications had just been left at her bedside table. In addition, LVN H was found to have placed the medications in the administration cup and initialed the MAR and then handed off the medications to RN A to administer to Resident #13; during identification of the medications Prednisone 20mg was noted to be missing in the cup. RN A crushed Resident #13's Potassium 20MEQ XR and placed in applesauce. E. The facility failed to ensure Resident #15's orders for Aspirin and Clonidine (blood pressure medication) were transcribed correctly onto her MAR. Resident #15 was admitted to the facility with an order to receive Aspirin and Clonidine every other day, but from 09/08/17 until 09/27/17 she received both medications daily. The facility also failed to ensure there were parameters in place to direct staff administering medication on when to hold the Clonidine, which resulted in Resident #15 receiving Clonidine when her blood pressure was low. F. The facility failed to ensure Resident #10's Diltiazem 240mg was administered for six days after being readmitted to the facility on [DATE]. The facility also failed to ensure Resident #10's blood sugar was routinely monitored or that parameters were established as to when Resident #10's insulin should be held for 11 days after he was readmitted . This deficient practice resulted in an Immediate Jeopardy (IJ) on 09/21/17. While the IJ was removed on 10/01/17, the facility remained out of compliance at a level of Actual Harm at a pattern that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. This failure could place all 90 residents in the facility at risk of not receiving medications as ordered, the wrong medications being administered, and medications being administered at the incorrect dose and/or time, which could result in serious medical complications, decline in condition, and even death. The findings included: Resident #1 Review of Resident #1's closed record Facesheet dated 09/19/17 revealed she was a [AGE] year old female, who was admitted to the facility on [DATE] under Physician A's care from 7-26-17 through 8-12-17 and Physician B followed her care from 8-13-17 to 8-26-17 for the following Diagnoses: [REDACTED]. The facesheet also identified the following: Date of Discharge: 08/26/17 Time: 9:30 AM. Review of Resident #1's history and physical from Hospital A, dated 07/22/17, prior to her admission to the facility, performed by Physician A revealed the following: This is a very pleasant [AGE] year old female with a past history of [DIAGNOSES REDACTED]and chronic combined systolic and diastolic heart failure, who unfortunately suffered a fall earlier this evening.She has a history of combined diastolic and systolic heart failure. She just visited the CHF (Congestive Heart Failure) clinic yesterday where she was at her normal weight and did not require any additional Lasix Past Medical History: Chronic Atrial Fibrillation, currently anticoagulated with Coumadin, Chronic combined systolic and diastolic heart failure, Diabetes Mellitus, Plan: We will hold her diuretics at least preoperatively . Record review of Resident #1's Initial Assessment, dated 07/27/17 revealed swelling in her left leg and her lungs were clear. Signed RN A Review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE], revealed that she was admitted to the facility from an acute hospital, her Brief Interview for Mental Status (BIMS) revealed a score of 14, which indicated she was cognitively intact. Further review of the MDS showed Resident #1 had the following active [DIAGNOSES REDACTED]. Resident #1 had the following health conditions: Shortness of breath with exertion (e.g., walking, bathing, transferring) and Shortness of Breath when lying flat. Weight 148 pounds. The MDS did not indicate Resident #1 was on a diuretic. Special Treatments indicated Resident #1 received oxygen therapy while a resident in the facility. Review of Resident #1's Care Plan dated 08/03/17, revealed .I have a history of Hypertension .My B/P (blood pressure) will stay in their normal limits, will not have hyper/hypotension over the next 90 days Approaches: Monitor B/P, increased edema, dizziness, headache, chest pain, and report to MD .I am a Diabetic and I am at risk for : frequent infections .hyper/[DIAGNOSES REDACTED] Ways to control diabetes: Insulin, oral hypoglycemic and diet .Goal: Diabetic status will remain stable as evidenced by residents normal limits over the next 90 days Approaches: Give resident meds as ordered, monitor labs and report abnormals to MD . Review of Resident #1's care plan did not address Resident #1's [DIAGNOSES REDACTED]. According to the US National Library of Medicine, Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. The weakening of the heart's pumping ability causes: Blood and fluid to back up into the lungs; The buildup of fluid in the feet, ankles and legs - called edema; Tiredness and shortness of breath. Common causes of heart failure are coronary artery disease, high blood pressure and diabetes. Accessed on 09/24/17. https://medlineplus.gov/heartfailure.html According to the American Heart Association, Symptoms of heart failure are: Buildup of excess fluid in body tissues (edema) .swelling in the feet, ankles, legs or abdomen or weight gain. You may find that your shoes feel tight. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention in the tissues. Tiredness, fatigue .a tired feeling all the time and difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries or walking Increased heart rate .heart palpitations, which feel like your heart is racing or throbbing. Accessed on 09/24/17 http://www.heart.org/HEARTORG/Conditions/HeartFailure/WarningSignsforHeartFailure/Warning-Signs-of-Heart-Failure_UCM_ 5_Article.jsp#.Wcac7suWzIU Review of Resident #1's Physician order [REDACTED].); Aspirin Enteric Coated 81mg PO once a day; Losartan Potassium 25mg Give 1 Tab PO once a day; Digoxin 0.125mg tablet give one tablet PO every other day, Hold if Pulse <60; Coreg 6.25mg tablet, Give ½ Tablet PO BID (twice a day), Januvia 100mg Tablet Give 1 tab PO (by mouth) once a day, Metformin HCL 1,000 MG Tablet Give 1 Tab PO BID (twice a day) . Review of Resident #1's Physician order [REDACTED].#1. In an interview on 09/18/17 at 4:25 PM, the DON said that on 08/08/17, Family Member A and Family Member B complained during the care plan meeting about Resident #1's overall care at the facility and had multiple concerns, specifically when her congestive heart failure symptoms getting worse. The DON said that she explained to the family that she would go and assess Resident #1 immediately following the care plan meeting (08/08/17) and find out for them what was going on. The DON said that she assessed Resident #1 and it seemed as though she needed some labs, a chest x-ray and Physician A to assess her regarding her congestive heart failure, however the DON said that she did not document her assessment and could not recall what Resident #1's specific symptoms were but she knew she needed attention. She said that she spoke with Physician A and he came to the facility that day (8/8/17) to see the resident. The DON did recall looking at her chart and finding labs that were lacking follow up on, specifically a digoxin level, Thyroid Stimulating Hormone Level, PT/INR. The DON said that she had no knowledge of Resident #1's medical history until the family expressed concerns on 8/8/17. In an interview on 09/19/17 at 4:56 PM with Family Member A and Family Member B, they said that from the time of admission until their mother was discharged from the facility on 08/26/17 numerous care issues were addressed with facility staff, specifically Family Member A and Family Member B had expressed concern to the DON on 08/08/17 regarding Resident #1's care since being admitted to the facility, they both said that they had addressed concerns regarding heart failure and cardiac history from the beginning of her admission; specifically her diuretic medication Lasix and laboratory values for Coumadin, both family members said they would discuss her care with the nurses at the nurses station and it seemed like it just went right over their heads and they didn't have time to check on our mother (Resident #1). Specifically, Family Member B asked RN A directly after Resident #1 was admitted about her PT/INR laboratory monitoring and RN A said that there was an order to have it drawn. Family Member A and Family Member B both said that they entrusted the nurses to be clarifying and looking into their concerns. On 08/08/17, a care plan meeting was held and at that time the DON profusely apologized for how things had been going with our mother and at that time we felt that the DON would address our concerns. Family Member B was unaware that her mother had had her diuretic medication Lasix discontinued while in the hospital and it was not resumed after discharge. Family Member B said that she had informed the admissions coordinator and several nurses, which she identified as LVN A and RN A of her mother's cardiac history with anticoagulant therapy and diuretic medications. She said that after the issues were addressed on 8/8/17, their mother (Resident #1) continued to show signs and symptoms of heart failure, specifically shortness of breath and edema. Family Member B said that she had asked the nurses about lung sounds and if they had checked her mother and they indicated she was fine. Family Member B said that she inquired about her mother being on a diuretic and was told by LVN A oh yeah, she is now on Lasix. Family Member B said that after expressing concerns with Physician A's care to RN A, she was encouraged by RN A to change care to Physician B. On 08/13/17, she said that Physician B saw Resident #1. Family Member B said that her mother had in the past attended the congestive heart failure clinic and she took it upon herself to make her mother an appointment to have her evaluated there after visiting her mother on 08/14/17 and finding her with symptoms of edema and shortness of breath. She said that she was seen at the CHF clinic on 8/15/17 and received IntraVenous Lasix to pull the fluid off and was to return weekly for follow up care on 08/24/17. Family Member B said that on the morning of 8/26/17, she received a phone call from her mother (Resident #1), she said that Resident #1 sounded upset and frightened and explained that she had had a difficult night due to shortness of breath and had been hot. Family Member B said that Resident #1 said she had told staff but that they were not paying attention to her and asked her to come to the facility. Family Member B said that when she arrived at the facility, LVN A was at her mother's bedside taking her vitals and Resident #1 was noted to have elevated blood pressure, heart rate and was short of breath. Family Member B said at that time she asked LVN A, Do I need to call 911 or are you? Family Member B said that 911 was called by the facility and her mother went to the emergency room and subsequently had an 11 day hospital stay due to her congestive heart failure. Family Member A said that she had received a phone call from the DON on 09/15/17 to inform her that while a resident at the facility there had been several medication errors identified with her mother's (Resident #1's) Lasix medication. Overall, Family Member A and Family Member B expressed concerns that Resident #1 from admission did not receive adequate care and treatment from the facility and subsequently had to endure an 11 day hospital stay for gross negligence of Resident #1's signs and symptoms of heart failure. Review of Physician A's Progress Notes dated 8/8/17 revealed the following: 8/8/17 Patient has been here x 2 weeks. She was admitted to (Hospital A) on 7/22/17 from (assisted living facility) after she fell and fractured her left hip. She is status [REDACTED]. She has not done well since admission. 1. Pain in hip affecting her sleep 2. She's getting very edematous in legs, gained 15 pounds in the last two weeks .PMH (past medical history) Diabetes Mellitus Type II, Bilateral Total Knee Arthroplasty, Atrial Fibrillation, PPM (Permanent PaceMaker), .Lungs: Clear no wheezes; Cardiac: [DIAGNOSES REDACTED]Slow 80bpm (beats per minute) Legs: + (positive) pitting .1. Debility: need to get her up or she will deteriorate PT/OT (Physical Therapy/Occupational Therapy) to work with her. 2. DM2 (Diabetes Mellitus Type 2) Accucheck fasting and HS (at bedtime), goal 100-160, meds reviewed .4.Edema Legs: Lasix to resume 40mg BID (twice a day) .7. Hypertension 140/90 Goal 8. Get her out of bed!!!! Signed Physician A. (There were no parameters on when to notify the physician regarding low or high blood sugar levels.) According to the U.S. National Library of Medicine, Edema is described as pitting or non-pitting. Pitting edema leaves a dent in the skin after you press the area with a finger for about 5 seconds. The dent will slowly fill back in. Non-pitting edema does not leave this type of dent when pressing on the swollen area. Accessed on 09/23/17 https://medlineplus.gov/ency/article/ 3.htm Record review of Physician A's signed Telephone Order dated 8/8/17 revealed the following orders: Lasix 40mg one PO (by mouth) BID x 2 weeks then down to Lasix 20mg QD (once daily) .Accucheck AM fasting BS (blood sugar) and nighttime blood sugar. Signed Physician A. (There were no parameters on when to notify the physician regarding low or high blood sugar levels.) Record review of both the Med Aide Medication Administration Record and Nurse Medication Administration Record (MAR) for August 2017 revealed the following: Med Aide MAR: Description: 8/8/17 Lasix 40mg PO QD (once a day) for 2 weeks then 20 QD; Administration time 8:00 AM Unsigned. Review of the administration record revealed Resident #1 received Lasix 40mg only once a day from 08/08/17 through 8/14/17 (7 days total). Another handwritten entry was found on 08/15/17 that revealed: Lasix 40mg PO BID; Administration time 8:00 AM and 6:00 PM for 2 wks then 20mg QD. 8/8/17 Signed LVN A. The MAR revealed Resident #1 still continued to only receive Lasix 40mg once a day on 08/15/17 and 08/16/17 (even when the order had been corrected to BID), there were not initials indicated for the 6:00 PM dose on either 8/15/17 or 08/16/17 to indicate Resident #1 received her Lasix 40mg. In an interview on 09/15/17 at 4:40 PM, LVN A said that she had received the written telephone order from Physician A on 08/08/17 to order Lasix 40mg PO BID for two weeks then 20mg PO QD. During this interview, LVN A reviewed the August MAR for Resident #1 and verified her handwriting for the entry of 8/8/17 Lasix 40mg PO QD (once a day) for 2 weeks then 20 QD. She said that the order was incorrect and that she had transcribed the order incorrectly, it should have been BID. In an interview on 09/18/17 at 3:18 PM, Med Aide B said that she worked on 08/15/17 and 08/16/17 but did not recall if she administered Resident #1's 6:00 PM dose of Lasix 40mg. She said that she could have possibly just forgot to initial the MAR but could not say for sure. She did not recall any issues with Resident #1's Lasix order and thought she had received it correctly. In an interview on 09/18/17 at 3:30 PM, RN A said that she did not recall administering Resident #1's Lasix on 08/15/17 or 08/16/17, however it had been a while since that date and she just couldn't recall for certain. Record review of Physician A's signed Telephone Order dated 8/10/17 revealed the following: Lasix 40mg PO BID x 10 days. Renal Panel on 08/17/17 . Signed Physician A. Record review of the Med Aid/Nurse Mar for August 2017 revealed the following handwritten entries: Description: Lasix 40mg PO BID x 10days ordered 8/10/17 Unsigned. The MAR revealed that Resident #1 received Lasix 40mg BID by Med Aide A for the following dates: August 10, 11, 15, 16th 2017. The MAR for Lasix 40mg BID on August 12, 13, 14, 17, 18, and 19th 2017 did not reveal any initials on these dates, which would have indicated Resident #1 received the Lasix 40mg BID. On 8/22/17, Resident #1 began receiving Lasix 20mg QD. Review of the initialed boxes for August 22, 23,24 and 25th revealed Resident #1 had received Lasix 20mg QD. There was handwritten documentation on this specific entry of Lasix 20mg to have changed on 8/24/17. In an interview and record review on 9/18/17 at 3:45 PM, Med Aid A said she had handwritten the entry onto the August MAR for Resident #1's Lasix order on 08/10/17. She verified she hand wrote Description: Lasix 40mg PO BID x 10days ordered 8/10/17. Med Aide A said that no one had instructed her to transcribe the order onto the MAR , and that it was not in her scope of practice to transcribe orders onto the MAR. She said I just did it myself, I know that (transcribing orders) was out of my scope of practice. At this time, Med Aide A was asked to review Resident #1's August MAR. Med Aide A verified that it was her initials and handwriting on 08/10, 11, 15 and 16th 2017 of the August MAR. She said she would not have initialed the MAR if she had not administered the medication. At this time, Med Aid A was given her time card report for August 10, 11, 15 and 16th 2017 and said it looks correct. Med Aid A said she was not sure now why her initials were documented on those dates for Resident #1's Lasix 40mg to have been administered if she was not clocked in and was unsure why her initials were not on the dates that she had worked. She said she did not know and could not remember now. Record review of Med Aid A's Time Card Report revealed Med Aid A did not work on August 10, 11, 15 and 16th, 2017 but did work on August 12, 13, 14, 17, and 18th, 2017. Med Aid A said she recalled Resident #1 and that she never refused her medications and was good about taking them. She said that during the time Resident #1 was a resident at the facility she did notice swelling in her feet. She said that she had informed the nurses regarding the swelling but could not recall exactly who and what dates. She said Resident #1 was short of breath when she exerted herself and mostly wanted to stay in bed. In an interview and record review on 09/18/17 at 3:18 PM, Med Aide B said that she remembered the family, specifically the daughters of Resident #1 constantly asking the nurses questions regarding Resident #1's care. She said that she did not ever check for edema on Resident #1 and said that the nurse's usually are the ones to assess for edema. During the interview Med Aide B was given her time card report to review and indicated that she had worked on August 10th, 11th and 15th, 2017. During the interview, Med Aide B was given page 5 of the August MAR to review that had the entries for Lasix 40mg BID and stated None of the open boxes on the MAR with the Lasix ordered twice per day are days that I worked, she said the days she worked had (Med Aide A's) initials in the boxes. Med Aide B said she did not recall this page of the MAR, I have not initialed it nor signed it. Record review of Med Aide B's Time Card Report revealed Med Aid B was clocked in and worked a full shift on August 10, 11, and 15th, 2017. Med Aid B was not clocked in for dates August 12, 13, 14, 16, 17, 18 or 19th, 2017. In an interview on 09/19/17 at 8:08 AM, Physician A said that he recalled seeing Resident #1 a couple of times. He said that he was contacted by the DON, unsure of date, and was asked to come and see Resident #1. He said that he had followed her in the hospital but had not been contacted by the nursing facility when she was admitted on [DATE]. He said that he was aware of her history of CHF and when he went to see her he felt that her CHF was exacerbated and she was noted to be short of breath, swollen and had some weight gain. He said he ordered labs at that time and wrote an order for [REDACTED]. Attempted phone interviews with LVN A were made on 09/18, 19 and 20th, 2017 with LVN A regarding Resident #1's care. The Administrator informed the surveyor on 09/19/17 that LVN A had been terminated. Record review of Resident #1's laboratory values on 08/09/17 that Physician A had ordered revealed: Comprehensive Metabolic Panel BUN (Blood Urea Nitrogen) High at 33 (reference range 8-25) NT-proBNP high at 7,660.0; normal reference range <450.0. According to the U.S. National Library of Medicine, A metabolic panel is a group of tests that measures different chemicals in the blood. These tests are usually done on the fluid (plasma) part of blood. The tests provide information about your body's chemical balance and metabolism. They can give doctors information about your muscles (including the heart), bones, and organs, such as the kidneys and liver. There are two types: basic metabolic panel (BMP) and comprehensive metabolic panel (CMP). The BMP checks your blood sugar, calcium, and electrolytes. The BMP also has tests such as creatinine to check your kidney function. The CMP includes all of those tests, as well as tests of your cholesterol, protein levels, and liver function. Accessed on 10/03/17. https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=CMP According to the Mayo Clinic, A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys and liver are working. A BUN test measures the amount of urea nitrogen that's in your blood. Accessed on 10/03/17. http://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/home/ovc- 239 According to the Mayo Clink, B-type natriuretic peptide (brain natriuretic peptide: BNP) is a small, ringed peptide secreted by the heart to regulate blood pressure and fluid balance . Studies have demonstrated that the measured concentrations of circulating BNP and NT-proBNP increase with the severity of CHF based on the NYHA classification. Accessed on 10/03/17 https://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/ Record review of Telephone Order signed by Physician B dated 08/23/17 revealed CMP (complete metabolic profile) . Record review of Resident #1's laboratory values dated 08/24/17 revealed the following abnormal results: .BUN 47 (Reference Range 8-25) .BUN/Creatinine Ratio 50.00 (H) (normal reference range 6-25) Record review of Physician B's signed Telephone Order dated 08/11/17 revealed the following: Transfer services to (Physician B) from (Physician A) per family request. Signed Physician B and written by RN A. Record review of Resident #1's physician progress notes [REDACTED]. History of Atrial Fibrillation, Hypertension, [DIAGNOSES REDACTED] and Diabetes Mellitus Type II .Lungs: Coarse Bilaterally CV (Cardiovascular) Irregular Extremities: Left Leg 2 plus edema .Plan: Continue Current Care, Needs Incentive Spirometer to bedside, expect her to attain independent status in 2-4 weeks. Signed Physician B. Record review of Resident #1's physician progress notes [REDACTED]. status [REDACTED]. Signed Physician Assistant B CHF Clinic. Record review of Resident #1's Physicians Progress Notes dated 08/24/17 from the CHF Clinic revealed the following: Weight down 5 pounds, legs still swollen, crackles in both lungs .I am going to continue her on Lasix 40mg twice a day since she is still swollen in her legs. Follow up CHF clinic 08/31/17. Signed Physician Assistant B. Record review of Physician Assistant B's signed Telephone Order dated 08/24/17 revealed the following: Lasix 40mg by mouth twice a day, follow up at CHF Clinic Thursday August 31st at 9:30 AM. Signed by Physician A and RN A. Record review of the Med Aid/Nurse MAR for August 2017 revealed an order that started on 08/24/17; it revealed: Description: Lasix 40mg PO twice daily (8:00 AM and 2:00 PM) dated 08/24/17 Follow up with CHF clinic on 08/31/17 Unsigned. Review of 8/24/17 revealed Resident #1 did not receive her two o'clock dose of Lasix 40mg. The box was blank. In addition the box was blank for the two o'clock dose of Lasix 40mg on 08/25/17 as well. In an interview on 09/18/17 at 3:18 PM, Med Aid B said that she was working on 8/24/17 and 08/25/17. She said that she did not initial the MAR for Resident #1's 2 o'clock Lasix 40mg administration. She said that she was at lunch during that time and that RN A would have been the one to have administered it. She said she always tells her nurse prior to clocking out for lunch if there are medications that need to be administered while she is away at lunch. In an interview on 09/18/17 at 3:30, RN A said that Med Aide B had never asked her to administer Resident #1's Lasix 40mg at 2 o'clock in the afternoon while she was at lunch. RN A said that Med Aid B very rarely ever asks her to pass any medications while she on her lunch break. In an interview on 09/19/17 at 6:28 PM, PT A said she had worked numerous times with Resident #1 during her stay at the facility from 07/26/17-8/26/17. PT A said that Resident #1 was very weak and she fatigued very easily during her therapy sessions. She said that throughout the course of her therapy Resident #1 had problems with swelling in both legs and she recalled that she had a lot of pain in her hip. She said that from a therapy standpoint Resident #1's weakness, pain and overall progress was limited to what she was able to do therapy wise. She said that she would work a little and then have to rest a little. She said that Resident #1 was very tired most of the time. She did recall initially she was in the bed quite a bit and recalled Resident #1 having cough and was not sure when that was. She said she did not recall talking to the nurses about her cough but did discuss the swelling but PT A could not recall who the nurse was that she told. PT A said that there was mention from Resident #1 that she had received IV Lasix from the CHF clinic at one point but could not remember the date. She said that during her care plan meeting she did remember the family being present and that concerns were discussed regarding Resident #1's swelling in her legs and the family wanted to ensure her legs were elevated. Record review of CHF Clinic records from 08/15/17 and 08/24/17 revealed the following: Visit Comment: 08/15/17, Weight 145 pounds, Lungs: Right Lower Lung Crackles, Left Lower Lung Diminished , 2+ pitting edema bilaterally, Patient here with her family from (Facility), She had left hip fracture and surgical repair. She was discharged to (Facility) but her diuretics were not given to her for several weeks and she had a 20 pound weight gain, SOB and leg edema before the family discovered that she was not getting her diuretics. (Physician B) restarted her Lasix at 40mg BID for 2 weeks then decrease to 20mg daily on 08/22/17. She has lost about 10 pounds since restarting Lasix but she is still having SOB and lower leg edema.She was given intravenous Lasix 80mg for continued heart failure symptoms. She is slowly improving. I will continue her on her current medication schedule and follow her up next week. Signed Physician Assistant B. 08/24/17 Weight 140.8 pounds, Lungs: Right Lower Lung Crackles, Left Lower Lung Crackles; 2+ pitting edema bilaterally, Patient here with her two daughters. Her weight is down 4.6 pounds from last week but she still has significant swelling of her legs. No resting shortness of breath but she does have dyspnea on exertion. She has orders to decrease her oral Lasix to 20mg daily starting today. She was given intravenous Lasix 80mg for continued heart failure symptoms. I will continue her for now on Lasix 40mg BID since she is still symptomatic. Follow up here next week. Signed Physician Assistant B. In an interview on 09/20/17 at 4:00 PM, LVN B said that medication aides are not supposed to transcribe orders. She said she does not have medication aides transcribe her orders. LVN B said if there were a bunch of holes on the MAR then she considers it not done. LVN B said that since she has been working at the facility (almost a year) new orders that are transcribed onto the MAR are supposed to be checked with their counterpart nurse to make sure the orders have been transcribed correctly, and did say that with new admissions, it did not always happen. In an interview on 09/20/17 at 3:40 PM, Physician B said that he had taken over Resident #1's care around mid-August. He said that he had no knowledge of her history of congestive heart failure or that she frequented the CHF clinic. He said that he was not contacted on 08/26/17 when her blood pressure and pulse was elevated and she was sent to the emergency room . In an interview on 09/18/17 at 4:25 PM and on 09/21/17 at 12:49 PM, the DON said she was here during Resident #1's admission. She could not recall who reviewed her admission records prior to her admitting to the facility. She said she had a poor recollection of Resident #1's [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to ensure that residents are free from significant medication errors for two (Resident #1and #11) of 15 residents reviewed for significant medication errors. A. LVN A transcribed an order for [REDACTED].#1 received [MEDICATION NAME] 40mg once a day rather than twice a day as ordered for a period of 7 days, in addition, after the order was corrected on the MAR to twice a day, there still continued to be missed doses reflected on the MAR for the following dates: 8/15/17 and 8/16/17. Med Aide A transcribed an additional order for [MEDICATION NAME] 40mg by mouth twice day onto the MAR and conflicting initials and time cards were revealed that did not justify Med Aide A's initials to have administered the medication when she was not clocked in. Resident #1 was found on 8/26/17 to have elevated vital signs and asked LVN A to have her sent to the emergency room where Resident #1 subsequently had an 11 day hospitalization due to [MEDICAL CONDITIONS] and other complications related to an exacerbation of her [MEDICAL CONDITION]. B. Ensure Resident #11 received [MEDICATION NAME] 40mg Injections following admission from 09/14/17 through 09/26/17. This deficient practice resulted in an Immediate Jeopardy (IJ) on 09/21/17. While the IJ was removed on 10/01/17, the facility remained out of compliance at a level of Actual Harm at a pattern that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. This failure could place twenty (20) Residents that received [MEDICATION NAME] and one (1) resident that received [MEDICATION NAME] who resided in the facility at risk for the potential for medications being omitted from administration, administration of wrong medication; wrong frequency, dosage or timing of medications; and/or serious complications and /or death. The findings included: Resident #1 Review of Resident #1's closed record Facesheet dated 09/19/17 revealed she was a [AGE] year old female, who was admitted to the facility on [DATE] under Physician A's care from 7-26-17 through 8-12-17 and Physician B followed her care from 8-13-17 to 8-26-17 for the following Diagnoses: [REDACTED]. The facesheet also identified the following: Date of Discharge: 08/26/17 Time: 9:30 AM. Review of Resident #1's history and physical from Hospital A, dated 07/22/17, prior to her admission to the facility, performed by Physician A revealed the following: This is a very pleasant [AGE] year old female with a past history of [MEDICAL CONDITION] and chronic combined systolic and diastolic heart failure, who unfortunately suffered a fall earlier this evening.She has a history of combined diastolic and systolic heart failure. She just visited the [MEDICAL CONDITIONS] clinic yesterday where she was at her normal weight and did not require any additional [MEDICATION NAME] Past Medical History: Chronic [MEDICAL CONDITION] Fibrillation, currently anticoagulated with [MEDICATION NAME], Chronic combined systolic and diastolic heart failure, Diabetes Mellitus, Plan: We will hold her diuretics at least preoperatively . Record review of Resident #1's Initial Assessment, dated 07/27/17 revealed swelling in her left leg and her lungs were clear. Signed RN A Review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE], revealed that she was admitted to the facility from an acute hospital, her Brief Interview for Mental Status (BIMS) revealed a score of 14, which indicated she was cognitively intact. Further review of the MDS showed Resident #1 had the following active [DIAGNOSES REDACTED]. Resident #1 had the following health conditions: Shortness of breath with exertion (e.g., walking, bathing, transferring) and Shortness of Breath when lying flat. Weight 148 pounds. The MDS did not indicate Resident #1 was on a diuretic. Special Treatments indicated Resident #1 received oxygen therapy while a resident in the facility. Review of Resident #1's Care Plan dated 08/03/17, revealed .I have a history of Hypertension .My B/P (blood pressure) will stay in their normal limits, will not have hyper/[MEDICAL CONDITION] over the next 90 days Approaches: Monitor B/P, increased [MEDICAL CONDITION], dizziness, headache, chest pain, and report to MD .I am a Diabetic and I am at risk for : frequent infections .hyper/[DIAGNOSES REDACTED] Ways to control diabetes: Insulin, oral hypoglycemic and diet .Goal: Diabetic status will remain stable as evidenced by residents normal limits over the next 90 days Approaches: Give resident meds as ordered, monitor labs and report abnormals to MD . Review of Resident #1's care plan did not address Resident #1's [DIAGNOSES REDACTED]. According to the US National Library of Medicine, Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. The weakening of the heart's pumping ability causes: Blood and fluid to back up into the lungs; The buildup of fluid in the feet, ankles and legs - called [MEDICAL CONDITION]; Tiredness and shortness of breath. Common causes of heart failure are [MEDICAL CONDITION], high blood pressure and diabetes. Accessed on 09/24/17. https://medlineplus.gov/heartfailure.html According to the American Heart Association, Symptoms of heart failure are: Buildup of excess fluid in body tissues ([MEDICAL CONDITION]) .swelling in the feet, ankles, legs or abdomen or weight gain. You may find that your shoes feel tight. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention in the tissues. Tiredness, fatigue .a tired feeling all the time and difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries or walking Increased heart rate .heart palpitations, which feel like your heart is racing or throbbing. Accessed on 09/24/17 http://www.heart.org/HEARTORG/Conditions/HeartFailure/WarningSignsforHeartFailure/Warning-Signs-of-Heart-Failure_UCM_ 5_Article.jsp#.Wcac7suWzIU Review of Resident #1's Physician order [REDACTED].); Aspirin [MEDICATION NAME] Coated 81mg PO once a day; Losartan Potassium 25mg Give 1 Tab PO once a day; [MEDICATION NAME] 0.125mg tablet give one tablet PO every other day, Hold if Pulse <60; [MEDICATION NAME] 6.25mg tablet, Give ½ Tablet PO BID (twice a day), [MEDICATION NAME] 100mg Tablet Give 1 tab PO (by mouth) once a day, [MEDICATION NAME] HCL 1,000 MG Tablet Give 1 Tab PO BID (twice a day) . Review of Resident #1's Physician order [REDACTED].#1. In an interview on 09/18/17 at 4:25 PM, the DON said that on 08/08/17, Family Member A and Family Member B complained during the care plan meeting about Resident #1's overall care at the facility and had multiple concerns, specifically when her [MEDICAL CONDITION] symptoms getting worse. The DON said that she explained to the family that she would go and assess Resident #1 immediately following the care plan meeting (08/08/17) and find out for them what was going on. The DON said that she assessed Resident #1 and it seemed as though she needed some labs, a chest x-ray and Physician A to assess her regarding her [MEDICAL CONDITION], however the DON said that she did not document her assessment and could not recall what Resident #1's specific symptoms were but she knew she needed attention. She said that she spoke with Physician A and he came to the facility that day (8/8/17) to see the resident. The DON did recall looking at her chart and finding labs that were lacking follow up on, specifically a [MEDICATION NAME] level, [MEDICAL CONDITION] Stimulating Hormone Level, PT/INR. The DON said that she had no knowledge of Resident #1's medical history until the family expressed concerns on 8/8/17. In an interview on 09/19/17 at 4:56 PM with Family Member A and Family Member B, they said that from the time of admission until their mother was discharged from the facility on 08/26/17 numerous care issues were addressed with facility staff, specifically Family Member A and Family Member B had expressed concern to the DON on 08/08/17 regarding Resident #1's care since being admitted to the facility, they both said that they had addressed concerns regarding heart failure and cardiac history from the beginning of her admission; specifically her diuretic medication [MEDICATION NAME] and laboratory values for [MEDICATION NAME], both family members said they would discuss her care with the nurses at the nurses station and it seemed like it just went right over their heads and they didn't have time to check on our mother (Resident #1). Specifically, Family Member B asked RN A directly after Resident #1 was admitted about her PT/INR laboratory monitoring and RN A said that there was an order to have it drawn. Family Member A and Family Member B both said that they entrusted the nurses to be clarifying and looking into their concerns. On 08/08/17, a care plan meeting was held and at that time the DON profusely apologized for how things had been going with our mother and at that time we felt that the DON would address our concerns. Family Member B was unaware that her mother had had her diuretic medication [MEDICATION NAME] discontinued while in the hospital and it was not resumed after discharge. Family Member B said that she had informed the admissions coordinator and several nurses, which she identified as LVN A and RN A of her mother's cardiac history with anticoagulant therapy and diuretic medications. She said that after the issues were addressed on 8/8/17, their mother (Resident #1) continued to show signs and symptoms of heart failure, specifically shortness of breath and [MEDICAL CONDITION]. Family Member B said that she had asked the nurses about lung sounds and if they had checked her mother and they indicated she was fine. Family Member B said that she inquired about her mother being on a diuretic and was told by LVN A oh yeah, she is now on [MEDICATION NAME]. Family Member B said that after expressing concerns with Physician A's care to RN A, she was encouraged by RN A to change care to Physician B. On 08/13/17, she said that Physician B saw Resident #1. Family Member B said that her mother had in the past attended the [MEDICAL CONDITION] clinic and she took it upon herself to make her mother an appointment to have her evaluated there after visiting her mother on 08/14/17 and finding her with symptoms of [MEDICAL CONDITION] and shortness of breath. She said that she was seen at the [MEDICAL CONDITION] clinic on 8/15/17 and received IntraVenous [MEDICATION NAME] to pull the fluid off and was to return weekly for follow up care on 08/24/17. Family Member B said that on the morning of 8/26/17, she received a phone call from her mother (Resident #1), she said that Resident #1 sounded upset and frightened and explained that she had had a difficult night due to shortness of breath and had been hot. Family Member B said that Resident #1 said she had told staff but that they were not paying attention to her and asked her to come to the facility. Family Member B said that when she arrived at the facility, LVN A was at her mother's bedside taking her vitals and Resident #1 was noted to have elevated blood pressure, heart rate and was short of breath. Family Member B said at that time she asked LVN A, Do I need to call 911 or are you? Family Member B said that 911 was called by the facility and her mother went to the emergency room and subsequently had an 11 day hospital stay due to her [MEDICAL CONDITION]. Family Member A said that she had received a phone call from the DON on 09/15/17 to inform her that while a resident at the facility there had been several medication errors identified with her mother's (Resident #1's) [MEDICATION NAME] medication. Overall, Family Member A and Family Member B expressed concerns that Resident #1 from admission did not receive adequate care and treatment from the facility and subsequently had to endure an 11 day hospital stay for gross negligence of Resident #1's signs and symptoms of heart failure. Review of Physician A's Progress Notes dated 8/8/17 revealed the following: 8/8/17 Patient has been here x 2 weeks. She was admitted to (Hospital A) on 7/22/17 from (assisted living facility) after she fell and fractured her left hip. She is status [REDACTED]. She has not done well since admission. 1. Pain in hip affecting her sleep 2. She's getting very [MEDICAL CONDITION] in legs, gained 15 pounds in the last two weeks .PMH (past medical history) Diabetes Mellitus Type II, Bilateral Total Knee Arthroplasty, [MEDICAL CONDITION] Fibrillation, PPM (Permanent PaceMaker), .Lungs: Clear no wheezes; Cardiac: [MEDICAL CONDITION] Fibrillation Slow 80bpm (beats per minute) Legs: + (positive) pitting .1. Debility: need to get her up or she will deteriorate PT/OT (Physical Therapy/Occupational Therapy) to work with her. 2. DM2 (Diabetes Mellitus Type 2) Accucheck fasting and HS (at bedtime), goal 100-160, meds reviewed .4.[MEDICAL CONDITION] Legs: [MEDICATION NAME] to resume 40mg BID (twice a day) .7. Hypertension 140/90 Goal 8. Get her out of bed!!!! Signed Physician A. (There were no parameters on when to notify the physician regarding low or high blood sugar levels.) According to the U.S. National Library of Medicine, [MEDICAL CONDITION] is described as pitting or non-pitting. Pitting [MEDICAL CONDITION] leaves a dent in the skin after you press the area with a finger for about 5 seconds. The dent will slowly fill back in. Non-[MEDICAL CONDITION] does not leave this type of dent when pressing on the swollen area. Accessed on 09/23/17 https://medlineplus.gov/ency/article/ 3.htm Record review of Physician A's signed Telephone Order dated 8/8/17 revealed the following orders: [MEDICATION NAME] 40mg one PO (by mouth) BID x 2 weeks then down to [MEDICATION NAME] 20mg QD (once daily) .Accucheck AM fasting BS (blood sugar) and nighttime blood sugar. Signed Physician A. (There were no parameters on when to notify the physician regarding low or high blood sugar levels.) Record review of both the Med Aide Medication Administration Record and Nurse Medication Administration Record (MAR) for August 2017 revealed the following: Med Aide MAR: Description: 8/8/17 [MEDICATION NAME] 40mg PO QD (once a day) for 2 weeks then 20 QD; Administration time 8:00 AM Unsigned. Review of the administration record revealed Resident #1 received [MEDICATION NAME] 40mg only once a day from 08/08/17 through 8/14/17 (7 days total). Another handwritten entry was found on 08/15/17 that revealed: [MEDICATION NAME] 40mg PO BID; Administration time 8:00 AM and 6:00 PM for 2 wks then 20mg QD. 8/8/17 Signed LVN A. The MAR revealed Resident #1 still continued to only receive [MEDICATION NAME] 40mg once a day on 08/15/17 and 08/16/17 (even when the order had been corrected to BID), there were not initials indicated for the 6:00 PM dose on either 8/15/17 or 08/16/17 to indicate Resident #1 received her [MEDICATION NAME] 40mg. In an interview on 09/15/17 at 4:40 PM, LVN A said that she had received the written telephone order from Physician A on 08/08/17 to order [MEDICATION NAME] 40mg PO BID for two weeks then 20mg PO QD. During this interview, LVN A reviewed the August MAR for Resident #1 and verified her handwriting for the entry of 8/8/17 [MEDICATION NAME] 40mg PO QD (once a day) for 2 weeks then 20 QD. She said that the order was incorrect and that she had transcribed the order incorrectly, it should have been BID. In an interview on 09/18/17 at 3:18 PM, Med Aide B said that she worked on 08/15/17 and 08/16/17 but did not recall if she administered Resident #1's 6:00 PM dose of [MEDICATION NAME] 40mg. She said that she could have possibly just forgot to initial the MAR but could not say for sure. She did not recall any issues with Resident #1's [MEDICATION NAME] order and thought she had received it correctly. In an interview on 09/18/17 at 3:30 PM, RN A said that she did not recall administering Resident #1's [MEDICATION NAME] on 08/15/17 or 08/16/17, however it had been a while since that date and she just couldn't recall for certain. Record review of Physician A's signed Telephone Order dated 8/10/17 revealed the following: [MEDICATION NAME] 40mg PO BID x 10 days. Renal Panel on 08/17/17 . Signed Physician A. Record review of the Med Aid/Nurse Mar for August 2017 revealed the following handwritten entries: Description: [MEDICATION NAME] 40mg PO BID x 10days ordered 8/10/17 Unsigned. The MAR revealed that Resident #1 received [MEDICATION NAME] 40mg BID by Med Aide A for the following dates: August 10, 11, 15, 16th 2017. The MAR for [MEDICATION NAME] 40mg BID on August 12, 13, 14, 17, 18, and 19th 2017 did not reveal any initials on these dates, which would have indicated Resident #1 received the [MEDICATION NAME] 40mg BID. On 8/22/17, Resident #1 began receiving [MEDICATION NAME] 20mg QD. Review of the initialed boxes for August 22, 23,24 and 25th revealed Resident #1 had received [MEDICATION NAME] 20mg QD. There was handwritten documentation on this specific entry of [MEDICATION NAME] 20mg to have changed on 8/24/17. In an interview and record review on 9/18/17 at 3:45 PM, Med Aid A said she had handwritten the entry onto the August MAR for Resident #1's [MEDICATION NAME] order on 08/10/17. She verified she hand wrote Description: [MEDICATION NAME] 40mg PO BID x 10days ordered 8/10/17. Med Aide A said that no one had instructed her to transcribe the order onto the MAR , and that it was not in her scope of practice to transcribe orders onto the MAR. She said I just did it myself, I know that (transcribing orders) was out of my scope of practice. At this time, Med Aide A was asked to review Resident #1's August MAR. Med Aide A verified that it was her initials and handwriting on 08/10, 11, 15 and 16th 2017 of the August MAR. She said she would not have initialed the MAR if she had not administered the medication. At this time, Med Aid A was given her time card report for August 10, 11, 15 and 16th 2017 and said it looks correct. Med Aid A said she was not sure now why her initials were documented on those dates for Resident #1's [MEDICATION NAME] 40mg to have been administered if she was not clocked in and was unsure why her initials were not on the dates that she had worked. She said she did not know and could not remember now. Record review of Med Aid A's Time Card Report revealed Med Aid A did not work on August 10, 11, 15 and 16th, 2017 but did work on August 12, 13, 14, 17, and 18th, 2017. Med Aid A said she recalled Resident #1 and that she never refused her medications and was good about taking them. She said that during the time Resident #1 was a resident at the facility she did notice swelling in her feet. She said that she had informed the nurses regarding the swelling but could not recall exactly who and what dates. She said Resident #1 was short of breath when she exerted herself and mostly wanted to stay in bed. In an interview and record review on 09/18/17 at 3:18 PM, Med Aide B said that she remembered the family, specifically the daughters of Resident #1 constantly asking the nurses questions regarding Resident #1's care. She said that she did not ever check for [MEDICAL CONDITION] on Resident #1 and said that the nurse's usually are the ones to assess for [MEDICAL CONDITION]. During the interview Med Aide B was given her time card report to review and indicated that she had worked on August 10th, 11th and 15th, 2017. During the interview, Med Aide B was given page 5 of the August MAR to review that had the entries for [MEDICATION NAME] 40mg BID and stated None of the open boxes on the MAR with the [MEDICATION NAME] ordered twice per day are days that I worked, she said the days she worked had (Med Aide A's) initials in the boxes. Med Aide B said she did not recall this page of the MAR, I have not initialed it nor signed it. Record review of Med Aide B's Time Card Report revealed Med Aid B was clocked in and worked a full shift on August 10, 11, and 15th, 2017. Med Aid B was not clocked in for dates August 12, 13, 14, 16, 17, 18 or 19th, 2017. In an interview on 09/19/17 at 8:08 AM, Physician A said that he recalled seeing Resident #1 a couple of times. He said that he was contacted by the DON, unsure of date, and was asked to come and see Resident #1. He said that he had followed her in the hospital but had not been contacted by the nursing facility when she was admitted on [DATE]. He said that he was aware of her history of [MEDICAL CONDITION] and when he went to see her he felt that her [MEDICAL CONDITION] was exacerbated and she was noted to be short of breath, swollen and had some weight gain. He said he ordered labs at that time and wrote an order for [REDACTED]. Attempted phone interviews with LVN A were made on 09/18, 19 and 20th, 2017 with LVN A regarding Resident #1's care. The Administrator informed the surveyor on 09/19/17 that LVN A had been terminated. Record review of Resident #1's laboratory values on 08/09/17 that Physician A had ordered revealed: Comprehensive Metabolic Panel BUN (Blood Urea Nitrogen) High at 33 (reference range 8-25) NT-proBNP high at 7,660.0; normal reference range <450.0. According to the U.S. National Library of Medicine, A metabolic panel is a group of tests that measures different chemicals in the blood. These tests are usually done on the fluid (plasma) part of blood. The tests provide information about your body's chemical balance and metabolism. They can give doctors information about your muscles (including the heart), bones, and organs, such as the kidneys and liver. There are two types: basic metabolic panel (BMP) and comprehensive metabolic panel (CMP). The BMP checks your blood sugar, calcium, and electrolytes. The BMP also has tests such as creatinine to check your kidney function. The CMP includes all of those tests, as well as tests of your cholesterol, protein levels, and liver function. Accessed on 10/03/17. https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=CMP According to the Mayo Clinic, A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys and liver are working. A BUN test measures the amount of urea nitrogen that's in your blood. Accessed on 10/03/17. http://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/home/ovc- 239 According to the Mayo Clink, B-type natriuretic peptide (brain natriuretic peptide: BNP) is a small, ringed peptide secreted by the heart to regulate blood pressure and fluid balance . Studies have demonstrated that the measured concentrations of circulating BNP and NT-proBNP increase with the severity of [MEDICAL CONDITION] based on the NYHA classification. Accessed on 10/03/17 https://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/ Record review of Telephone Order signed by Physician B dated 08/23/17 revealed CMP (complete metabolic profile) . Record review of Resident #1's laboratory values dated 08/24/17 revealed the following abnormal results: .BUN 47 (Reference Range 8-25) .BUN/Creatinine Ratio 50.00 (H) (normal reference range 6-25) Record review of Physician B's signed Telephone Order dated 08/11/17 revealed the following: Transfer services to (Physician B) from (Physician A) per family request. Signed Physician B and written by RN A. Record review of Resident #1's physician progress notes [REDACTED]. History of [MEDICAL CONDITION] Fibrillation, Hypertension, [MEDICAL CONDITION] and Diabetes Mellitus Type II .Lungs: Coarse Bilaterally CV (Cardiovascular) Irregular Extremities: Left Leg 2 plus [MEDICAL CONDITION] .Plan: Continue Current Care, Needs Incentive Spirometer to bedside, expect her to attain independent status in 2-4 weeks. Signed Physician B. Record review of Resident #1's physician progress notes [REDACTED]. status [REDACTED]. Signed Physician Assistant B [MEDICAL CONDITION] Clinic. Record review of Resident #1's Physicians Progress Notes dated 08/24/17 from the [MEDICAL CONDITION] Clinic revealed the following: Weight down 5 pounds, legs still swollen, crackles in both lungs .I am going to continue her on [MEDICATION NAME] 40mg twice a day since she is still swollen in her legs. Follow up [MEDICAL CONDITION] clinic 08/31/17. Signed Physician Assistant B. Record review of Physician Assistant B's signed Telephone Order dated 08/24/17 revealed the following: [MEDICATION NAME] 40mg by mouth twice a day, follow up at [MEDICAL CONDITION] Clinic Thursday August 31st at 9:30 AM. Signed by Physician A and RN A. Record review of the Med Aid/Nurse MAR for August 2017 revealed an order that started on 08/24/17; it revealed: Description: [MEDICATION NAME] 40mg PO twice daily (8:00 AM and 2:00 PM) dated 08/24/17 Follow up with [MEDICAL CONDITION] clinic on 08/31/17 Unsigned. Review of 8/24/17 revealed Resident #1 did not receive her two o'clock dose of [MEDICATION NAME] 40mg. The box was blank. In addition the box was blank for the two o'clock dose of [MEDICATION NAME] 40mg on 08/25/17 as well. In an interview on 09/18/17 at 3:18 PM, Med Aid B said that she was working on 8/24/17 and 08/25/17. She said that she did not initial the MAR for Resident #1's 2 o'clock [MEDICATION NAME] 40mg administration. She said that she was at lunch during that time and that RN A would have been the one to have administered it. She said she always tells her nurse prior to clocking out for lunch if there are medications that need to be administered while she is away at lunch. In an interview on 09/18/17 at 3:30, RN A said that Med Aide B had never asked her to administer Resident #1's [MEDICATION NAME] 40mg at 2 o'clock in the afternoon while she was at lunch. RN A said that Med Aid B very rarely ever asks her to pass any medications while she on her lunch break. In an interview on 09/19/17 at 6:28 PM, PT A said she had worked numerous times with Resident #1 during her stay at the facility from 07/26/17-8/26/17. PT A said that Resident #1 was very weak and she fatigued very easily during her therapy sessions. She said that throughout the course of her therapy Resident #1 had problems with swelling in both legs and she recalled that she had a lot of pain in her hip. She said that from a therapy standpoint Resident #1's weakness, pain and overall progress was limited to what she was able to do therapy wise. She said that she would work a little and then have to rest a little. She said that Resident #1 was very tired most of the time. She did recall initially she was in the bed quite a bit and recalled Resident #1 having cough and was not sure when that was. She said she did not recall talking to the nurses about her cough but did discuss the swelling but PT A could not recall who the nurse was that she told. PT A said that there was mention from Resident #1 that she had received IV [MEDICATION NAME] from the [MEDICAL CONDITION] clinic at one point but could not remember the date. She said that during her care plan meeting she did remember the family being present and that concerns were discussed regarding Resident #1's swelling in her legs and the family wanted to ensure her legs were elevated. Record review of [MEDICAL CONDITION] Clinic records from 08/15/17 and 08/24/17 revealed the following: Visit Comment: 08/15/17, Weight 145 pounds, Lungs: Right Lower Lung Crackles, Left Lower Lung Diminished , 2+ [MEDICAL CONDITION] bilaterally, Patient here with her family from (Facility), She had left [MEDICAL CONDITION] and surgical repair. She was discharged to (Facility) but her diuretics were not given to her for several weeks and she had a 20 pound weight gain, SOB and leg [MEDICAL CONDITION] before the family discovered that she was not getting her diuretics. (Physician B) restarted her [MEDICATION NAME] at 40mg BID for 2 weeks then decrease to 20mg daily on 08/22/17. She has lost about 10 pounds since restarting [MEDICATION NAME] but she is still having SOB and lower leg [MEDICAL CONDITION].She was given intravenous [MEDICATION NAME] 80mg for continued heart failure symptoms. She is slowly improving. I will continue her on her current medication schedule and follow her up next week. Signed Physician Assistant B. 08/24/17 Weight 140.8 pounds, Lungs: Right Lower Lung Crackles, Left Lower Lung Crackles; 2+ [MEDICAL CONDITION] bilaterally, Patient here with her two daughters. Her weight is down 4.6 pounds from last week but she still has significant swelling of her legs. No resting shortness of breath but she does have dyspnea on exertion. She has orders to decrease her oral [MEDICATION NAME] to 20mg daily starting today. She was given intravenous [MEDICATION NAME] 80mg for continued heart failure symptoms. I will continue her for now on [MEDICATION NAME] 40mg BID since she is still symptomatic. Follow up here next week. Signed Physician Assistant B. In an interview on 09/20/17 at 4:00 PM, LVN B said that medication aides are not supposed to transcribe orders. She said she does not have medication aides transcribe her orders. LVN B said if there were a bunch of holes on the MAR then she considers it not done. LVN B said that since she has been working at the facility (almost a year) new orders that are transcribed onto the MAR are supposed to be checked with their counterpart nurse to make sure the orders have been transcribed correctly, and did say that with new admissions, it did not always happen. In an interview on 09/20/17 at 3:40 PM, Physician B said that he had taken over Resident #1's care around mid-August. He said that he had no knowledge of her history of [MEDICAL CONDITION] or that she frequented the [MEDICAL CONDITION] clinic. He said that he was not contacted on 08/26/17 when her blood pressure and pulse was elevated and she was sent to the emergency room . In an interview on 09/18/17 at 4:25 PM and on 09/21/17 at 12:49 PM, the DON said she was here during Resident #1's admission. She could not recall who reviewed her admission records prior to her admitting to the facility. She said she had a poor recollection of Resident #1's [DIAGNOSES REDACTED]. She said that the family was upset. She said she did recall Resident #1 having [MEDICAL CONDITION] to her legs. She said that she contacted Physician A to come and see Resident #1. The DON said that she had no knowledge of the medication errors regarding her [MEDICATION NAME] until 09/15/17, at which time she completed a medication error report and had contacted her daughter. She said that there were several things lacking with Resident #1's plan of care when she reviewed the chart and was not sure how it all got in such a mess. She said that she was contacted on 08/26/17 by LVN A and was told that her blood pressure and pulse were elevated and she advised LVN A to send her to the emergency room . She said to her knowledge, Resident #1 had high blood pressure and possible pneumonia. She said that normally the ADONs are responsible for monitoring that charting was being completed and she spot checked charts also. Record review of the Medication Variance Report, dated 09/15/17, revealed the following: .Name of Person Reporting Variance: (DON) Date and Time of Report: 9/15/17 17:30 Name of Party Responsible for Variance (Med Aide A) Date and Time Variance Occurred: Varied Dated/times .Error Type: Missed dose or omission .Notification: State at 1300 .Medication [MEDICATION NAME] 40mg Cause of Error: Transcription Error and Frequent interruptions .Signed by DON and Administrator on 09/15/17 Record review of a typed notification for Resident #1 to the responsible party revealed the following: Re: Medication Error Report for (Resident #1) written on 09/15/17. I called and left me(TRUNCATED)

Based on observation, interview and record review, the facility failed to administer, order and have available medications in accordance with the physician's orders [REDACTED].#1, #2, #3, #4, #5, #7, #8, #14, #15, #16, #17, and Resident #18) out of 21 residents whose medication regiments were reviewed. Residents #3, 4, 5, 8 and 14 did not receive any of their scheduled medications as of 3:20 p.m. on 03/09/2017. Some of the missed medications included: a. Resident #3's Carredilol (anti-hypertensive) missed one dose, Furosemide (diuretic) missed one dose, Flomax (enlarged prostate) missed one dose. b. Resident #4's Clopidogrel (anti-platelet) missed one dose, Metoprolol Tartrate , Norvasc, Lisinopril (all three meds anti- hypertensive) missed one dose each med. c. Resident #5's Topamax (anti-convulsant) was not available in the facility, missed three doses. Primidone (anti-convulsant) missed two doses, Sotalol (cardiac med) missed one dose, Cartier XT (anti-hypertensive) missed one med, Prednisone (anti-inflammatory) missed one dose, Pancreaze DR (replacement enzyme for pancreas) missed one dose. d. Resident #8's Levothyroxine (thyroid replacement) missed three doses, ProAir and Bre Ellipta (bronchidilators) missed two doses each med. e. Resident #14's Cardizem (cardiac med) was not available, missed one dose, glyburide (oral diabetic) missed two doses, Actos and Metformin (oral diabetic) missed one dose each med. Residents #1, 2, 7, 15, 16, 17 and 18 did not receive scheduled medications as ordered: f. Resident #1 did not receive the metoprolol tartrate (used to treat high blood pressure) at 8:00 a.m. because it was not available. g. Resident # 2's Lisinipril (anti-hypertensive) missed one dose, the nurse was unable to locate medication at the time of the med pass, missed one dose (medication was later found in the discontinued box). h. Resident #7's Flomax (medication that makes it easier to urinate with enlarged prostate) missed 46 doses. i. Resident #15's Duoneb (bronchidilator) nebulizer treatments missed two doses. j. Resident #16's Ticagrelor (anti-platelet) missed one dose, nurse was unable to find med, Anoro, Ellipta (bronchodilator) missed total five doses. k. Resident #17 did not receive Lorazepam at noon and Gabapentin at 2:00p.m. l. Resident #18's Travatan Z (lower pressure in the eye) missed two doses, Metformin (oral diabetic) missed one dose These failures resulted in an identification of an Immediate Jeopardy (IJ) on 03/10/17. While the IJ was lowered on 03/13/17, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as pattern because the facility was still monitoring the effectiveness of the Plan of Removal. These deficient practices could affect 44 residents with physician ordered medications by placing them at risk for delay in physician ordered treatments and interventions, worsening of medical conditions, hospitalization s, and death. The findings include: In an interview on 03/09/17 at 3:20 p.m. with LVN A she said that she had not given any of Resident #4's scheduled medication for 03/09/17. She said that she started the shift (6:00 a.m. to 6:00 p.m.) late because she was a late call from the agency. She said that she arrived at the facility around 8:30 a.m. She said that when she arrived she counted the narcotic medications on the medication cart's for Halls 100, 200, 300 and 400 with the charge nurses (LVN B and LVN C). She said that her assignment for the day 03/09/17 was to administer the PO medications only to the residents residing on these halls (100-400). She said that the charge nurses were to do the accuchecks, administer the insulins, the inhalers, and the nebulizer treatments. She said that this was the first day she had worked on this side (South Side of the facility halls 100-400) and she did not know any of the residents. She said that she had not had time to administer medications to Resident #4 and four other residents residing on the 400 hall, (Residents #3, #5, #8 and #14). a. Resident #3 Record review of Resident #3's MAR indicated [REDACTED]. Review of Resident #3's MAR, dated March 2017, revealed the resident was to receive the following medication: 1. Furosemide (used as a water pill that prevents the body from absorbing too much salt. Used to treat fluid retention in people with a kidney disorder). 20 mg by mouth twice a day at 8:00 a.m. for CKD. Further review of the same MAR indicated [REDACTED]. 2. Uloric (for high uric acid levels, used to treat gout) 40 mg by mouth daily at 8:00 a.m. Further review of the same MAR indicated [REDACTED]. 3. Aspirin; (used to treat and prevent heart attacks by thinning the blood) enteric coated (EC) 81 mg by mouth daily at 9:00 a.m. for CAD. Further review of the same MAR indicated [REDACTED]. 4. Carvedilol (used to treat heart failure and high blood pressure, helps the blood flow through the arteries and veins) 6.2 mg by mouth twice a day at 7:00 a.m. for CAD and HTN. Further review of the same MAR indicated [REDACTED]. 5. Metamucil (is a bulk forming fiber laxative.) powder one (1) tablespoon in 10 ounces of water or juice daily followed by another 10 ounces of water at 9:00 a.m. for constipation. Further review of the same MAR indicated [REDACTED]. 6. Flomax (is used to relax the muscles in the prostate and bladder neck, making it easier to urinate) 0.4 mg by mouth at hours of sleep (HS) at 8:00 p.m. for an enlarged prostate. Further review of the same MAR indicated [REDACTED]. b. Resident #4 Record review of Resident #4's MAR indicated [REDACTED]. Review of Resident #4's MAR, dated March 2017, revealed the resident was to receive the following medication: 1. fish oil (supplement for a healthy heart, Omega-3) 1,000 mg (2) by mouth twice a day at 8:00 a.m. Further review of the same MAR indicated [REDACTED]. 2. Metoprolol Tartrate (used to treat high blood pressure, prevent angina (chest pain), and to improve survival after a heart attack) 25 mg by mouth twice a day at 8:00 a.m. for HTN. Further review of the same MAR indicated [REDACTED]. 3. Norvasc (used to dilate (widen) the blood vessels and improves blood flow) 5 mg by mouth twice a day at 8:00 a.m. and 8:00 p.m. for HTN. Further review of the same MAR indicated [REDACTED]. 4. Clopidogrel (helps prevent platelets in your blood stream from sticking together and forming a blood clot) 75 mg by mouth daily at 8:00 A.M. for HTN. Further review of the same MAR indicated [REDACTED]. 5. Duloxetine HCL DR (used to treat major depressive disorders and anxiety disorders in adults) 60 mg by mouth daily at 8:00 a.m. for DD. Further review of the same MAR indicated [REDACTED]. 6. Lisinopril (is used to treat high blood pressure, CHF, and to improve survival after a heart attack) 20 mg by mouth daily at 8:00 a.m. for HTN. Further review of the same MAR indicated [REDACTED]. 7. Metformin HCL ER (is an oral diabetes medicine that helps control blood sugar levels) 750 mg (2) by mouth daily at 8:00 a.m. for DM. Further review of the same MAR indicated [REDACTED]. 8. Vitamin B12 (supplement that helps with metabolism of fats and carbohydrates and is essential in the development of healthy blood cells, nerve cells, and protein in the body) 500 mg by mouth daily at 8:00 a.m. Further review of the same MAR indicated [REDACTED]. 9. Gemfibrozil (helps reduce cholesterol and triglycerides (fatty acids) in the blood) 600 mg by mouth twice a day with food at 7:00 a.m. and 5:00 p.m. for hypercholesterolemia. Further review of the same MAR indicated [REDACTED]. 10. Novolin 70-30 (is a hormone that works by lowering levels of glucose (sugar) in the blood); 36 units twice a day before meals 7:00 a.m. and 5:00 p.m. for DM. Further review of the same MAR indicated [REDACTED]. c. Resident #5 Record review of Resident #5's MAR indicated [REDACTED] Review of Resident #5's MAR, dated March 2017, revealed the resident was to receive the following medication: 1. Primidone (used to control seizures) 250 mg tablet three times per day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. for tremors and as anticonvulsant's. Further review of the same MAR indicated [REDACTED]. 1. Topamax (is a seizure medication that is used to treat seizures and migraines) 100 mg twice a day 8:00 a.m. and 8:00 p.m. for migraines and seizures. Further review of the same MAR indicated [REDACTED]. The same MAR indicated [REDACTED]. 3. Lyrica (affects chemicals in the brain that send pain signals across the nervous system) 100 mg by mouth twice a day at 8:00 a.m. and 8:00 p.m. for spastic [DIAGNOSES REDACTED]. Further review of the same MAR indicated [REDACTED]. 4. Sotalol (affects the heart and circulation) 80 mg by mouth twice a day at 8:00 a.m. and 8:00 p.m. for CAD. Further review of the same MAR indicated [REDACTED]. 5. Cartier XT (used to treat high blood pressure and chronic stable angina (chest pain)) 240 mg every day at 8:00 a.m. for HTN. Further review of the same MAR indicated [REDACTED]. 6. Fenofibrate (helps reduce cholesterol and triglycerides (fatty acids) in the blood stream) 145 mg tablet once daily at 8:00 a.m. for hypercholesterolemia. Further review of the same MAR indicated [REDACTED]. 7. Folic Acid (is a type of B vitamin that is normally found in foods; it helps your body produce and maintain new cells) 0.4 mg tablet once daily at 8:00 a.m. for DD. Further review of the same MAR indicated [REDACTED]. 8. Lexapro (is an anti- depressant and is used to treat anxiety in adults) 20 mg once a day at 8:00 a.m. for DD. Further review of the same MAR indicated [REDACTED]. 9. Nexium DR (helps decrease the amount of acid produced in the stomach) 40 mg once a day at 8:00 a.m. for GERD. Further review of the same MAR indicated [REDACTED]. 10. Pancreaze DR (used in patients whose body does not produce enough pancreatic enzymes) 4,200 units tablet once daily at 8:00 a.m. for improving digestion of food by replacing digestive enzymes. Helps the body use fats, proteins, and sugars from food. Further review of the same MAR indicated [REDACTED]. 11. Prednisone (prevents the release of substances in the body that cause inflammation) 5 mg tablet once daily at 8:00 a.m. for arthritis. Further review of the same MAR indicated [REDACTED]. 12. Baclofen (is a muscle relaxer and is used to treat muscle symptoms including spasm, pain and stiffness) 10 mg three times per day 8:00 a.m., 2:00 p.m., and 8:00 p.m. for spastic [DIAGNOSES REDACTED]. Further review of the same MAR indicated [REDACTED]. In an interview on 03/09/17 at 3:30 p.m. with LVN A said that she was unable to find the Topamax 100 mg medication for Resident #5 to administer during her 8:00 a.m. medication pass. She said that she wrote NA (not available) and circled the box under the date 03/09/17 to indicate the medication was not given as it was unavailable. Observation of the medication cart for Halls 300 and 400 on 03/09/17 at 5:30 p.m. with the CNO and LVN B revealed the medication Topamax 100 mg for Resident #5 was not on the medication cart. Record review on 03/09/17 at 5:30 p.m. of the pharmacy faxes of ordered medication (where the medication label for re-ordering is affixed to a pharmacy order sheet and faxed to the facility pharmacy) did not reveal Topamax 100 mg for Resident #5 as having been ordered on any day during the month of March 2017. Record review on 03/09/17 at 5:30 p.m. revealed the Pharmacy delivery invoices for March 2017 did not show that the Topamax 100 mg was re-ordered for Resident #5. In an interview at 5:45 p.m. with the CNO she said that she could not locate a day and time that the medication Topamax 100 mg for Resident #5 was ever reordered. d. Resident #8 Record review of Resident #8's MAR indicated [REDACTED]. Review of Resident #8's MAR, dated March 2017, revealed the resident was to receive the following medication: 1. Levothyroxine (is a thyroid medication that replaces a hormone normally produced by your thyroid gland to regulate the body's energy and metabolism) 200 mg by mouth daily at 6:00 a.m. for [DIAGNOSES REDACTED]. Further review of the same MAR indicated [REDACTED]. 2. Proair HFA (a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) 90 mcg inhaler two (2) puffs twice a day at 8:00 a.m. and 8:00 p.m. for asthma. Further review of the same MAR indicated [REDACTED]. 3. Breo Ellipta (is a once daily combination medicine used in adults with asthma or COPD to improve symptoms and prevent bronchospasm or asthma attacks) 100-25 mcg inhalation one puff daily at 8:00 a.m. for asthma. Resident #8 did not receive the Breo Ellipta inhaler at 8:00 a.m. as the boxes under the dates 03/06/17 and 03/09/17 were blank. 4. Aspirin (is a salicylate, it works by reducing substances in the body that cause pain, fever, and inflammation) 81 mg by mouth daily at 9:00 a.m. for mild pain and inflammation. Further review of the same MAR indicated [REDACTED]. 5. Telmisartan (keeps blood vessels from narrowing, which lowers blood pressure and improves blood flow) 80 mg daily at 9:00 a.m. for HTN. Further review of the same MAR indicated [REDACTED]. 6. Gabapentin (affects chemicals and nerves in the body that are involved in the cause of some types of pain) 600 mg by mouth twice daily at 8:00 a.m. and 4:00 p.m. for pain. Further review of the same MAR indicated [REDACTED]. 7. Acidophilus (helps maintain an acidic environment in the body, which can prevent the growth of harmful bacteria) capsule by mouth three times per day at 6:00 a.m., 12:00 p.m., and 6:00 p.m. for improving digestive health. Further review of the same MAR indicated [REDACTED]. e. Resident #14 Record review of Resident #14's MAR indicated [REDACTED]. Review of Resident #14's MAR, dated March 2017, revealed the resident was to receive the following medication: 1.Glyburide (is an oral diabetes medicine that helps control blood sugar levels) 5 mg two (2) tablets by mouth twice a day at 8:00 a.m. and 8:00 p.m. for DM. Further review of the same MAR indicated [REDACTED]. 2. Metformin HCL (is an oral diabetes medicine that helps control blood sugar levels) 1,000 mg by mouth twice a day 8:00 a.m., and 8:00 p.m. for DM. Further review of the same MAR indicated [REDACTED]. 3. Albuterol (is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) 2.5 mg/3ml per inhalation twice a day 8:00 a.m., and 8:00 p.m. for COPD. Further review of the same MAR indicated [REDACTED]. 5. Actos (is an oral diabetes medicine that helps control blood sugar levels) 45 mg tablet by mouth daily at 8:00 a.m. for DM. Further review of the same MAR indicated [REDACTED]. 6. Protonix DR (is a proton pump inhibitor that decreases the amount of acid produced in the stomach) 40 mg tablet by mouth daily at 8:00 a.m. for GERD. Further review of the same MAR indicated [REDACTED]. 7. Cardizem (is a calcium channel blocker, it works by relaxing the muscles of your heart and blood vessels) 120 mg by mouth daily 8:00 a.m. for HTN. Further review of the same MAR indicated [REDACTED]. In an interview on 03/09/17 at 3:45 p.m. with LVN A she said that she was unable to find the Cardizem medication for Resident #14. She said that she had looked through the medication cart and the medication room and was unable to find the Cardizem medication for Resident #4. The 8:00 a.m. dose was not given. Observation of the medication cart for Halls 300 and 400 on 03/09/17 at 5:30 p.m. with the CNO the Cardizem medication for Resident #14 was available in the medication cart, however, observation of medication cart's overflow medications revealed an abundant quantity of extra cards of medications. f. Resident #1 Record review of Resident #1's MAR indicated [REDACTED]. Resident #1 was scheduled to receive metoprolol tartrate 25 mg daily at 8:00 a.m In an interview on 03/09/17 at 3:30 p.m. with LVN A she said that Resident #1 did not receive the metoprolol tartrate (used to treat high blood pressure) at 8:00 a.m. because it was not available. She said that this medication was not in the medication cart and she was unable to find this medication in the med (medication) room. In an interview on 3/09/17 at 4:30 a.m. with the Chief Nursing Officer (CNO) she said that she was unable to locate the metoprolol tartrate for Resident #1 in the medication cart or in the med room. Observation on 3/9/17 at 5:15 p.m. of the medication cart for Halls 400 and 500 revealed there was a large amount of excess over flow medications available in the med drawer. There was no metoprolol tartrate in the facility and available to administer to Resident #1. Observation on 03/09/17 at 5:30 p.m. of the medication room revealed a lot of clutter; papers scattered throughout the med room on counter tops, medications that needed to be placed in medication cart scattered about. Record review of the pharmacy faxes of ordered medications and the pharmacy delivery invoices on 03/09/17 at 5:30 p.m. with the CNO revealed metoprolol tartrate for Resident #1 was not ordered or delivered in the month of March 2017. In a second interview on 3/9/2017 at 5:35 p.m. with the CNO she said that Resident #1 did not have metoprolol tartrate available at the time of the 8:00 a.m. med pass. Observation on 3/9/17 at 6:30 p.m. the CNO presented a medication card for Resident #1's metoprolol tartrate 25 mg. She said that it was delivered from the facility pharmacy on 03/09/17 at 4:00 p.m. She said that the medication was not available at 8:00 a.m. at the time of the morning med pass. g. Resident #2 Record review of Resident #2's MAR indicated [REDACTED]. Review of Resident #2's MAR, dated March 2017, revealed she was to receive Lantus (used to lower levels of glucose (sugar) in the blood) 100/units (u) 20 u subcutaneously (SQ) daily. Further review of the same MAR indicated [REDACTED]. In an interview on 03/09/17 at 3:30 p.m. with LVN A she said that she was not administering the insulins, the breathing treatments, the accu checks or the inhalers. She said that the charge nurse (licensed vocational nurse (LVN) B and LVN C) were doing those tasks. She said that she was just administering the by mouth (PO) medications. In an interview on 03/09/07 at 4:30 p.m. with LVN B she said that she had administered Resident #2's insulin that morning at 8:00 a.m. that she had not initialed the MAR indicated [REDACTED]. Review of Resident #2's MAR, dated March 2017, revealed she was to receive Lisinopril (Used to treat high blood pressure, congestive heart failure and to improve survival after a heart attack) 40 mg by mouth daily. The MAR indicated [REDACTED]. In an interview on 03/09/2017 at 3:35 p.m. with LVN A she said that Resident #2 did not receive the Lisinopril because it was not available. She said this medication was not in the medication cart and she was unable to find this medication in the med room. Observation on 03/09/17 at 3:40 p.m. of the medication cart for Halls 400 and 500 revealed there was no Lisinopril 40 mg for Resident #2 on the medication cart. In an interview on 03/09/17 at 5:35 p.m. with the chief nursing officer (CNO) she said that there were no Lisinopril 40 mg tablets for Resident #2. She said that initial's with a circle around the box is indicative that the medication was not given. She said the correct procedure is to write on the back of the MAR indicated [REDACTED]. Observation/interview on 03/09/17 at 7:30 p.m. the CNO presented a medication card for Resident #2's Lisinopril 40 mg. She said the medication was in the discontinued box in the medication room. She said that the medication had been discontinued and then reordered. She said that Lisinopril is also in the facility emergency kit. She said that Lisinopril for Resident #2 was not on the med cart but was available at the 8:00 a.m. med pass. She said that LVN A should have notified her that she was unable to find the medication. h. Resident #7 Record review of Resident #7's clinical record revealed he was admitted to the facility 11 -7-16 with a readmission date of [DATE]. Resident #7's [DIAGNOSES REDACTED]. Review of Resident #7's Quarterly MDS dated [DATE] revealed a BIMS of 14, mood of one, limited supervision with bed mobility, transfer, walking, dressing, eating, toilet use, personal hygiene and extensive assistance of one bathing. Resident #7 used a walker or wheelchair or mobility, rated his pain at six, received insulin 7 of the last 7 days and received blood transfusions. Review of Resident #7's care plan dated 11-7-16 revealed assistance with ADL's, do not resuscitate, risk of falls, risk of pressure ulcers, diabetes, [DIAGNOSES REDACTED], cirrhosis with paracentesis, alert and oriented times 2, vision impairment, coronary artery disease, hypertension, therapeutic diet, and not tolerating renal restriction. Record review of Resident #7's MAR, dated March 2017, revealed the resident was to receive the following medication: Review of Resident #7's Physician order [REDACTED].Tamsulosin HCL 0.4 mg capsule. Give one cap P.O. Q day at HS . (Tamsulosin hydrochloride (Flomax) capsules are indicated for the treatment of [REDACTED].drugs.com accessed 03-20-17. Review of Resident #7's Telephone Orders dated 01-19-17 revealed, .DC Flomax . Review of Resident #7's Telephone Orders dated 01-23-17 revealed, .Flomax 0.4 mg p.o. @ HS . Review of Resident #7's Nurses eMAR for February and March 2017 did not reveal Flomax listed. In an interview on 03-14-17 at 1:40 p.m., the CNO said a medication aide (MA) told her Resident #7 had been receiving his Flomax because it was on the medication cart. When this investigator showed the CNO the Flomax was not on the February 2017 orders, she repeated that the medication was on the medication cart per the MA. When asked how a medication could be given if it was not listed on the MAR, the CNO replied that there must be a page missing from the February 2017 MAR. The CNO looked in her computer and said the February 2017 MAR indicated [REDACTED]. The CNO comfirmed R

Based on interview and record review, the facility failed to ensure that 1 of 5 residents (Resident # 1) reviewed for continuity of care and lab results received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by: Resident #1 had physician ordered lab studies 10/04/16 for kidney function and a urine microscopy. The urine microscopy results had high levels of blood cells and leukocyte esterase, white blood cells, red blood cells and bacteria, indicative of a urinary tract infection. Resident #1's physician was only notified by fax on 10/06/16, and a verbal telephone message was left. Resident #1 had a change in condition 10/10/16 and was transferred to the hospital, where he continued to deteriorate in the emergency room . Resident #1 was admitted to the hospice inpatient unit from the emergency room . This deficient practice could affect a facility census of 6 residents with Foley Catheters by placing them at risk for delays in physician ordered interventions, unnecessary hospitalization s, worsening medical conditions, and/or death. The findings include: Review of Resident #1's closed record Face Sheet, undated, revealed he was a [AGE] year old male admitted to the facility 07/11/16 with [DIAGNOSES REDACTED]. Physician B was listed as Resident #1's primary care physician (PCP). Review of Resident #1's Admission MDS dated [DATE] revealed adequate hearing, unclear speech, he was unable to complete a BIMS (severe cognitive impairment), had inattention, rejected care 1-3 of the last 7 days, needed extensive assistance with transfers, dressing, toileting and bathing, used a wheelchair for mobility, had an indwelling catheter and was occasionally incontinent of bowel. Review of Resident #1's Care Plan dated 07/20/16 revealed his Foley Catheter, dependence on ADLs and presence of a UTI in the last 30 days. Interventions included encouraging Resident #1 to drink more fluids by offering fluids with each resident contact. Review of Resident #1's Physician order [REDACTED].Order was faxed to NH for urine microscopy and BMP . (A urine microscopy looks at a sample of your urine under a microscope. It can see cells from your urinary tract, blood cells, crystals, bacteria, parasites, and cells from tumors. (A Basic Metabolic Profile is a group of blood tests that provides information about your body's metabolism www.medlineplus.com accessed 10/14/16) Review of Resident #1's Urinalysis dated 10/04/16 and received by the facility on 10/06/16 revealed his urine was cloudy, had a large amount of blood, protein leukocyte esterase, white blood cells, red blood cells, bacteria and triple [MEDICATION NAME] crystals. Attached to the urinalysis was a sensitivity report that read, .Culture result: proteus mirabilis with antibiotics listed as S for sensitive to treat the organism or R as being resistant to the organism . Fax transmission confirmation sheets revealed the results were faxed to Physician D's (a urologist) office on 10/06/16 at 11:18 a.m., 11:19 a.m. and 11:22 a.m. (Proteus mirabilis P. mirabilis, a motile gram-negative bacterium that differentiates from a short vegetative rod to an elongated, highly flagellated form, is found in soil, water, and the human intestinal tract. Its virulence factors are in some cases distinct from those described for E. coli; in other instances, however, virulence factors are shared between the two uropathogenic species. <http://www.umich.edu/~hltmlab/research/mirabillis/infection.htm>) accessed 10/13/16 (Triple [MEDICATION NAME] crystals may be normal but often are associated with alkaline urine and UTI (typically associated with Proteus species) http://www.aafp.org/afp/2005/0315/p1153.html.) accessed 10/13/16 In an interview on 10/10/16 at 3:07 p.m., RN A, a hospital emergency room nurse, said Resident #1 was still in the emergency room . RN A said Resident #1 was going to be admitted to the hospital, but had taken a turn for the worse and was going to be admitted to the inpatient hospice unit at the hospital. She said the facility told her they had tried to reach Resident #1's physician (Physician B) regarding the results of the urinalysis, but the physician was out of the country. Review of Resident #1's emergency room History and Physical dated 10/10/16 revealed, .obtained a urine culture in the nursing home, and were waiting on results, and she (Resident #1's daughter) was uncertain of those results and uncertain if he had received any antibiotics between that time and now. He does have a history of previous urinary tract infections. She (Resident #1's daughter) states that he has had an indwelling Foley for about 2 months in duration, and was informed today that he was very tachypneic, (increased respiratory rate http://www.merriam-webster.com/medical/tachypnea; accessed 10/24/16)and had altered mental status, and was therefore brought to the hospital for evaluation. Upon seeing her father, the patient's daughter does state that he is very confused, and in the E.R. (emergency room ) urinalysis was obtained which was positive for leukocyte esterase, WBC's greater than 180, and bacteria 3+. He was given a normal saline 1L (one liter) bolus and started on antibiotics with [MEDICATION NAME]. He did have his Foley changed and it was noted that immediately 1L (Liter) of urine was obtained after the replacement of the new Foley due to sediment that obstructing the old Foley . (Leukocyte esterase is a screening test used to detect a substance that suggests there are white blood cells in the urine. This may mean you have a urinary tract infection <https://medlineplus.gov/ency/article/ 1.htm>. If this test is positive, the urine should be examined under a microscope for white blood cells and other signs that point to an infection. <https://medlineplus.gov/ency/article/ 4.htm>) accessed 10/13/16 Review of Resident #1's urinalysis obtained 10/10/16 at 10:07 a.m. at the emergency room revealed appearance-turbid, blood-moderate, protein>500 and leukocytes esterase-large, (indicative of a urinary tract infection). In an interview on 10/10/16 at 3:18 p.m., a nurse assigned to answer phone calls for Physician B said there was a physician assigned on-call for Physician B while he was away. She said the on-call physician was able to be reached by calling Physician B's office and then pressing 1. In an interview on 10/11/16 at 1:05 p.m., LVN C said that on 10/06/16, she worked 6:00 a.m.-6:00 p.m., and after receiving Resident #1's urine and blood lab results, she faxed them to Physician D, a urologist who ordered the urinalysis and BMP (basic metabolic profile) LVN C said she also called Physician D's office that morning and left a message for a return phone call regarding the lab results, but Physician D's office did not return the call. She said she left the information on the 24-hour report for the next shift. LVN C said she did not work 10/7, 10/8 or 10/9, but when she returned to work 10/10/16, Resident #1 was lying in bed on his side. She said Resident #1's catheter tubing was empty, and that the night shift CNA reported only emptying around 300 cc's from his urinary catheter earlier that morning. LVN C said Resident #1's daughter was notified of his status and requested he be sent to the emergency room , so she sent him to the hospital. (A basic metabolic panel is a blood test that measures your sugar (glucose) level, electrolyte <http://www.webmd.com/hw-popup/electrolytes-and-electrolyte-imbalances> and fluid balance, and kidney <http://www.webmd.com/kidney-stones/kidneys> function. www.webmd.com accessed 10/13/16 <http://www.webmd.com>). accessed Review of Resident #1's Departmental Notes dated 10/06/16 at 3:37 p.m. revealed, Resident's labs bmp and us with c and s faxed to (Physician D's name) this morning and dr called per labs. No new orders given at this time. Resident voices no complaint of pain or discomfort at this time. VS 97.4-99-18-100/50. Resident encouraged to drink more fluids. 600cc of amber urine noted draining from bedside bag . Review of Resident #1's Departmental Notes dated 10/10/16 at 8:26 a.m. revealed, .Resident resting in bed and is lethargic. Resident's urine output has been low and his respirations noted to be at 22. Family requests that he be sent to ER (emergency room ) via ambulance. Dr. (physician B's name) notified unable to reach at this time . Review of Resident #1's Departmental Notes dated 10/10/16 at 8:36 a.m. revealed, .Resident resting in bed and is lethargic. Resident's urine output has been low and his respirations noted to be at 22. Family requests that he be sent to ER via ambulance. (Physician B's name) notified unable to reach at this time . Review of the facility's 24-hour report regarding Resident #1 revealed: 10/06/16- .Sent UA; C&S & BMP (Physician D's name). Awaiting reply from MD on UA results . 10/07/16- .Awating relpy from MD on UA results . 10/08/16- .Awaiting reply from MD on UA results . 10/09/16- .Awaiting reply from MD on UA results F/U on Monday-emesis x 1 . In an interview on 10/11/16 at 3:30 p.m. the DON said staff nurses spent a lot of time faxing results to physician offices as well as calling physicians. The DON said many times, physicians or their staff did not return phone calls, and she did not know what else to do about it. The DON said that she expected her nurses to fax lab results to physician's offices and follow up with a phone call to the physician, including weekends, nights and holidays. In an interview on 10/12/16 at 10:20 a.m., RN E said she worked 6:00 a.m.-6:00 p.m. 10/7, 8 and 9. RN E said Resident #1's catheter was draining yucky colored urine. She said she faxed Resident #1's lab results from 10/06/16 to Physician B's office on 10/07/16 and left a voice message as well. In an interview on 10/12/16 at 12:48 p.m., Physician D's Nurse Practitioner (NP) said she saw Resident #1 in her office the week before, and ordered the urine microscopy and BMP. The NP said she was concerned about Resident #1's hematuria and wanted to check his kidney function to see if he was a candiate for scans to identify the cause of his hematuria. The NP said she had been out and had just seen Resident #1's lab results earlier that morning, 10/12/16. When asked if someone in the office had notified Physician D of the results, the NP said the results were not flagged and Physician D had not been made aware of them. The NP said her records indicated one phone call from the facility regarding the lab results, but did not know what date the call was received. In an interview on 10/12/16 at 1:43 p.m., CNA F said she worked 10/08/16, 6:00 a.m.-2:00 p.m. CNA F said Resident #1's catheter bag only had around 200cc's of dark yellow urine, and that she reported it to RN E. In an interview on 10/12/16 at 1:45 p.m., ADON G said she was under the impression that Physician D did not want to do anything about Resident #1's urinalysis results. The ADON walked away and did not elaborate on her comment. In an interview on 10/12/16 at 2:05 p.m., CNA H said she worked 2:00-10:00 p.m. on Saturday, 10/08/16. CNA H said Resident #1 did not want to get up but his family had brought snacks, so he got up and visited with them. She said she only emptied about 50cc's of urine from Resident #1's catheter bag on her shift. CNA H said she reported this to RN E. In an interview on 10/12/16 at 2:09 p.m., CNA I said she worked Saturday, 10/08/16 from 2:00 p.m.-Sunday, 10/09/16 at 6:00 a.m. CNA I said Resident #1 stayed in bed because he did not feel well. She said that while she and another CNA were cleaning Resident #1 on the night shift, he was a little out of it, and she reported her observation to the nurse on duty. She was unable to remember which nurse she told. In an interview on 10/12/16 at 11:50 a.m., the DON said the facility did not have a policy regarding documentation or informing physicians of lab results, that the facility used state and federal guidelines. Review of CMS 672 dated 10/11/16 revealed 6 residents with Foley catheters.

Based on interview and record review, the facility failed to notify the physician of lab results for 1 of 5 residents (Resident # 1) reviewed for physician notification of lab results. Resident #1 had physician ordered lab studies 10/04/16 for kidney function and a urine microscopy. The urine microscopy results had high levels of blood cells and leukocyte esterase, white blood cells, red blood cells and bacteria, indicative of a urinary tract infection. Resident #1's physician was only notified by fax on 10/06/16, and a verbal telephone message was made. Resident #1 had a change in condition 10/10/16 and was transferred to the hospital, where he continued to deteriorate in the emergency room . Resident #1 was admitted to the hospice inpatient unit from the emergency room . This deficient practice could affect a facility census of 6 residents with Foley Catheters by placing them at risk for delays in physician ordered interventions, unnecessary hospitalization s, worsening medical conditions, and/or death. The findings include: Review of Resident #1's closed record Face Sheet, undated, revealed he was a [AGE] year old male admitted to the facility 07/11/16 with [DIAGNOSES REDACTED]. Physician B was listed as Resident #1's primary care physician (PCP). Review of Resident #1's Admission MDS dated [DATE] revealed adequate hearing, unclear speech, he was unable to complete a BIMS (severe cognitive impairment), had inattention, rejected care 1-3 of the last 7 days, needed extensive assistance with transfers, dressing, toileting and bathing, used a wheelchair for mobility, had an indwelling catheter and was occasionally incontinent of bowel. Review of Resident #1's Care Plan dated 07/20/16 revealed his Foley Catheter, dependence on ADLs and presence of a UTI in the last 30 days. Review of Resident #1's Physician order [REDACTED].Order was faxed to NH for urine microscopy and BMP . (A urine microscopy looks at a sample of your urine under a microscope. It can see cells from your urinary tract, blood cells, crystals, bacteria, parasites, and cells from tumors. (A Basic Metabolic Profile is a group of blood tests that provides information about your body's metabolism www.medlineplus.com accessed 10/24/16) <HTML><META HTTP-EQUIV=content-type CONTENT=text/html;charset=utf-8> The basic metabolic panel is a group of blood tests that provides information about your body's metabolism</A>.https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=167&ContentID=urinanalysis_microscopic_exam) accessed 10/14/16. Review of Resident #1's Urinalysis dated 10/04/16 and received by the facility on 10/06/16 revealed his urine was cloudy, had a large amount of blood, protein leukocyte esterase, white blood cells, red blood cells, bacteria and triple [MEDICATION NAME] crystals. Attached to the urinalysis was a sensitivity report that read, .Culture result: proteus mirabilis with antibiotics listed as S for sensitive to treat the organism or R as being resistant to the organism . Fax transmission confirmation sheets revealed the results were faxed to Physician D's (a urologist) office on 10/06/16 at 11:18 a.m., 11:19 a.m. and 11:22 a.m. (Proteus mirabilis P. mirabilis, a motile gram-negative bacterium that differentiates from a short vegetative rod to an elongated, highly flagellated form, is found in soil, water, and the human intestinal tract. Its virulence factors are in some cases distinct from those described for E. coli; in other instances, however, virulence factors are shared between the two uropathogenic species. <http://www.umich.edu/~hltmlab/research/mirabillis/infection.htm>) accessed 10/13/16 (Triple [MEDICATION NAME] crystals may be normal but often are associated with alkaline urine and UTI (typically associated with Proteus species) http://www.aafp.org/afp/2005/0315/p1153.html.) accessed 10/13/16 In an interview on 10/10/16 at 3:07 p.m., RN A, a hospital emergency room nurse, said Resident #1 was still in the emergency room . RN A said Resident #1 was going to be admitted to the hospital, but had taken a turn for the worse and was going to be admitted to the inpatient hospice unit at the hospital. She said the facility told her they had tried to reach Resident #1's physician (Physician B) regarding the results of the urinalysis, but the physician was out of the country. Review of Resident #1's emergency room History and Physical dated 10/10/16 revealed, .obtained a urine culture in the nursing home, and were waiting on results, and she (Resident #1's daughter) was uncertain of those results and uncertain if he had received any antibiotics between that time and now. He does have a history of previous urinary tract infections. She (Resident #1's daughter) states that he has had an indwelling Foley for about 2 months in duration, and was informed today that he was very tachypneic, and had altered mental status, and was therefore brought to the hospital for evaluation. Upon seeing her father, the patient's daughter does state that he is very confused, and in the E.R. (emergency room ) urinalysis was obtained which was positive for leukocyte esterase, WBC's greater than 180, and bacteria 3+. He was given a normal saline 1L (one liter) bolus and started on antibiotics with [MEDICATION NAME]. He did have his Foley changed and it was noted that immediately 1L (Liter) of urine was obtained after the replacement of the new Foley due to sediment that obstructing the old Foley . (Leukocyte esterase is a screening test used to detect a substance that suggests there are white blood cells in the urine. This may mean you have a urinary tract infection <https://medlineplus.gov/ency/article/ 1.htm>. If this test is positive, the urine should be examined under a microscope for white blood cells and other signs that point to an infection. <https://medlineplus.gov/ency/article/ 4.htm>) accessed 10/13/16 Review of Resident #1's urinalysis obtained 10/10/16 at 10:07 a.m. at the emergency room revealed appearance-turbid, blood-moderate, protein>500 and leukocytes esterase-large, indicative of a urinary tract infection. In an interview on 10/10/16 at 3:18 p.m., a nurse assigned to answer phone calls for Physician B said there was a physician assigned on-call for Physician B while he was away. She said the on-call physician was able to be reached by calling Physician B's office and then pressing 1. In an interview on 10/11/16 at 1:05 p.m., LVN C said that on 10/06/16, she worked 6:00 a.m.-6:00 p.m., and after receiving Resident #1's urine and blood lab results, she faxed them to Physician D, a urologist who ordered the urinalysis and BMP (basic metabolic profile) LVN C said she also called Physician D's office that morning and left a message for a return phone call regarding the lab results, but Physician D's office did not return the call. She said she left the information on the 24-hour report for the next shift. LVN C said she did not work 10/7, 10/8 or 10/9, but when she returned to work 10/10/16, Resident #1 was lying in bed on his side. She said Resident #1's catheter tubing was empty, and that the night shift CNA reported only emptying around 300 cc's from his urinary catheter earlier that morning. LVN C said Resident #1's daughter was notified of his status and requested he be sent to the emergency room , so she sent him to the hospital. (A basic metabolic panel is a blood test that measures your sugar (glucose) level, electrolyte <http://www.webmd.com/hw-popup/electrolytes-and-electrolyte-imbalances> and fluid balance, and kidney <http://www.webmd.com/kidney-stones/kidneys> function. www.webmd.com accessed 10/13/16 <http://www.webmd.com>). accessed Review of the facility's 24-hour report regarding Resident #1 revealed: 10/06/16- .Sent UA; C&S & BMP (Physician D's name). Awaiting reply from MD on UA results . 10/07/16- .Awating relpy from MD on UA results . 10/08/16- .Awaiting reply from MD on UA results . 10/09/16- .Awaiting reply from MD on UA results F/U on Monday-emesis x 1 . In an interview on 10/11/16 at 3:30 p.m. the DON said staff nurses spent a lot of time faxing results to physician offices as well as calling physicians. The DON said many times, physicians or their staff did not return phone calls, and she did not know what else to do about it. The DON said that she expected her nurses to fax lab results to physician's offices and follow up with a phone call to the physician, including weekends, nights and holidays. In an interview on 10/12/16 at 10:20 a.m., RN E said she worked 6:00 a.m.-6:00 p.m. 10/7, 8 and 9. RN E said Resident #1's catheter was draining yucky colored urine. She said she faxed Resident #1's lab results from 10/06/16 to Physician B's office on 10/07/16 and left a voice message as well. Review of Resident #1's Departmental Notes dated 10/10/16 at 8:26 a.m. revealed, .Resident resting in bed and is lethargic. Resident's urine output has been low and his respirations noted to be at 22. Family requests that he be sent to ER (emergency room ) via ambulance. Dr. (physician B's name) notified unable to reach at this time . In an interview on 10/12/16 at 11:50 a.m., the DON said the facility did not have a policy regarding documentation or informing physicians of lab results, that the facility used state and federal guidelines. In an interview on 10/12/16 at 12:48 p.m., Physician D's Nurse Practitioner (NP) said she saw Resident #1 in her office the week before, and ordered the urine microscopy and BMP. The NP said she was concerned about Resident #1's hematuria and wanted to check his kidney function to see if he was a candiate for scans to identify the cause of his hematuria. The NP said she had been out and had just seen Resident #1's lab results earlier that morning, 10/12/16. When asked if someone in the office had notified Physician D of the results, the NP said the results were not flagged and Physician D had not been made aware of them. The NP said her records indicated one phone call from the facility regarding the lab results, but did not know what date the call was received. In an interview on 10/12/16 at 1:43 p.m., CNA F said she worked 10/08/16, 6:00 a.m.-2:00 p.m. CNA F said Resident #1's catheter bag only had around 200cc's of dark yellow urine, and that she reported it to RN E. In an interview on 10/12/16 at 1:45 p.m., ADON G said she was under the impression that Physician D did not want to do anything about Resident #1's urinalysis results. In an interview on 10/12/16 at 2:05 p.m., CNA H said she worked 2:00-10:00 p.m. on Saturday, 10/08/16. CNA H said Resident #1 did not want to get up but his family had brought snacks, so he got up and visited with them. She said she only emptied about 50cc's of urine from Resident #1's catheter bag on her shift. CNA H said she reported this to RN E. In an interview on 10/12/16 at 2:09 p.m., CNA I said she worked Saturday, 10/08/16 from 2:00 p.m.-Sunday, 10/09/16 at 6:00 a.m. CNA I said Resident #1 stayed in bed because he did not feel well. She said that while she and another CNA were cleaning Resident #1 on the night shift, he was a little out of it, and she reported her observation to the nurse on duty. She was unable to remember which nurse she told. Review of CMS 672 dated 10/11/16 revealed 6 residents with Foley catheters.

Based on interview and record review, the facility failed to follow their policy to implement Advanced Directives for one (Resident #1) of five residents reviewed for Advanced Directives. On [DATE] Resident #1's family member executed an Out of Hospital Do Not Resuscitate (OOHDNR) document regarding Resident #1. Physician A signed the OOHDNR regarding Resident #1 on [DATE]. On [DATE] Resident #1 became unresponsive. The facility failed to honor the OOHDNR and cardiopulmonary resuscitation (CPR) was performed on the resident by facility staff. Resident #1 was revived and sent to the hospital via Emergency Medical Services (EMS). Resident #1 was placed on a ventilator while in the emergency room (ER) and then admitted to the Intensive Care Unit (ICU). On [DATE] the family had Resident #1 taken off the ventilator and on [DATE] Resident #1 passed away. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could affect 45 residents who had implemented Advanced Directives establishing their desire not to be resuscitated. Findings included: Record review of Resident #1's Five Day Minimum Data Set (MDS) assessment, dated [DATE], revealed he was an [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS also revealed that Resident #1 requires the physical assistance of staff for eating, toileting, and personal hygiene. The MDS revealed Resident #1 was unable to complete the Brief Interview for Mental Status, and his mental status was not assessed by staff. Record review of Resident #1's clinical record revealed an Out of Hospital Do Not Resuscitate Order. The order was signed by Resident #1's adult child on [DATE], witnesses by two facility staff on [DATE], and signed by Physician A on [DATE]. The order revealed the adult child of Resident #1 signed the document agreeing with the following declaration: To my knowledge the adult person is incompetent or otherwise mentally or physically incapable of communication and is without a legal guardian, agent or proxy. Based upon the known desires of the person or a determination of the best interests of the person, I direct that none of the following resuscitation measures be initiated or continued for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. Record review of Resident #1's physician's telephone orders revealed an order, dated [DATE], indicating Resident #1 was a full code. The order was completed by LVN B. The telephone order was not signed by the physician. Further review of Resident #1's physician's telephone orders revealed no other orders related to the resident's code status. In an interview on [DATE] at 4:35 PM the Social Worker stated she completed Resident #1's OOHDNR with the family and the physician on [DATE]. The Social Worker stated Resident #1 came in towards the end of the day on [DATE]. The Social Worker stated the family reported Resident #1 was on hospice in the hospital so she discussed an OOHDNR with the family. The Social Worker stated the family indicated to her Resident #1 had been a DNR in the hospital and they would like him to continue to be a DNR at the facility. The Social worker stated she had the family complete the OOHDNR and she and another staff member witnessed the document. The Social Worker stated she placed the uncompleted (because not signed by the physician) document in the resident's chart. The Social Worker stated she was then informed Physician A t was in the facility so she had him sign OOHDNR for Resident #1. The Social Worker stated she then went to the nurse's station and notified LVN C that she was changing Resident #1's code status from full code to DNR, and also asked that LVN C write a telephone order indicating Resident #1's code status was a DNR. The Social Worker stated she then removed the uncompleted OOHDNR and replaced it with the document signed by the physician. The Social Worker stated she also changed the color coded sheet at the front of the chart that was used to indicate a resident's code status. The Social Worker stated a green sheet indicated a full code and a red sheet indicated a DNR. The Social Worker stated while putting in the completed OOHDNR she removed the green full code sheet in Resident #1's chart and replaced it with a red DNR sheet. The Social Worker stated she also removed the current telephone order that stated full code. The Social Worker stated LVN C was speaking with an unknown agency nurse when she informed her about the change in code status and asked her to write a telephone order. The Social Worker stated LVN C indicated she did not hear what the Social Worker stated, and the unknown agency nurse then repeated the Social Worker's request for the nurse to obtain a DNR telephone order for Resident #1. The Social Worker stated after she informed the nursing staff of the change in code status and updated the paper work in the resident's chart, her role in the code status was completed. In an interview on [DATE] at 5:00 PM CNA A stated that (on [DATE]) she was in the hallway and heard people saying that Resident #1 was not breathing or responding. CNA A stated at that time a lot of people rushed into the room and RN A asked for Resident #1's code status. CNA A stated an unknown CNA responded that Resident #1 was a Full Code. CNA A stated she was asked to get the crash cart after Resident #1 was identified as a full code. CNA A stated Resident #1 was hooked up to the Automatic External Defibrillator (AED). CNA A stated the AED indicated Resident #1's airway was good and chest compressions should be continued. CNA A stated LVN A came into room and assisted RN A with CPR. CNA A stated another nurse came and told all the staff not assisting with the code to leave the room to allow space for EMS. CNA A stated she understood that a resident's code status could be found in the chare or on the care card. CNA A described the care card as a card with stickers that identified information about the resident, such as a red sticker that indicated a resident was DNR or a green sticker that indicated a resident was a full code. CNA A stated the care cards are located in the resident's closet. CNA A stated she was not sure if Resident #1's care card was in his closet at the time of the incident. In an interview on [DATE] at 9:53 AM with RN A she confirmed she was the nurse who initially began CPR on Resident #1. RN A stated two CNAs reported to her that Resident #1 was unresponsive. RN A stated she assessed Resident #1, found him unresponsive, and asked one of the CNAs what his code status was. RN A stated she was told Resident #1 was a full code by one of the CNAs, but couldn't remember which CNA it was. RN A stated she asked the CNA to check Resident #1's chart and the CNA returned to the room with the chart. RN A stated the CNA once again reported Resident #1's code status as full code so she began to perform CPR on Resident #1 because he had no pulse and no respirations. RN A stated she applied the Automated External Defibrillator (a portable electronic device used to restore a regular heart rhythm during sudden [MEDICAL CONDITION]) to Resident #1, and then she began providing breaths and chest compressions to the resident. RN A stated that RN B came in to assist in providing CPR and after a second round of CPR Resident #1 was found to have a pulse and was breathing. RN A stated the paramedics arrived at this point, and one of CNAs began to help gather Resident #1's information from his chart. RN A stated at this time a Do Not Resuscitate order was located in Resident #1's chart. RN A stated that she did not ever look at Resident #1's chart and did not see his code status for herself. RN A stated that prior to the incident involving Resident #1 she was not provided with any training related to code status, and that she was not aware of residents having care cards in their closets identifying their code status. RN A stated following the incident she was told that she should check the code status herself before performing CPR. In an interview on [DATE] at 10:15 AM with Medication Aide (MA) A she stated that on the day of the incident with Resident #1, two CNAs came out of Resident #1's room and asked her where the nurse was because Resident #1 did not look well. MA A stated that she went directly into Resident #1's room and attempted to obtain his vital signs. MA A stated Resident #1 appeared to be in distress. MA A stated RN A came into Resident #1's room, assessed the resident, and then asked for Resident #1's code status. MA A stated a CNA (unsure of name) yelled out from the hallway He is a full code. MA A stated the AED was applied and it indicated that no shock was necessary and to begin CPR. MA A stated RN A initiated CPR, and was then assisted by LVN A. MA A stated she left the room at this point to assist in locating an Ambu bag, and that when she returned to the room Resident #1 was being removed from the facility by EMS. MA A stated she did hear EMS yell out that Resident #1 had a DNR in his chart. MA A stated she had not received any training or in service in regards to code status and that after the incident she did not recall being in serviced about code status. In an interview on [DATE] at 10:38 AM with RN B she stated that on the day of the incident she entered Resident #1's room after CPR had already been initiated. RN B stated she saw a large crowd of staff in Resident #1's room and asked for all staff to vacate the room unless they were assisting with the code. RN B stated that she witnessed Resident #1 receiving CPR, with RN A doing chest compressions and LVN A administering breaths. RN B stated she asked what Resident #1's code status was and RN A indicated that he was a full code. RN B stated she asked RN A to stop compressions and check for a pulse. RN B stated Resident #1 had a pulse at that time so she directed RN A to maintain the airway until EMS arrived. RN B stated EMS arrived and was reviewing Resident #1's chart when they located an OOHDNR. RN B stated she had not received any training at orientation in regards to code status and had not been educated on the care cards located in resident's wardrobes indicating their code status. RN B stated she reviewed the 24 hour report after the incident, and there was nothing that indicated Resident #1's code status had changed. RN B indicated that she never saw Resident #1's chart in the room nor did she verify his code status. In an interview on [DATE] at 11:06 AM with the VP (Vice President) of Clinical Services she stated that her expectation is for a nurse to identify a resident's code status by looking in the front of the chart or at the resident care card. She stated that RN A should have asked to see the chart and confirmed code status herself rather than taking a CNAs word. In an interview on [DATE] at 12:03 PM with LVN E he stated a code status is found in front of chart and there is either a green sheet to indicate full code or a red sheet that indicates a DNR. LVN E did not identify the care card as a place to locate a resident's code status, and stated that the code status cannot be located anywhere in the Residents rooms. In an interview on [DATE] at 12:46 PM LVN A stated he assisted in performing CPR on Resident #1. LVN A stated he was working on the north side of the facility when a CNA called out that a resident had coded. LVN A stated he went to the resident's room to see if he could assist. LVN A stated when he entered the room RN A was doing chest compressions on Resident #1 and also giving the resident breaths. LVN A stated an Ambu bag (a bag valve mask commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) was located and he assisted with the Ambu bag. LVN A stated he did not hear anyone involved in the incident talk about Resident #1's code status until after the resident was taken out of the facility by EMS. LVN A stated he had never had to change a resident's code status and he was not sure exactly what is involved in changing a resident's code status. LVN A stated he had not received any training on code status while working at the facility. LVN A stated he knows a change in the code status should be put on the 24 hour report, but stated he does not know who is responsible for changing the resident's care card. In an interview on [DATE] at 1:03 PM with LVN C she stated that the social worker informed her Physician A signed the DNR for Resident #1. LVN C stated at that time she was very distracted with other things such as giving report and she did not fully understand that his code status had changed. LVN C stated that she was not sure if she had received training prior to hire on code status and that in the event she needed to identify a code status for a resident she would entrust another nurse to look in the chart and verify the code status. In an interview on [DATE] at 1:20 PM with LVN F she stated that when she came on duty the morning of the incident with Resident #1 she received no report that his code status had changed. LVN F stated that this was the first time she was the nurse for Resident #1, and that she had not reviewed Resident #1's chart and was not familiar with what his code status. She indicated that prior to the incident she went on break and was not in the facility during the time CPR was performed. On [DATE] at 3:45 PM the Administrator, DON, and VP of Clinical Services were informed that an Immediate Jeopardy had been identified in the area of Resident Rights. In an interview on [DATE] at 10:55 AM with CNA C, a former employee, she stated that at the time of the incident with Resident #1 she heard RN A yelled out asking for Resident #1's code status. CNA C stated that she obtained Resident #1's chart and saw a telephone order in the chart that indicated Resident #1 was full code. CNA C stated she informed RN A that he was a full code. CNA C stated that when she looked at Resident #1's chart there was neither a red or green sheet in the front of the chart indicating whether or not he was a full code or a DNR. CNA C stated that while medical records were being obtained for the EMS an out of hospital DNR order was found behind the face sheet of Resident #1's chart. CNA C stated that she had never been told she could not check a code status nor had she received any training in regards to code status upon orientation. In an interview on [DATE] at 2:15 PM with a family member of Resident #1 she stated that we had signed a DNR because we did not want my father to have to go through anymore suffering. Record review of Resident #1's hospital record revealed the following narrative from EMS about when they arrived at the facility in response to a call to 911: . EMS was met at the door by (local fire department). EMS was informed that when (local fire department) arrived on scene the pt (patient) was not breathing and NH (nursing home) staff a NRB (Non-Rebreather) at 15 LPM (liters per minute) and AED on the pt. (Local fire department) removed the NRB and placed on OPA (oropharyngeal airway). The pt had no gag reflex and handled the OPA . (Local fire department) started ventilations with a BVM (bag valve mask) at 15 LPM of O2 (oxygen) at ,[DATE] breaths per minute. The nursing home staff related to EMS that the pt was a full code, but then they handed EMS a valid DNR. The pt's airway and breathing were maintained by EMS throughout the call via OPA and BVM with O2 at 15 LPM at ,[DATE] breaths a minute. The American Red Cross identified a Non-Rebreather as a face mask with an attached oxygen reservoir bag and one-way valve between the mask and bag; victim inhales oxygen from the bag and exhaled air escapes through flutter valves on the side of the mask. http://www.redcross.org/images/MEDIA_CustomProductCatalog/m 82_ AdministeringEmergencyOxygenFactandSkill.pdf Accessed on [DATE] The Medical Dictionary identified an Oropharyngeal Airway as a curved plastic device used to establish an airway in a patient by displacing the tongue . This device is used only in unconscious patients who do not have a gag reflex. http://medical-dictionary.thefreedictionary.com/oropharyngeal+airway Accessed on [DATE] The American Red Cross identified a Bag Valve Mask as a hand-held breathing device consisting of a self-infl ating bag, a one-way valve and a face mask that should be used with victims with difficulty breathing or victims who are not breathing. http://www.redcross.org/images/MEDIA_CustomProductCatalog/m 82_ AdministeringEmergencyOxygenFactandSkill.pdf Accessed on [DATE] Record review of Resident #1's hospital records revealed a History and Physical, dated [DATE] and signed by Physician B, which indicated the following: . Today, the patient was found in the nursing home to be unresponsive and he was sent to the emergency room . There was a lot of confusion about whether the family wanted to rescind the DNR and the whole hospice plan. For this reason, and because of the patient's extreme condition on arrival to the emergency room , he was emergently intubated here in the emergency room . As I said, there is a lot of disagreement among the family members about which direction to go . The patient, in the meantime, is being admitted to the ICU, intubated. Record review of Resident #1's hospital records revealed the following in a physician progress notes [REDACTED]. Record review of Resident #1's hospital records revealed a Death Pronouncement, dated [DATE] and signed by Physician B, and indicated the pronouncement of death for Resident #1 was made on [DATE]. Record review of Resident #1's hospital records revealed the following in a Discharge Summary, dated [DATE] and signed by Physician B: . (Resident #1) was found unresponsive at the nursing home . and (Resident #1's wife) requested, due to his impending [MEDICAL CONDITION], that he be intubated and placed on the ventilator. Record review of the Staff Development/Inservice Attendance Sheet, dated [DATE], revealed the topic to be Checking Status before CPR. The objective was identified as Nurses must personally review code status of a patient before performing CPR. This in-service was not signed by RN A, RN B, or LVN A. Record review of the facility policy entitled Advance Directives, undated, revealed the policy was to ensure the facility honors the resident's wishes regarding end of life. The procedure was 1. Upon admission, the resident or authorized representative will be asked if they have an Advanced Directive. 6. If the resident is a Full Code a green sheet will be placed in a plastic sleeve in front of the chart along with the telephone order for Full Code. 7. If the resident is a DNR a red sheet will be placed in a plastic sleeve in the front of the chart along with the OOHDNR and the telephone order to reflect DNR. 9. Staff will recognize the color coded sheets in the event of a change of condition. 11. If the resident or authorized representative elects to execute an Advanced Directive at any time during their stay at the facility, the social worker or designee will meet with them and initiate the changes. A facility representative will notify the physician of the changes. Record review of the facility policy entitled Adult Cardiopulmonary Resuscitation, undated, revealed the policy to establish circulation and ventilation on a resident with absence of respirations and pulse. The procedure was to . 3. Delegate a specific individual to check the resident's medical record to establish the current code status. Record review of the facility policy entitled Rights of the Elderly, undated, revealed . (t) An elderly individual may: (1) make a living will by executing a directive under the Natural Death Act . (2) execute a durable power of attorney for health care . The following Plan of Removal was submitted by the facility on [DATE] at 9:30 AM: Area Requesting Attention: Resident Rights Specific to Resident Code Status. Corrective Action Taken: Licensed Nurses, CNA's, and CMA's were educated regarding Advanced Directive, Code Status, how to update changes in code status, notification of physician regarding change of condition. Person Responsible: ED/Nurse Management Date Completed: [DATE] and [DATE] Corrective Action Taken: 100% chart audit was done to ensure resident code status was correct. All telephone orders were reviewed to ensure the order matches the red or green sheet in the front of the residents chart. Person Responsible: Nurse Management Date Completed: [DATE], [DATE] and [DATE] Follow Up/Comments/Recommendations: No discrepancies identified during any of the audit. Corrective Action Taken: Licensed nurses were educated to review the first page of the resident chart to identify code status. There will be a red or green sheet with accompanying telephone order. Person Responsible: CNO & Nurse Managers Date Completed: [DATE] and [DATE] Corrective Action Taken: Licensed staff have been educated on updating a resident chart in the event a code status changes. This includes ensuring the red or green sheet and physician telephone are current and visible in the front plastic sleeve of the resident chart. Person Responsible: CNO and Nurse Managers Date Completed: [DATE] Corrective Action Taken: Charts will be audited weekly by the social service department or nurse management to ensure physician telephone order matches red/green sheet and results will be reported weekly to Standards of Care. Person Responsible: IDT Date Completed: [DATE], [DATE] and weekly Corrective Action Taken: Interviews have been and will continue to be conducted with licensed nursing staff weekly to ensure they understand the Advance Directive Policy. Once the resident's code status has been identified, a telephone order will be written for full code or DNR, per resident/responsible party wishes. A red or green sheet will be placed in a plastic sheet in the front of the chart with a copy of the physician telephone order. Person Responsible: CNO and Nurse Managers Date Completed: [DATE], [DATE] and weekly Corrective Action Taken: Adult Cardiopulmonary Resuscitation policy was revised to state that an individual from the nursing or social service department, that have been specifically educated on identification of code status, will communicate a residents code status. A licensed nurse will visibly check the OOHDNR or telephone order to verify code status. Person Responsible: CNO Date Completed: [DATE] Corrective Action Taken: Resident Care Cards will be monitored by nursing management, in the absence of nurse management, the charge nurse will monitor. Person Responsible: CNO and Nurse Managers Date Completed: [DATE], [DATE] and weekly Corrective Action Taken: Binders with Code Status process will be placed at both nurses stations to ensure any agency nursing staff are aware of the process prior to start of their shift. Agency supervisor has been provided a copy of in-service guidelines and advanced directive policy with a signature sheet as proof of education. A sign in sheet was placed in the book for agency nurses to sign to verify that they have read the information in the book. Person Responsible: CNO and Nurse Managers or designee will check the book daily to ensure compliance. Corrective Action Taken: Facility conducted QA&A meeting on [DATE] with acting DON, Administrator, COO, and Medical Director to discuss self-report related to CPR being administered on a DNR resident Code status audits will be reviewed in QA&A monthly x's 3 months. Person Responsible: CNO Date Completed: [DATE] Corrective Action Taken: Facility notified following physician of resident in question, responsible party, and DADs of events. Person Responsible: Administrator Date Completed: [DATE] Corrective Action Taken: all nursing employees will be educated regarding code status during general orientation. Person Responsible: HR/CNO Date Completed: [DATE] Observations and record reviews on [DATE] between 12:20 PM-1:00 PM identified 43 resident's charts that had correct code status identified in the front of the chart, along with a telephone order or out of hospital DNR signed by the physician and all care cards in these residents rooms were correctly identified in the residents wardrobes. Interviews conducted on [DATE] between 4:00 PM and 6:20PM with 8 LVN's and 3 RN's that work the 6am to 6pm shift, the DON, 2 Agency LVN's that work the 6pm to 6am and 2 LVN's that work 6pm to 6am. All indicated that they had been in serviced in regards to code status and reported that a licensed nurse must verify the code status by looking in the chart at the telephone order in the front of the chart or the out of hospital DNR located in the front of the chart before initiating a full code on a resident. In an interview with the Administrator on [DATE] at 6:20 PM he stated that he along with the DON and LVN D would be available throughout the weekend to in service all staff for all shifts regarding verification of code status prior to coming on the floor to work. The Immediate Jeopardy lifted on [DATE] at 6:23PM. The facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Record review of the Physician Orders List, dated [DATE], revealed 45 residents are identified as having a DNR Code Status.

Based on observation, interview and record review, the facility failed to ensure that 1 of 25 residents (Resident # 5) reviewed for continuity of care and skin integrity received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to: A) Assess and provide measures to prevent Resident #5's left heel wound from deteriorating and communicate with Resident #5's orthopedic physician and the outpatient wound care for continuity of care; Findings Include: Review of Resident #5's Face Sheet dated 11/23/15 revealed she was a [AGE] year old female admitted to the facility 09/09/15 with a readmission date of [DATE]. Review of Resident #5's unsigned Physician order [REDACTED]. Review of Resident #5's Admission MDS dated [DATE] revealed a BIMS score of 14 (cognitively intact), had no behaviors, was able to make her own choices of customary and routine activities, needed extensive assistance with transfers, dressing, hygiene and bathing, and was always incontinent of bowel and bladder. Resident #5's Admission MDS documented 'No' to swallowing Disorder: loss liquids/solids from mouth, holds food in mouth/cheeks, cough/choke with meals/meds and difficulty or pain swallowing. Under the Skin Conditions section of the MDS, Resident #5 was documented as having one Pressure Ulcer as a Stage III (skin that is not intact), with un-staged slough/eschar (Eschar-black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder that the surrounding skin), measuring 2.0 cm by 1.8 cm. Review of Resident #5's Quarterly MDS dated [DATE] revealed documentation of 'No' to swallowing Disorder: loss liquids/solids from mouth, holds food in mouth/cheeks, cough/choke with meals/meds and difficulty or pain swallowing. The Quarterly MDS documented Resident #5's Pressure Ulcer measurements as 2.0 cm by 3.0 cm. Review of Resident #5's Care Plan dated 09/22/15 revealed skin breakdown or concerns. In an interview on 11/30/15 at 4:20 p.m., Resident #5's family member said Resident #5's wound was getting worse. She said the facility had not notified her about Resident #5's left heel wound, and that Resident #5's right foot was also getting red. Resident #5's family member said that she did not feel like the facility was taking care of the wound. In an interview on 12/02/15 at 8:20 a.m., the DON said Resident #5 went to wound care 12/01/15. The DON was unable to find a physician's orders [REDACTED].#5 to outpatient wound care. The DON found a Physician order [REDACTED]. Wound care L (left) heel) . This surveyor asked the DON how the facility communicated with the physician and outpatient wound care. The DON said, That's what Physician B must have sent to the wound care office. The DON said she would have to request notes from outpatient wound care to find out what treatment Resident #5 received 12/01/15. Observation on 12/01/15 at 3:30 p.m. revealed Resident #5 being wheeled in to the facility by her sister. Resident #5's sister said they had been to wound care and that Resident #5 was to return to wound care 12/04/15. Resident #5 was observed to have a dressing covering her entire left foot. In an interview on 12/01/15 at 3:30 p.m., LVN A said she did not know Resident #5 had gone to wound care. When this surveyor asked LVN A about transportation for Resident #5 to and from wound care, LVN A said she did not know how she went or returned. Review of Resident #5's Doctor's Progress Notes dated 11/02/15 revealed, .Heel wound healing slowly .strict pressure precautions on L (left) heel . The progress note was signed by Physician B. Review of Resident #5's Doctor's Progress Notes dated 11/19/15 revealed, .Heel ulceration stable .Outpatient wound care . Review of Resident #5's physician's orders [REDACTED].Evaluate and Treat Wound Care L (left) heel . Review of the facility's Wound Assessment Report dated 11/30/15 revealed, .Upon weekly skin assessment this nurse noted the wound had increased in size. Skin around area was moist and white. Moderate amount of serosanguineous drainage noted on dressing, area 1 cm by 1 cm uncovered by scab. Will notify (name of Physician C) of wound condition as soon as possible . Review of Resident #5's Departmental Notes dated 10/11/15 revealed, .SDTI (suspect deep tissue injury) to L (left) heel . Review of Resident #5's eTAR for November 2015 revealed, .Apply dry protective [MEDICATION NAME] (an absorbent waterproof dressing www.medline.com <http://www.medline.com>) dressings to unstagable PU (Pressure Ulcer) to L (left) Heel prn (as needed) until healed .Apply dry protective [MEDICATION NAME] dressings to unstagable PU MWF (Monday-Wednesday-Friday) and prn until healed . Review of a fax received by the facility from the Wound Care Center 12/03/15 and dated 12/01/15 read, .Pt (patient) is a [AGE] year old female that had a spiral [MEDICAL CONDITION] tibia/fibula 08/06/15. She had surgery on 08/08/15 .went to rehab and then SNF (skilled nursing facility) .had developed an unstagable pressure ulcer on the left posterior heel .Wound left posterior heel is a chronic necrotic tissue (unstagable) pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 4 cm length x 5.5 cm width x 0.3 cm depth .Wound bed is 1-25% eschar, 51-75% slough, 1-25% pink, spongy granulation .Procedures: Wound (pressure ulcer) is located on the left, posterior heel. There was a surgical debridement performed by (name of physical therapist) .remove dermis and muscle along with devitalized tissue: necrotic/eschar and slough .post debridement stage noted as necrotic tissue (unstagable) .The wound was deep and necrotic material including what appeared to be necrotic muscle was debrided . CMS 672 dated 11/19/15 revealed 13 residents in the facility with pressure ulcers and 5 residents admitted to the facility with pressure ulcers, and identified 8 resident with an indwelling urinary catheter. Interview with the DON on 12/3/15 revealed 1 resident with a [DEVICE] in the facility.

Based on observation, interview and record review, the facility failed to use the comprehensive assessment of 3 of 7 residents (Resident #4 #5 and #21) reviewed for pressure ulcers to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to: 1. Prevent Resident #4 from developing a pressure ulcer; 2. Ensure Resident #5's pressure ulcer on her left heel did not deteriorate. 3. Ensure Resident ID #21, did not develop pressure sores, the resident who is very interviewable stated she had not received helped with incontinent care on one entire night shift ( 11/30/15) as she could not call for help due to the call light not in reach. Resident ID #21 stated the nurse aide never came in her room until the day shift came on the following morning. The resident was discovered to have multiple open wounds to the coccyx. These failures could affect any of the 13 residents in the facility with pressure sores and result in worsening of the current pressure sore and/or development of new pressure sores. The findings included: Resident #4 (facility-acquired pressure sores) Record review of an undated Face Sheet (resident admission record) revealed Resident #4 is a [AGE] year-old female admitted to the facility on [DATE] from another nursing facility. [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) for admission, dated 2/12/15 documented Resident #4 had no Stage 1 or higher pressure ulcers. Record review of the MDS dated [DATE] documented Resident #4 had no Stage 1 or higher pressure ulcers. The MDS documented that a Brief Interview for Mental Status could not be completed due to resident is rarely/never understood and has short-term and long-term memory problems. Under Functional Status the MDS documented Resident #4 had total dependence (full staff performance), on the assistance of one staff for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing. MDS documented Resident's range of motion to be impaired on both sides and in both upper and lower extremities (arms and legs), she uses a wheelchair, and she is always incontinent of bowel and bladder. by 1/16 inch open area on her left sacrum. The area was surrounded by red skin 2 inches in diameter. During an interview on 11/23/15 at 2:00 p.m. LVN D said the pressure ulcer was discovered around the 9th of November. LVN D said I started filling in for the regular treatment nurse around the 9th of this month and the pressure ulcer was found around that time. Record Review of Nurses Note dated 11/11/15 for Resident #4 revealed late entry for 11/10/15, resident has stage 2 pressure ulcer to sacrum, 2 cm x 1 cm x 0.01 cm. Record Review of physician's orders [REDACTED].#4 revealed an order for [REDACTED]. Record review of Weekly Skin Reviews for Resident #4 revealed an assessment dated [DATE] that documented no new dry skin, old S/T (skin tear) to left elbow. There were no markings on the diagram of a human body indicating a pressure sore. The Weekly Skin Review dated 11/16/15 documented dry skin no areas noted. A line was drawn to an area on the left buttock of a human diagram and St II was documented. The Weekly Skin Review dated 11/23/15 documented dry skin all over body no new areas. A line was drawn to an area on the left buttock of a human diagram and Stg II was documented. During an interview with the DON on 11/24/15 at 3:15 p.m. this surveyor requested additional Weekly Skin Review documents for the time between 10/23/15 and 11/16/15. The DON said the rest are on the computer. The DON went to the computer (laptop) and pulled up a Skin Inspection Report for Resident #4 for the dates of 2/15/15 through 11/2/15. The report did not contain information that identified the type or location of skin issues for Resident #4. Record Review of the Care Plan dated 2/6/2015 with revisions dated 4/23/15 revealed no approaches for care or treatment of [REDACTED]. Apply barrier cream; Weekly head to toe skin assessment by licensed nurse, any finding to be documented and reported to MD and responsible party; Turn and reposition at least every 2 hours. Approaches for risk for falls included: Staff to check for incontinence at least every 2 hours. During an interview on 11/24/15 at 3:15 p.m. the DON verified that the care plan this surveyor was looking at on the computer was the care plan for Resident #4. The DON said all the care plans except for weights and falls are on the computer. Record Review of the ADL Assistance and Support dated November 2015 documented the level of assistance Resident #4 required each day for her activities of daily living, including bed mobility (which was documented as extensive with assistance of one staff for the majority of the time from 11/1/15-11/23/15 and total dependence with assistance of one staff during the evenings and/or nights of 11/15/15-11/17/15). The ADL sheet on which tasks are listed and staff document completion of the task, turning and repositioning every 2 hours was not listed as a task under the heading Description. Resident #5 Review of Resident #5's Face Sheet dated 11/23/15 revealed she was a [AGE] year old female admitted to the facility 09/09/15 with a readmission date of [DATE]. Review of Resident #5's unsigned Physician order [REDACTED]. Review of Resident #5's Admission MDS dated [DATE] revealed a BIMS score of 14 (cognitively intact), had no behaviors, was able to make her own choices of customary and routine activities, needed extensive assistance with transfers, dressing, hygiene and bathing, and was always incontinent of bowel and bladder. Under the Skin Conditions section, Resident #5 was documented as having a Pressure Ulcer to her left heel as a Stage III (skin that is not intact), with un-staged slough/eschar (Eschar-black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than the surrounding skin), measuring 2.0 cm by 1.8 cm. Review of Resident #5's Quarterly MDS dated [DATE] revealed documentation of Resident #5's Pressure Ulcer to the left foot measurements as 2.0 cm by 3.0 cm. Review of Resident #5's Care Plan dated 09/22/15 revealed no skin breakdown or concerns. In an interview on 11/30/15 at 4:20 p.m., Resident #5's family member said Resident #5's wound was getting worse. She said the facility had not notified her about Resident #5's left heel wound, and that Resident #5's right foot was also getting red. Resident #5's family member said that she did not feel like the facility was taking care of the wound. Observation on 12/01/15 at 7:55 a.m. revealed Resident #5 in her bed with a breakfast tray in front of her on her overbed table. Resident #5's left heel was not lifted to prevent pressure on the area. Observation on 12/01/15 at 12:45 p.m. revealed Resident #5 out of her room. In an interview on 12/01/15 at 12:46 p.m., LVN A said she did not know where Resident #5 was. LVN A said, I've been off for three days. Observation on 12/01/15 at 3:30 p.m. revealed Resident #5 being wheeled in to the facility by her sister. Resident #5's sister said they had been to wound care and that Resident #5 was to return to wound care 12/04/15. Resident #5 was observed to have a dressing covering her entire left foot. In an interview on 12/01/15 at 3:30 p.m., LVN A said she did not know Resident #5 had gone to wound care. When this surveyor asked LVN A about transportation for Resident #5 to and from wound care, LVN A said she did not know how she went or returned. Review of Resident #5's Doctor's Progress Notes dated 11/02/15 revealed, .Heel wound healing slowly .strict pressure precautions on L (left) heel . The progress note was signed by Physician B. Review of Resident #5's Doctor's Progress Notes dated 11/19/15 revealed, .Heel ulceration stable .Outpatient wound care . Review of Resident #5's physician's orders [REDACTED].Evaluate and Treat Wound Care L (left) heel . Review of the facility's Wound Assessment Report dated 11/30/15 revealed, .Upon weekly skin assessment this nurse noted the wound had increased in size. Skin around area was moist and white. Moderate amount of serosanguineous drainage noted on dressing, area 1 cm by 1 cm uncovered by scab. Will notify (name of Physician C) of wound condition as soon as possible . Review of Resident #5's Departmental Notes dated 10/11/15 revealed, .SDTI (suspect deep tissue injury) to L (left) heel . Review of Resident #5's eTAR for November 2015 revealed, .Apply dry protective [MEDICATION NAME] (an absorbent waterproof dressing www.medline.com <http://www.medline.com>) dressings to unstagable PU (Pressure Ulcer) to L (left) Heel prn (as needed) until healed .Apply dry protective [MEDICATION NAME] dressings to unstagable PU (Pressure Ulcer) MWF (Monday-Wednesday-Friday) and prn until healed . In an interview on 12/02/15 at 8:20 a.m., the DON said Resident #5 went to wound care 12/01/15. The DON was unable to find a physician's order [REDACTED].#5 to outpatient wound care. The DON found a Physician order [REDACTED]. Wound care L (left) heel) . This surveyor asked the DON how the facility communicated with the physician and outpatient wound care. The DON said, That ' s what Physician B must have sent to the wound care office. The DON said she would have to request notes from outpatient wound care to find out what treatment Resident #5 received 12/01/15. Review of a fax received by the facility from the Wound Care Center 12/03/15 and dated 12/01/15 read, .Pt (patient) is a [AGE] year old female that had a spiral [MEDICAL CONDITION] tibia/fibula 08/06/15. She had surgery on 08/08/15 .went to rehab and then SNF (skilled nursing facility) .had developed an unstagable pressure ulcer on the left posterior heel .Wound left posterior heel is a chronic necrotic tissue (unstagable) pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 4 cm length x 5.5 cm width x 0.3 cm depth .Wound bed is 1-25% eschar, 51-75% slough, 1-25% pink, spongy granulation .Procedures: Wound (pressure ulcer) is located on the left, posterior heel. There was a surgical debridement performed by (name of physical therapist) .remove dermis and muscle along with devitalized tissue: necrotic/eschar and slough .post debridement stage noted as necrotic tissue (unstagable) .The wound was deep and necrotic material including what appeared to be necrotic muscle was debrided . Resident ID #21 Review of Resident #21 ' s face sheet dated 12/01/2015 indicated resident was [AGE] years of age and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident#21 ' s Initial MDS (Minimum Data Set) dated 11/18/15 revealed BIMS (Brief Interview for Mental Status) score of 15 indicating she is cognitively intact. Initial MDS (Minimum Data Set) dated 11/18/15 revealed Resident #21 required Extensive assistance of two persons for toilet use. Initial MDS (Minimum Data Set) dated 11/18/15 revealed Resident #21 does not have Stage 1 or higher pressure ulcer. Record Review of Resident #21 ' s Admission Nursing Assessment completed by LVN I dated 11/16/15 revealed extensive assistance - resident involved in activity, staff provide one person physical assist for weight-bearing support for toilet use. Admission Nursing assessment dated [DATE] reveals redness present to sacral/coccyx and open area or blister location as sacral/coccyx area. Record Review of Resident #21 ' s Care plan dated 11/20/15 revealed she is at risk for skin breakdown due to decreased mobility. Resident #21 ' s Care plan revealed the following interventions; monitor skin routinely and as needed and report problems with redness, irritation or open areas to my physician and family, provide treatment as ordered by my physician, assist her to turn and reposition when in bed and to change positions frequently when in the wheelchair. Resident #21 ' s care plan dated 11/20/15 revealed she requires extensive assistance with her ADL ' s due to weakness and decreased mobility. Resident #21 ' s Care plan revealed the following interventions; shower per shower schedule, assist with dressing and care of hair, nails and oral care, assist with all transfers, assist to turn and reposition when in bed. Resident #21 ' s Care plan dated 11/25/15 revealed she was at risk for incontinent episodes and possible UTI (Urinary tract Infection). Resident #21 ' s Care plan revealed the following interventions; remove catheter and monitor me for incontinent episodes, report episodes of increased urinary incontinence to physician and family, assist with toileting including transfers, hygiene and adjusting clothing, monitor for signs and symptoms of UTI (Urinary Tract Infection) and report problems to physician. Resident #21 ' s care plan dated 11/24/15 revealed she has impaired vision. Resident #21 ' s Care plan revealed the following interventions; place frequently used items within reach and place items directly in front for better viewing. Resident #21 ' s care plan dated 11/24/15 revealed she has difficulty participating in social conversations due to paralysis of vocal cords. Resident #21 ' s Care plan revealed the following interventions; allow plenty of time to respond and provide a quiet environment when discussing important issues. Record Review of Weekly Skin Review completed by ADON for Resident #21 dated 11/16/15 revealed swelling bilateral lower extremities and no open areas noted. Record Review of Weekly Skin Review completed by LVN D for Resident #21 dated 11/25/15 revealed swelling bilateral lower extremities. Observation of Resident #21 during surveyor skin rounds revealed 12/02/15 at 5:20 p.m., there were three open areas to coccyx. LVN H and RN A said they were not aware of open areas to coccyx. RN A measured areas as Stage II upper coccyx 1 x 1 cm, Stage II lower coccyx .5 x .5cm and sheer lower coccyx 2.2 x 1 cm. Record Review of Weekly Skin Review dated 12/2/15 revealed to see wound report. Wound Assessment Report completed by ADON for Resident #21 dated 12/2/15 at 6:49 p.m. revealed pressure ulcer to coccyx identified wound on 12/2/15. Wound Assessment Report dated 12/2/15 at 6:53 p.m. revealed a Stage 2 wound measuring 1cm x 1cm. Wound Assessment Report dated 12/2/15 at 6:55 p.m. completed by ADON revealed a Stage 1 pressure ulcer to sacrum measuring 1.0cm x 1.2cm. Record Review of physician's order [REDACTED]. Record Review of Weekly skin review completed by LVN I dated 12/03/15 revealed 1.8cmx 0.7 x 0.1 Stage II coccyx, 1.0 x 1.0 Stage I left inner buttock and 1.0 x 1.3 Stage I right inner buttock. Record Review of Departmental Notes by ADON dated 12/3/15 at 3:52pm reveals family and physician H was notified of change in condition. Record Review of Resident #21 ' s Comprehensive Care Plan dated 12/03/15 reveals resident has current skin concerns of open [MEDICAL CONDITION]. Comprehensive Care plan listed the following interventions; perform treatments per order, if no improvement x 2 weeks, report to physician, monitor areas for increase breakdown, signs/symptoms of infection, report to physician, monitor for pain, keep physician and family informed of residents progress, assess for possible reasons for skin concerns, report findings to physician. Comprehensive Care Plan dated 12/3/15 lists open areas as 1.8 x 0.7 Stage II coccyx, 1.0 x 1.0 Stage I left inner buttock and 1.0 x 1.3 Stage I right inner buttock. Interview with CNA J on 12/02/15 at 3:37 p.m., said she worked Saturday (11/28/15) 2 p.m. to 10 p.m. CNA J said CNA K stated she did not change Resident #21 on her shift Saturday (11/28/15) because Resident #21 did not request to be changed. CNA J said linens had brown ring from mid -back to knee area. CNA J said she asked CNA K to assist changing Resident #21, CNA K said it was after 2 and peace and left. CNA J said she reported this to LVN I on Saturday (11/28/15). Interview with Resident #21 on 12/02/15 at 3:40 p.m., she said it takes staff some time to answer her call. She said she lies in urine for periods of time making her feel terrible. Interview with CNA K on 12/03/15 at 11:35 a.m., she said she checked on Resident #21 Saturday (11/28/15) around 6:30 a.m. - 6:40 a.m., again at 8:45 a.m. - 9:30 a.m. and 12:50 p.m.- 1:20 p.m. CNA K said resident #21 was scheduled for shower on Saturday but has history of refusing showers. She said she would need to check ADL ' s (Activities of Daily Living) sheet to determine if she was bathed. CNA K said no skin issues were noted on Saturday but Tuesday (12/01/15) Resident #21 was noted to have one small sore on tailbone area that she applied cream to. CNA K said she changed Resident #21 between 12:50 p.m. - 1:20 p.m. with assistance of COTA A. CNA K said she is to check Resident #21 every 2 hours and change if wet. Interview with COTA A on 12/03/2015 at 12:03p.m., she said she did not work on Saturday (11/28/15). She said on 12/02/15 (Wednesday) at 12:30 p.m. she did assist CNA K with Resident #21 and transported her to therapy. Interview with LVN I on 12/03/2015 at 12:30p.m., she said CNA J reported to her Saturday (11/28/15) that CNA K left Resident #21 wet. LVN I said Resident #21 was saturated with urine. LVN I said no skin breakdown was reported to her on Saturday (11/28/15). LVN I said she asked CNA K to assist in changing Resident #21 but CNA K left the building. LVN I failed to report the incident to administrative staff that Resident ID #21 had not been changed the entire day shift by CNA K. Interview by Resident ID #21 on 12/02/15 at 3:40 PM when asked about the incident that occurred on day shift of 11/29/15, the resident stated it takes staff awhile to answer the call lights and then reflected on the night of the 30th that she never received incontinent care the entire night due to call light was not in reach and no one came in her room. Policy and Procedure: Review of the facility's policy, Skin Risk Review/Checks received 12/03/15, undated, revealed, Policy: To ensure the proper evaluation of all residents' skin and potential skin breakdown. Also to ensure timely identification and notification of newly identified skin problems .If the area is pressure related, the area should be staged as follows: -STAGE I: Apersistent area of redness, without a break in the skin, that is non-blanchable -STAGE II: A partial thickness loss of skin layers either the dermis or epidermis that presents clinically as an abrasion, blister or shallow crater -STAGE III: A full thickness of skin loss exposing the subcutaneous tissues. Presents as a deep crater with or without undermining adjacent tissue -STAGE IV: A full thickness loss of skin and subcutaneous tissue exposing muscle and/or bone -UTD (unable to determine): Any pressure area that has eschar or slough present preventing accurate staging .When a resident is at high risk for skin breakdown or currently has skin breakdown the following interventions will be put in place: -Pressure relieving mattress -Pressure relieving cushion to wheelchair -Baseline dietary assessment to assure nutritional needs are being met. Make supplement and vitamin recommendations -Weekly weights -Turning and repositioning plan as needed -Positioning devices as needed -Weekly measurements by nurse -Weekly head to toe assessments. CMS 672 dated 11/19/15 revealed 13 residents with pressure ulcers with 5 residents having pressure ulcers upon admission.

Based on observation, interview and record review, the facility failed to use the comprehensive assessment of 3 of 7 residents (Resident #4 #5 and #21) reviewed for pressure ulcers to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to: 1. Prevent Resident #4 from developing a pressure ulcer; 2. Ensure Resident #5's pressure ulcer on her left heel did not deteriorate. 3. Ensure Resident ID #21, did not develop pressure sores, the resident who is very interviewable stated she had not received helped with incontinent care on one entire night shift ( 11/30/15) as she could not call for help due to the call light not in reach. Resident ID #21 stated the nurse aide never came in her room until the day shift came on the following morning. The resident was discovered to have multiple open wounds to the coccyx. These failures could affect any of the 13 residents in the facility with pressure sores and result in worsening of the current pressure sore and/or development of new pressure sores. The findings included: Resident #4 (facility-acquired pressure sores) Record review of an undated Face Sheet (resident admission record) revealed Resident #4 is a [AGE] year-old female admitted to the facility on [DATE] from another nursing facility. [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) for admission, dated 2/12/15 documented Resident #4 had no Stage 1 or higher pressure ulcers. Record review of the MDS dated [DATE] documented Resident #4 had no Stage 1 or higher pressure ulcers. The MDS documented that a Brief Interview for Mental Status could not be completed due to resident is rarely/never understood and has short-term and long-term memory problems. Under Functional Status the MDS documented Resident #4 had total dependence (full staff performance), on the assistance of one staff for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing. MDS documented Resident's range of motion to be impaired on both sides and in both upper and lower extremities (arms and legs), she uses a wheelchair, and she is always incontinent of bowel and bladder. by 1/16 inch open area on her left sacrum. The area was surrounded by red skin 2 inches in diameter. During an interview on 11/23/15 at 2:00 p.m. LVN D said the pressure ulcer was discovered around the 9th of November. LVN D said I started filling in for the regular treatment nurse around the 9th of this month and the pressure ulcer was found around that time. Record Review of Nurses Note dated 11/11/15 for Resident #4 revealed late entry for 11/10/15, resident has stage 2 pressure ulcer to sacrum, 2 cm x 1 cm x 0.01 cm. Record Review of physician's orders [REDACTED].#4 revealed an order for [REDACTED].>Record review of Weekly Skin Reviews for Resident #4 revealed an assessment dated [DATE] that documented no new dry skin, old S/T (skin tear) to left elbow. There were no markings on the diagram of a human body indicating a pressure sore. The Weekly Skin Review dated 11/16/15 documented dry skin no areas noted. A line was drawn to an area on the left buttock of a human diagram and St II was documented. The Weekly Skin Review dated 11/23/15 documented dry skin all over body no new areas. A line was drawn to an area on the left buttock of a human diagram and Stg II was documented. During an interview with the DON on 11/24/15 at 3:15 p.m. this surveyor requested additional Weekly Skin Review documents for the time between 10/23/15 and 11/16/15. The DON said the rest are on the computer. The DON went to the computer (laptop) and pulled up a Skin Inspection Report for Resident #4 for the dates of 2/15/15 through 11/2/15. The report did not contain information that identified the type or location of skin issues for Resident #4. Record Review of the Care Plan dated 2/6/2015 with revisions dated 4/23/15 revealed no approaches for care or treatment of [REDACTED]. Apply barrier cream; Weekly head to toe skin assessment by licensed nurse, any finding to be documented and reported to MD and responsible party; Turn and reposition at least every 2 hours. Approaches for risk for falls included: Staff to check for incontinence at least every 2 hours. During an interview on 11/24/15 at 3:15 p.m. the DON verified that the care plan this surveyor was looking at on the computer was the care plan for Resident #4. The DON said all the care plans except for weights and falls are on the computer. Record Review of the ADL Assistance and Support dated (MONTH) (YEAR) documented the level of assistance Resident #4 required each day for her activities of daily living, including bed mobility (which was documented as extensive with assistance of one staff for the majority of the time from 11/1/15-11/23/15 and total dependence with assistance of one staff during the evenings and/or nights of 11/15/15-11/17/15). The ADL sheet on which tasks are listed and staff document completion of the task, turning and repositioning every 2 hours was not listed as a task under the heading Description. Resident #5 Review of Resident #5's Face Sheet dated 11/23/15 revealed she was a [AGE] year old female admitted to the facility 09/09/15 with a readmission date of [DATE]. Review of Resident #5's unsigned Physician order [REDACTED]. Review of Resident #5's Admission MDS dated [DATE] revealed a BIMS score of 14 (cognitively intact), had no behaviors, was able to make her own choices of customary and routine activities, needed extensive assistance with transfers, dressing, hygiene and bathing, and was always incontinent of bowel and bladder. Under the Skin Conditions section, Resident #5 was documented as having a Pressure Ulcer to her left heel as a Stage III (skin that is not intact), with un-staged slough/eschar (Eschar-black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than the surrounding skin), measuring 2.0 cm by 1.8 cm. Review of Resident #5's Quarterly MDS dated [DATE] revealed documentation of Resident #5's Pressure Ulcer to the left foot measurements as 2.0 cm by 3.0 cm. Review of Resident #5's Care Plan dated 09/22/15 revealed no skin breakdown or concerns. In an interview on 11/30/15 at 4:20 p.m., Resident #5's family member said Resident #5's wound was getting worse. She said the facility had not notified her about Resident #5's left heel wound, and that Resident #5's right foot was also getting red. Resident #5's family member said that she did not feel like the facility was taking care of the wound. Observation on 12/01/15 at 7:55 a.m. revealed Resident #5 in her bed with a breakfast tray in front of her on her overbed table. Resident #5's left heel was not lifted to prevent pressure on the area. Observation on 12/01/15 at 12:45 p.m. revealed Resident #5 out of her room. In an interview on 12/01/15 at 12:46 p.m., LVN A said she did not know where Resident #5 was. LVN A said, I've been off for three days. Observation on 12/01/15 at 3:30 p.m. revealed Resident #5 being wheeled in to the facility by her sister. Resident #5's sister said they had been to wound care and that Resident #5 was to return to wound care 12/04/15. Resident #5 was observed to have a dressing covering her entire left foot. In an interview on 12/01/15 at 3:30 p.m., LVN A said she did not know Resident #5 had gone to wound care. When this surveyor asked LVN A about transportation for Resident #5 to and from wound care, LVN A said she did not know how she went or returned. Review of Resident #5's Doctor's Progress Notes dated 11/02/15 revealed, .Heel wound healing slowly .strict pressure precautions on L (left) heel . The progress note was signed by Physician B. Review of Resident #5's Doctor's Progress Notes dated 11/19/15 revealed, .Heel ulceration stable .Outpatient wound care . Review of Resident #5's physician's orders [REDACTED].Evaluate and Treat Wound Care L (left) heel . Review of the facility's Wound Assessment Report dated 11/30/15 revealed, .Upon weekly skin assessment this nurse noted the wound had increased in size. Skin around area was moist and white. Moderate amount of serosanguineous drainage noted on dressing, area 1 cm by 1 cm uncovered by scab. Will notify (name of Physician C) of wound condition as soon as possible . Review of Resident #5's Departmental Notes dated 10/11/15 revealed, .SDTI (suspect deep tissue injury) to L (left) heel . Review of Resident #5's eTAR for (MONTH) (YEAR) revealed, .Apply dry protective [MEDICATION NAME] (an absorbent waterproof dressing www.medline.com <http://www.medline.com>) dressings to unstagable PU (Pressure Ulcer) to L (left) Heel prn (as needed) until healed .Apply dry protective [MEDICATION NAME] dressings to unstagable PU (Pressure Ulcer) MWF (Monday-Wednesday-Friday) and prn until healed . In an interview on 12/02/15 at 8:20 a.m., the DON said Resident #5 went to wound care 12/01/15. The DON was unable to find a physician's order [REDACTED].#5 to outpatient wound care. The DON found a Physician order [REDACTED]. Wound care L (left) heel) . This surveyor asked the DON how the facility communicated with the physician and outpatient wound care. The DON said, That ' s what Physician B must have sent to the wound care office. The DON said she would have to request notes from outpatient wound care to find out what treatment Resident #5 received 12/01/15. Review of a fax received by the facility from the Wound Care Center 12/03/15 and dated 12/01/15 read, .Pt (patient) is a [AGE] year old female that had a spiral [MEDICAL CONDITION] tibia/fibula 08/06/15. She had surgery on 08/08/15 .went to rehab and then SNF (skilled nursing facility) .had developed an unstagable pressure ulcer on the left posterior heel .Wound left posterior heel is a chronic necrotic tissue (unstagable) pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 4 cm length x 5.5 cm width x 0.3 cm depth .Wound bed is 1-25% eschar, 51-75% slough, 1-25% pink, spongy granulation .Procedures: Wound (pressure ulcer) is located on the left, posterior heel. There was a surgical debridement performed by (name of physical therapist) .remove dermis and muscle along with devitalized tissue: necrotic/eschar and slough .post debridement stage noted as necrotic tissue (unstagable) .The wound was deep and necrotic material including what appeared to be necrotic muscle was debrided . Resident ID #21 Review of Resident #21 ' s face sheet dated 12/01/2015 indicated resident was [AGE] years of age and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident#21 ' s Initial MDS (Minimum Data Set) dated 11/18/15 revealed BIMS (Brief Interview for Mental Status) score of 15 indicating she is cognitively intact. Initial MDS (Minimum Data Set) dated 11/18/15 revealed Resident #21 required Extensive assistance of two persons for toilet use. Initial MDS (Minimum Data Set) dated 11/18/15 revealed Resident #21 does not have Stage 1 or higher pressure ulcer. Record Review of Resident #21 ' s Admission Nursing Assessment completed by LVN I dated 11/16/15 revealed extensive assistance - resident involved in activity, staff provide one person physical assist for weight-bearing support for toilet use. Admission Nursing assessment dated [DATE] reveals redness present to sacral/coccyx and open area or blister location as sacral/coccyx area. Record Review of Resident #21 ' s Care plan dated 11/20/15 revealed she is at risk for skin breakdown due to decreased mobility. Resident #21 ' s Care plan revealed the following interventions; monitor skin routinely and as needed and report problems with redness, irritation or open areas to my physician and family, provide treatment as ordered by my physician, assist her to turn and reposition when in bed and to change positions frequently when in the wheelchair. Resident #21 ' s care plan dated 11/20/15 revealed she requires extensive assistance with her ADL ' s due to weakness and decreased mobility. Resident #21 ' s Care plan revealed the following interventions; shower per shower schedule, assist with dressing and care of hair, nails and oral care, assist with all transfers, assist to turn and reposition when in bed. Resident #21 ' s Care plan dated 11/25/15 revealed she was at risk for incontinent episodes and possible UTI (Urinary tract Infection). Resident #21 ' s Care plan revealed the following interventions; remove catheter and monitor me for incontinent episodes, report episodes of increased urinary incontinence to physician and family, assist with toileting including transfers, hygiene and adjusting clothing, monitor for signs and symptoms of UTI (Urinary Tract Infection) and report problems to physician. Resident #21 ' s care plan dated 11/24/15 revealed she has impaired vision. Resident #21 ' s Care plan revealed the following interventions; place frequently used items within reach and place items directly in front for better viewing. Resident #21 ' s care plan dated 11/24/15 revealed she has difficulty participating in social conversations due to paralysis of vocal cords. Resident #21 ' s Care plan revealed the following interventions; allow plenty of time to respond and provide a quiet environment when discussing important issues. Record Review of Weekly Skin Review completed by ADON for Resident #21 dated 11/16/15 revealed swelling bilateral lower extremities and no open areas noted. Record Review of Weekly Skin Review completed by LVN D for Resident #21 dated 11/25/15 revealed swelling bilateral lower extremities. Observation of Resident #21 during surveyor skin rounds revealed 12/02/15 at 5:20 p.m., there were three open areas to coccyx. LVN H and RN A said they were not aware of open areas to coccyx. RN A measured areas as Stage II upper coccyx 1 x 1 cm, Stage II lower coccyx .5 x .5cm and sheer lower coccyx 2.2 x 1 cm. Record Review of Weekly Skin Review dated 12/2/15 revealed to see wound report. Wound Assessment Report completed by ADON for Resident #21 dated 12/2/15 at 6:49 p.m. revealed pressure ulcer to coccyx identified wound on 12/2/15. Wound Assessment Report dated 12/2/15 at 6:53 p.m. revealed a Stage 2 wound measuring 1cm x 1cm. Wound Assessment Report dated 12/2/15 at 6:55 p.m. completed by ADON revealed a Stage 1 pressure ulcer to sacrum measuring 1.0cm x 1.2cm. Record Review of physician's order [REDACTED]. Record Review of Weekly skin review completed by LVN I dated 12/03/15 revealed 1.8cmx 0.7 x 0.1 Stage II coccyx, 1.0 x 1.0 Stage I left inner buttock and 1.0 x 1.3 Stage I right inner buttock. Record Review of Departmental Notes by ADON dated 12/3/15 at 3:52pm reveals family and physician H was notified of change in condition. Record Review of Resident #21 ' s Comprehensive Care Plan dated 12/03/15 reveals resident has current skin concerns of open [MEDICAL CONDITION]. Comprehensive Care plan listed the following interventions; perform treatments per order, if no improvement x 2 weeks, report to physician, monitor areas for increase breakdown, signs/symptoms of infection, report to physician, monitor for pain, keep physician and family informed of residents progress, assess for possible reasons for skin concerns, report findings to physician. Comprehensive Care Plan dated 12/3/15 lists open areas as 1.8 x 0.7 Stage II coccyx, 1.0 x 1.0 Stage I left inner buttock and 1.0 x 1.3 Stage I right inner buttock. Interview with CNA J on 12/02/15 at 3:37 p.m., said she worked Saturday (11/28/15) 2 p.m. to 10 p.m. CNA J said CNA K stated she did not change Resident #21 on her shift Saturday (11/28/15) because Resident #21 did not request to be changed. CNA J said linens had brown ring from mid -back to knee area. CNA J said she asked CNA K to assist changing Resident #21, CNA K said it was after 2 and peace and left. CNA J said she reported this to LVN I on Saturday (11/28/15). Interview with Resident #21 on 12/02/15 at 3:40 p.m., she said it takes staff some time to answer her call. She said she lies in urine for periods of time making her feel terrible. Interview with CNA K on 12/03/15 at 11:35 a.m., she said she checked on Resident #21 Saturday (11/28/15) around 6:30 a.m. - 6:40 a.m., again at 8:45 a.m. - 9:30 a.m. and 12:50 p.m.- 1:20 p.m. CNA K said resident #21 was scheduled for shower on Saturday but has history of refusing showers. She said she would need to check ADL ' s (Activities of Daily Living) sheet to determine if she was bathed. CNA K said no skin issues were noted on Saturday but Tuesday (12/01/15) Resident #21 was noted to have one small sore on tailbone area that she applied cream to. CNA K said she changed Resident #21 between 12:50 p.m. - 1:20 p.m. with assistance of COTA A. CNA K said she is to check Resident #21 every 2 hours and change if wet. Interview with COTA A on 12/03/2015 at 12:03p.m., she said she did not work on Saturday (11/28/15). She said on 12/02/15 (Wednesday) at 12:30 p.m. she did assist CNA K with Resident #21 and transported her to therapy. Interview with LVN I on 12/03/2015 at 12:30p.m., she said CNA J reported to her Saturday (11/28/15) that CNA K left Resident #21 wet. LVN I said Resident #21 was saturated with urine. LVN I said no skin breakdown was reported to her on Saturday (11/28/15). LVN I said she asked CNA K to assist in changing Resident #21 but CNA K left the building. LVN I failed to report the incident to administrative staff that Resident ID #21 had not been changed the entire day shift by CNA K. Interview by Resident ID #21 on 12/02/15 at 3:40 PM when asked about the incident that occurred on day shift of 11/29/15, the resident stated it takes staff awhile to answer the call lights and then reflected on the night of the 30th that she never received incontinent care the entire night due to call light was not in reach and no one came in her room. Policy and Procedure: Review of the facility's policy, Skin Risk Review/Checks received 12/03/15, undated, revealed, Policy: To ensure the proper evaluation of all residents' skin and potential skin breakdown. Also to ensure timely identification and notification of newly identified skin problems .If the area is pressure related, the area should be staged as follows: -STAGE I: Apersistent area of redness, without a break in the skin, that is non-blanchable -STAGE II: A partial thickness loss of skin layers either the dermis or epidermis that presents clinically as an abrasion, blister or shallow crater -STAGE III: A full thickness of skin loss exposing the subcutaneous tissues. Presents as a deep crater with or without undermining adjacent tissue -STAGE IV: A full thickness loss of skin and subcutaneous tissue exposing muscle and/or bone -UTD (unable to determine): Any pressure area that has eschar or slough present preventing accurate staging .When a resident is at high risk for skin breakdown or currently has skin breakdown the following interventions will be put in place: -Pressure relieving mattress -Pressure relieving cushion to wheelchair -Baseline dietary assessment to assure nutritional needs are being met. Make supplement and vitamin recommendations -Weekly weights -Turning and repositioning plan as needed -Positioning devices as needed -Weekly measurements by nurse -Weekly head to toe assessments. CMS 672 dated 11/19/15 revealed 13 residents with pressure ulcers with 5 residents having pressure ulcers upon admission.

Based on interview and record review, the facility failed to ensure 1 of 5 residents reviewed for weight changes maintained acceptable parameters of nurtritional status (body weight) as evidenced by: 1. Resident #9 lost 6.34% of her weight in one month (between May 2015 and June 2015), 10.54% in 3 months (between May 2015 and August 2015) and 21.46% in 6 months (between May 2015 and November 2015). This failure could affect 4 residents who were identified by the facility as having unplanned weight changes. Findings included: Record Review of Resident #9's Record of Admission revealed an [AGE] year old female originally admitted to the facility on [DATE]. Record Review of Resident #9's History and Physical dated 10/30/2015 revealed the following Diagnoses: [REDACTED]. Record Review of Resident #9's Weight change history report printed 12/01/15 revealed an admission weight of 271.20 lbs. Record Review of Resident # 9's weight record revealed that resident #9 weight was 271.20 pounds on May 14, 2015; then on June 17, 2015 resident ' s weight was recorded as 254.00 pounds (loss of 17.2 pounds or 6.34% in 34 days). Record Review of Resident # 9's weight change history report revealed the following: 05/14/2015 271.20 05/19/2015 266.60 05/28/2015 259.60 06/11/2015 261.00 06/17/2015 254.00 07/23/2015 242.00 07/29/2015 242.60 08/06/2015 242.00 08/07/2015 242.60 09/06/2015 240.00 10/05/2015 224.40 11/04/2015 211.20 11/12/2015 213.6 11/19/2015 213 11/26/2015 212.4 Weight Change History report has handwritten notes by DON regarding [MEDICATION NAME] 25mg daily from admit, restarted 07/17/2015, stopped 10/30/2015. [MEDICAL CONDITION] adjusted 05/14/2015 to 05/31/2015 and changed again on 06/07/2015. Record Review of Resident #9's Comprehensive Plan of Care dated 11/6/15 revealed that the facility implemented a plan of care for unplanned weight loss due to recent illness and hospital stay, readmit 11/06/15. Interventions to include: serve diet as ordered and offer subs if <75% is eaten- monitor intake, Dietary Manager to discuss/monitor for preferences, offer snacks with in dietary limits, weight every week until stable - report to M.D./R.P. if 5% loss/gain and Registered Dietitian A to review residents medical records and make recommendations - nursing to follow-up. Record Review of Resident #9's Resident Profile Report reveals Regular Diet and Regular Texture. Likes include soup, salads and tomatoes. Dislikes include hot cereal and cold cereal. Record Review of Resident #9's Dietary notes dated 10/19/2015 reveals significant weight loss: Weight = 224 lbs. (7%) x 1 month. BMI 33/obese range. Regular diet, eats in room independently. Visited at noon meal, at <50% complaining of the taste of food. Pleased with weight loss, however would like milkshakes. Updated likes/dislikes. Recommend add sliced tomatoes to meals as available, milk shakes TID (three times daily) with meals. Goal: stable weight 215-233. Electronically Signed by Dietitian A. Record Review of Resident #9's Dietary notes dated 11/16/2015 reveals significant weight loss continues on return from hospital: Wt. = 211, -13 lbs (6%) this past month. Original weight on first admission = 271 lbs. End Stage [MEDICAL CONDITION], high protein nutritional supplements not indicated. Diet: Regular, eats on 50-75% per CNA. Estimated needs ([MEDICAL CONDITION]) = (73kg) 1825 Kcal (25/kg); 50 g protein/day (.7/kg) 2190 c water/day (30/kg). Pertinent labs 11/15: NS 129/low; K 4.7/ok. Recommend 1) DC Regular diet, start Regular Renal Low Protein (small meat/egg portions); 2) DC 12cc Hi Cal BID, Start 8 oz Milk Shakes TID all meals, high carbohydrate snacks, cookies, corn chips, toast and jelly, Honey Buns between meals; Goal: Stable weight 203-219. Electronically signed by Dietitian A. Record Review of Resident #9's Notification of Weight Change dated 10/05/2015 to physician reveals weight and skin committee recommendations as Resident loss -15.6 pounds x 30 days -6.5%. Resident receives snacks BID (twice daily). Signed by ADON on 10/05/2015. No physician signature or note on form. Record Review of Resident #9's Progress Notes dated 12/01/2015 at 13:34 by physician reveals: I was notified about weight loss upon readmission to Silver Spring after November hospitalization . Patient was found to be dehydrated and overly [MEDICAL CONDITION] which I felt likely pronounced her weight loss. Recommended continued monitoring after [MEDICAL CONDITION] adjusted as well as follow up of TSH ([MEDICAL CONDITION] Stimulating Hormone). Progress note signed by Physician E. Record Review of Resident #9's medical chart on 12/03/2015, No TSH ([MEDICAL CONDITION] Stimulating Hormone) lab results in chart. In an interview on 12/02/2015 at 3:45pm ADON said she will fax or hand deliver changes in weights to physicians. She will follow-up weekly to ensure physician response. She said Dietitian A reports are discussed with physician. If physician doesn ' t agree with recommendations, report is filed in Dietitian A report book. If Dietitian A makes recommendation for snacks or supplements, she will write orders. She said resident #9 is not a weekly weight. She said physician did not agree with Dietitian A recommendations from 11/16/2015, no new orders received. In an interview on 12/01/2015 at 12:12 P. M., the DON regarding 60 lb. weight loss from admission on 05/14/2015 to 11/01/2015 said facility policy is to notify physician of 5% weight loss in one month. DON said ADON takes care of tracking weights and notifying physician. Once physician is notified of weight loss, note is filed in chart. DON sent message to physician regarding 60 pound weight loss at this time. In an interview on 12/01/2015 at 12:12 P. M., the Admin said the Dietitian A has been involved, physician had seen resident and dietary manager had visited with Resident regarding food preferences. In an interview on 12/01/2015 at 12:25 P. M., the Dietitian A said she did see resident on admission. The note from admission was reviewed with Dietitian A. No additional Dietitian A notes in chart. Dietitian A said she puts notes in computer and will print if has computer access or will handwrite notes. DON submitted Dietitian A notes dated 10/19/2015 and 11/16/2015. Dietitian A said she made recommendations on 11/16/15. Dietitian A said she wished recommendations were taken care of in a timely manner. She said she tracks weights monthly. She sees residents only if loses 5% in one month or 7.5 % in 3 months or if flagged for referral or wound until resolved. If resident ' s weight stabilizes, she doesn ' t see them. Dietitian A said weight loss for Resident #9 could be related to end stage [MEDICAL CONDITION] and her weight loss could be fluid related. In an interview on 12/01/2015 at 3:00 P. M., DON said Resident #9 receives a regular diet. DON informed of recommendations by Dietitian A. DON said she would follow-up with physician. In an interview on 12/03/15 at 2:45 p.m. with RNA A, she said that she is responsible for weighing the residents. She said that new admissions get weighed weekly times four weeks or until their weight stabilizes and then they move over to monthly weights. She said all residents who weigh less than one hundred (100) pounds and those residents who have gastric tubes are also weighed weekly. She said that if a resident starts showing a weight loss then they are moved from the monthly weight to weekly weights. She said that when that occurs she lets the DON and ADON know so the resident's weight loss can be addressed. Record review of the facility policy titled Weight and Skin Process, undated and received from the VPCS A on 12/3/15, revealed the following: The weight and skin committee is an interdisciplinary approach of reviewing and communicating the nutritional and skin status of residents. The members of the committee review/evaulate residents through the assessment process to determine the need to implement interventions. In addition the committee reviews/evaluates the effectiveness of current interventions and provides resident assessment information and request treatment recommendations from the physician or nurse practitioner . 2. Weekly and/or monthly weights are reviewed on each resident. Any weight loss is identified. 3. Weekly review includes residents that have one or more of the following; a. Weight Less than 100 pounds. b. Have had a 4% or more loss c. New admissions for the fiest 4 weeks . d. Have had 4 % or more gain. 4. Once a month all weights are reviewed for losses or gains . 6. An ongoing supplement list is maintained to identify residents receiving a supplement to include the type and frequency/ 7. The supplement list should be reviewed weekly to validate that the residents are not refusing the supplement or that the supplement is still necessary . 10. Based on committee recommendations the treatment nurse and/or nurse manager will complete the weight/skin change notification form and have the physician and/or nurse practitioner review and approve recommendations within 72 hours. 11. The nursing committee members will notify responsible parties of weight loss and any other significant changes identified . 14. Weight/Skin Notification form, once completed, and any orders are carried out should become part of the residents' medical record. Record review of the facility's 802 undated and received from the facility 11/30/15 revealed 4 people identified with weight loss.