Every finding on record at Summit Hills Skilled Nursing Facility

Based on record review, interview, and facility policy review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) form in the required time frame for 2 (Resident (R)18 and R50) of 3 residents reviewed for beneficiary notices. Findings included: A facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised 09/2022, revealed 1. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS [Centers for Medicare and Medicaid Services] form 1012) is issued to the resident at least two calendar days before benefits end. A Face Sheet revealed the facility admitted R18 on 11/14/25. According to the Face Sheet, the resident had a medical history that included diagnoses of aftercare following joint replacement surgery with the presence of a left artificial shoulder joint. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/25, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. R18's Notice of Medicare Non-Coverage indicated the last covered day of skilled services was 01/22/26, and the resident's Power of Attorney (POA)/family was notified verbally by phone on 01/21/26. A Face Sheet revealed the facility admitted R50 on 11/06/25. According to the Face Sheet, the resident had a medical history that included diagnoses of pneumonitis due to inhalation of food and vomit, pleural effusion, and gastrostomy status. An admission MDS, with an ARD of 11/12/2025, revealed R50 had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. R50's Notice of Medicare Non-Coverage indicated the last covered day of skilled services was 12/12/2025, and the resident's family was notified verbally on 12/11/2025. During an interview on 01/30/26 at 12:49 PM, the Social Worker stated she would talk to the residents and Responsible Party about discharge several days before their last covered day but did not issue the form until the day before. She said she thought it was timely. During an interview on 01/30/26 at 1:14 PM, the Administrator stated that the NOMNC should be issued two days (48 hours) before the last covered day (LCD) of skilled services. The Administrator stated that the Social Service Department was responsible for issuing the NOMNCs. He reviewed R18's and R50's NOMNCs and confirmed that they were done 24 hours, not 48 hours, before the LCD.

Based on observation, interview, record review, and facility policy review, the facility failed to develop individualized person-centered care plans for 2 (Resident (R)17 and R19) of 2 residents reviewed for respiratory services. Specifically, the facility failed to ensure care plans addressed the use of a non-invasive mechanical CPAP (Continuous Positive Airway Pressure) ventilator for R17 and the use of oxygen for R19. Findings included: 1. A facility policy titled, Care Plans, Comprehensive Person-Centered, dated 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also indicated, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A Face Sheet indicated the facility admitted R17 on 12/19/25. According to the Face Sheet, the resident had a medical history that included diagnoses of pneumonia, respiratory failure, disorders of the lung, and chronic obstructive pulmonary disease (COPD). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/25, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received oxygen therapy, and the use of a non-invasive mechanical ventilator was not coded. R17's hospital Discharge Summary dated 12/19/25 revealed discharge/follow up instructions that included CPAP use at bedtime. R17's Clinical Admission record, dated 12/19/25, indicated the use of oxygen and CPAP. A nurse practitioner's encounter Progress Note[s], dated 12/23/25 at 3:09 PM, indicated R17 had obstructive sleep apnea, and the resident stated they were trying to be compliant with the CPAP. A physician's encounter Progress Note[s], from 12/25/25 and dated 01/04/26 at 1:37 PM, indicated R17 had obstructive sleep apnea and used CPAP at night. R17's Care Plan Report, included a focus area, initiated 12/22/25, that indicated the resident had an altered respiratory status related to difficulty breathing related to COPD, respiratory failure, and congestive heart failure. Interventions directed staff to: administer medications as ordered and monitor for effectiveness and side effects; monitor for changes; monitor for signs and symptoms of respiratory distress and report to the physician as needed; position the resident with proper alignment for optimal breathing; and use pain management as appropriate. R17's Care Plan Report, included a focus area, initiated 12/22/25, for oxygen therapy related to ineffective gas exchange. Interventions directed staff tochange the resident's position every two hours to facilitate lung secretion movement and drainage; give medications as ordered; give oxygen if the resident ate but in a different manner, e.g. [exempli gratia, for example], changing from a mask to a nasal cannula, and returning the resident to their usual oxygen delivery method after the meal; monitor for signs of respiratory distress and report to the physician as needed; and to ensure oxygen settings via nasal at 2 l [liters]. R17's Care Plan Report did not include the use of the CPAP. Observations on 01/28/26 at 1:28 PM, 01/29/26 at 12:06 PM, and 01/30/26 at 10:35 AM revealed a CPAP machine on R17's nightstand with the mask lying on top of the machine in a plastic bag. During an interview on 01/30/26 at 10:35 AM, R17 stated they were wearing the CPAP mask every night for as long as they could, and it was getting easier to wear. During an interview on 01/30/26 at 12:48 PM, the Director of Nursing (DON) stated that the use of the CPAP should have been included in R17's care plan. During an interview on 01/30/26 at 3:16 PM, the Administrator stated that he expected CPAP use to be included in the care plan. 2. A Face Sheet indicated the facility admitted R19 on 07/10/2018. According to the Face Sheet, R19 had a medical history that included a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/04/25, revealed R19 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A Director of Nursing's (DON) Long Term Care Evaluation, Progress Note[s], dated 01/07/26 at 1:21 PM, indicated R19 used oxygen via a nasal cannula (flexible tubing to deliver oxygen to the nose) with an oxygen saturation of 98%.A nursing Progress Note[s], dated 01/11/26 at 4:54 AM, indicated R19 was currently on 2 liters of continuous oxygen. R19's Care Plan Report did not include the use of oxygen. An observation on 01/28/26 at 1:04 PM revealed R19 lying in bed, their oxygen concentrator was on at 2 liters, the humidifier bottle was dated 01/02/26, and the tubing was dated 01/23/26. During an interview on 01/30/26 at 12:48 PM, the DON stated the use of oxygen should be included in the care plan and confirmed that it was not included in R19's care plan. During an interview on 01/30/26 at 3:16 PM, the Administrator stated that he expected the use of oxygen to be included in the care plan.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a physician order was in place for respiratory services for 2 (Resident (R)17 and R19) of 2 residents reviewed for respiratory care. Specifically, the facility failed to have physician orders in place for the use of a non-invasive mechanical CPAP (Continuous Positive Airway Pressure) ventilator for R17 and for the use of oxygen for R19. Findings included: 1. A facility policy titled, CPAP/BiPAP [CPAP/Bilevel Positive Airway Pressure] Support, revised 03/2015, specified, 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP [positive end-expiratory pressure] pressure for the machine. A Face Sheet indicated the facility admitted R17 on 12/19/25. According to the Face Sheet, the resident had a medical history that included diagnoses of pneumonia, respiratory failure, disorders of the lung, and chronic obstructive pulmonary disease (COPD). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/25, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received oxygen therapy, but the use of a non-invasive mechanical ventilator was not coded. R17's Care Plan Report included a focus area, initiated 12/22/25, that indicated the resident had an altered respiratory status related to difficulty breathing related to COPD, respiratory failure, and congestive heart failure. Interventions directed staff to: administer medications as ordered and monitor for effectiveness and side effects; monitor for changes; monitor for signs and symptoms of respiratory distress and report to the physician as needed; position the resident with proper alignment for optimal breathing; and use pain management as appropriate. R17's Care Plan Report included a focus area, initiated 12/22/25, for oxygen therapy related to ineffective gas exchange. Interventions directed staff to: change the resident's position every two hours to facilitate lung secretion movement and drainage; give medications as ordered; give oxygen if the resident ate but in a different manner, e.g. [exempli gratia, for example], changing from a mask to a nasal cannula, and returning the resident to their usual oxygen delivery method after the meal; monitor for signs of respiratory distress and report to the physician as needed; and to ensure oxygen settings via nasal at 2 l [liters]. R17's hospital Discharge Summary dated 12/19/25 revealed discharge/follow up instructions that included CPAP use at bedtime. The Discharge Summary specified AutoCPAP [auto-titrating CPAP] with a home setting of 10-15 centimeters of water (pressure level setting) at bedtime. R17's Clinical Admission record, dated 12/19/25, indicated the use of oxygen and CPAP. R17's Order Recap Report, for the timeframe of 12/01/25 through 01/29/26, revealed no orders for CPAP therapy. A nurse practitioner's encounter Progress Note[s], dated 12/23/25 at 3:09 PM, indicated R17 had obstructive sleep apnea, and the resident stated they were trying to be compliant with the CPAP. A nurse's Progress Note[s], dated 12/23/25 at 5:25 AM, revealed R17 was resting in bed with their CPAP in place. A physician's encounter Progress Note[s], from 12/25/25 and dated 01/04/26 at 1:37 PM, indicated R17 had obstructive sleep apnea and used CPAP at night. A nurse's Progress Note[s], dated 01/09/26 at 12:45 AM, revealed R17 was resting in bed, and their CPAP was in place. A nurse's Progress Note[s], dated 01/10/26 at 3:02 AM, revealed R17 was resting in bed, and their CPAP was in place. Observations on 01/28/26 at 1:28 PM, 01/29/26 at 12:06 PM, and 01/30/26 at 10:35 AM revealed a CPAP machine on R17's nightstand with the mask lying on top of the machine in a plastic bag. During an interview on 01/30/26 at 10:35 AM, R17 stated they were wearing the CPAP mask every night for as long as they could, and it was getting easier to wear. During an interview on 01/30/26 at 12:48 PM, the Director of Nursing (DON) confirmed that R17 did not have an order for the CPAP. The DON stated that orders should include the settings, when to use the device, and the amount of oxygen. The DON stated the admitting nurse was responsible for transcribing orders at admission, and the unit manager or the DON would double-check the orders within 24 hours. The DON stated she did not know what happened to the orders for R17's CPAP. During an interview on 01/30/26 at 2:41 PM, Licensed Practical Nurse (LPN)1 stated that when admitting a resident, they followed hospital discharge instructions, but CPAP orders were usually entered by the Nurse Practitioner (NP) after their assessment. LPN1 did not recall completing R17's admission or if CPAP orders were available at that time. During an interview on 01/30/26 at 2:55 PM, the NP stated that if a resident arrived with CPAP orders from the hospital, the facility should continue those orders. The NP stated that if no orders were present, but the resident used a CPAP, she would enter the orders after her assessment. The NP stated that nurses were expected to call her to review all orders for confirmation. The NP stated she was aware that R17 had a CPAP but did not know that orders were missing. The NP stated that orders should include the settings, even if they were home settings, and instructions for when to use the device. During an interview on 01/30/26 at 3:16 PM, the Administrator stated that he expected CPAP orders to be in place and reviewed by a clinician. 2. A Face Sheet indicated the facility admitted R19 on 07/10/2018. According to the Face Sheet, R19 had a medical history that included a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/04/25, revealed R19 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. R19's Care Plan Report, did not include a respiratory focus or the use of oxygen therapy. R19's Order Recap Report, dated from 01/01/26 through 01/29/26, contained an order, started 10/01/25, for oxygen tubing and humidifier change at bedtime every Thursday. The Order Recap Report revealed no order for oxygen therapy administration, including the prescribed liters of oxygen and the method of delivery. A Director of Nursing's (DON) Long Term Care Evaluation Progress Note[s], dated 01/07/26 at 1:21 PM, indicated R19 used oxygen via nasal cannula (flexible tubing to deliver oxygen to the nose) with an oxygen saturation of 98%. A nursing Progress Note[s], dated 01/11/26 at 4:54 AM, indicated R19 was currently on 2 liters of continuous oxygen. An observation on 01/28/26 at 1:04 PM revealed R19 lying in bed, and their oxygen concentrator was on at 2 liters. The humidifier bottle was dated 01/02/26, and the tubing was dated 01/23/26. During an interview on 01/30/26 at 12:48 PM, the Director of Nursing (DON) stated R19 did not have an oxygen order, but only an order for tubing changes. The DON stated R19 should have an order specifying oxygen usage, liters, monitoring every shift, and filter and tubing changes. The DON stated the facility switched to a new electronic health record (EHR) on 10/01/2025, and the nurse managers were responsible for entering orders into the new EHR system. The DON stated R19's oxygen order was located in the previous system, dated 03/04/24, for 1-3 liters of oxygen per minute per nasal cannula to maintain an oxygen saturation of greater than or equal to 88 percent. During an interview on 01/30/26 at 3:16 PM, the Administrator stated that he expected oxygen orders to be in place and reviewed by a clinician.

Based on observation, interview, and facility policy review, the facility failed to ensure all items in the refrigerator, freezer, and dry storage were sealed, labeled, and dated. The facility also failed to ensure that hair coverings were used properly. These failures had the potential to affect all 24 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Receiving and Storage, revealed, .Dry foods that are stored after opening have to be labeled and dated .All foods stored in the refrigerator or freezer are covered, labeled and dated (use-by date). The following observations on 01/20/25 at 9:21 AM in the kitchen were made with and verified by the Dietary Manager (DM) and the Director of Dining (DD). 1. The walk-in refrigerator contained a tray that had a large amount of dried blood from thawing meat. 2. The walk-in freezer contained one bag of processed potatoes and one bag of egg rolls that were not sealed shut. 3. The dry storage room contained one box of open grits, and one large bag of rice, not sealed shut. There was also a wrapped package of tortilla shells that were not labeled and dated. One bag of rigatoni was outdated and should have been removed on 01/01/25. 4. In the stand-up refrigerator was an individual sized container of yogurt that was open and had partially been eaten from. During an observation on 01/20/25 at 12:45 PM of the dining room revealed the utility aide (UA) serving food with her ponytail hanging out of her hair covering. When asked why all of her hair was not in the hair covering, she stated I did not know that it had to be up since it was pulled back. During an interview with the Administrator on 01/22/25 at 1:16 PM revealed, My expectation of the kitchen is to adhere to regulations and serve nutritious food to the residents. During an interview with the DD on 01/22/25 at 1:38 PM revealed, I was embarrassed by the findings in the kitchen. My expectation of the kitchen is that all menus and diets are reviewed and that we adhere to facility policies, procedures, and infection control.

Based on record review and interview, the facility failed to maintain communication with the dialysis center for one of one resident (Resident (R) 127) who attended dialysis three times per week out of a total sample of 16 residents. The failure of the facility to communicate with the dialysis center prior to and after dialysis could affect the care of the resident as well as prevent continuity of care. Findings include: Review of R127's Face Sheet, undated and located under the Face Sheet tab of the electronic medical record (EMR), revealed R127 was admitted on [DATE] with a diagnosis of End Stage Renal Disease (ESRD). Review of R127's EMR Progress Notes tab, and Misc. (Miscellaneous) tab revealed no documentation of communication sent to the dialysis center with R127, regarding R127's physical condition, including vital signs and weights. Review of R127's Care Plan located under the Care Plan tab of the EMR, related to Dialysis revealed the Care Plan did not address what documentation/communication would be sent with R127 or faxed to the dialysis center prior to the resident starting his dialysis treatment and after the dialysis treatment. On 01/21/25 at 10:01 AM, the survey team requested the Dialysis book. At 1:12 PM, the survey team was told by the Director of Nursing (DON) that they did not have dialysis sheets. A request was also made for a policy related to Dialysis and was not received by the time of the exit of the survey. During an interview with the DON on 01/21/25 at 1:12 PM revealed We send the dialysis book with the resident on Monday, Wednesday, and Friday for his dialysis treatment. We never get our information sheets returned and sometimes the book does not return with the resident. When the DON was asked how they know R127's weight before and after treatment or how much fluid was removed, the DON stated, We do not know that, but if there was an issue with the resident, the dialysis center would call us. During an interview on 01/22/25 at 1:24 PM with the Administrator revealed This has been a huge learning experience for us, and we need to hold people accountable for communication and make sure that our resident is properly cared for. During an interview with the DON on 01/22/25 at 1:28 PM revealed When residents come into the facility on dialysis, all orders need to be placed and information for care needs to be documented before and after dialysis.

Based on interview and record review, the facility failed to ensure Resident (R)5's was treated with respect and dignity regarding personal care for 1 of 5 residents reviewed for dignity. Findings include: R5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Admission Minimum Data Set (MDS) for R5, she has the Brief Interview of Mental Status (BIMS) score of 14 out 15, which indicates that she is cognitively intact. An interview on 07/13/22 at 10:30 AM with R5 revealed A few days ago, a Certified Nursing Assistant (CNA)1 had attempted to force me to urinate in my brief, I felt embarrassed by this because I didn't have to use the restroom at that time and I can still use the toilet, but she didn't want to come back later to assist me. The resident further stated that they had told Social Services about this incident and filed a grievance with the facility. Record Review on 07/13/22 at 11:00 AM revealed a grievance dated 07/05/22 filed by R5 that stated R5 was upset over the CNA last night from 7:00 PM - 7:00 AM. She said she came in her room and wanted her to use the bathroom and R5 told her that she couldn't go now. The CNA acted mad and while walking out of the room mumbled something under her breath. R5 told her she couldn't go and she did not want to be treated like a dog. An interview with the Social Services Director on 07/13/22 at 1:30 PM revealed she assisted the resident with filing the grievance and had told the Director of Nursing (DON) about this incident. An interview with the DON on 07/13/22 at 3:14 PM revealed that she had interviewed CNA1 and CNA1 stated she did not force R5 to use the restroom, but asked her if she needed to go to the restroom. The DON further stated that CNA1 said to R5, Go ahead and try and she would be back to check on her. The DON stated that she re-educated CNA1 about using different wording instead of go ahead and try and to show the resident how to use the call light to ask for help, whenever she is ready. A phone interview with CNA1 on 07/13/22 at 4:30 PM revealed that the DON had re-educated them on how to better speak with residents during care.

Based on interview, record review, and facility policy review, the facility failed to ensure target symptoms were identified and monitored for medication efficacy for five of five residents (Resident (R) 1, R3, R11, R12, and R21) reviewed for unnecessary medications. This failure had the potential to affect the lowest possible effective dose and/or gradual dose reductions for any of these five residents receiving psychoactive medications. Findings include: 1. Review of R3's Face Sheet, provided on 10/14/21, showed an admitted [DATE] with medical diagnoses that included cognitive communication deficit; major depressive disorder, severe, with psychotic features; and dementia. Review of R3's October 2021 Physician Orders included, but was not limited to, the following medications and start dates: [MEDICATION(S)] (an antidepressant) 7.5 milligrams (mg) at bedtime starting 02/03/21; and [MEDICATION(S)] (an antidepressant) 10 mg daily starting on 05/26/21. The Physician Orders did not include orders for monitoring of a target sign or symptom for effectiveness or side effect monitoring. Review of R3's August, September, and October 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of monitoring for targeted behaviors or side effects for the psychoactive medications. 2. Review of R11's Face Sheet, provided on 10/14/21, showed an admitted [DATE] with medical diagnoses that included [CONDITION(S)], anxiety disorder, post-traumatic stress disorder, cognitive communication deficit, and major depressive disorder. Review of R11's October 2021 Physician Orders included, but was not limited to, the following medications and start dates: [MEDICATION(S)] 20 mg daily starting 07/07/21; and trazadone (an antidepressant) 50 mg at bedtime for [CONDITION(S)] The form included orders directing staff to monitor for behavior symptoms and side effects for [MEDICATION(S)] every shift, but did not address these for the Trazadone R11's August, September, and October 2021 TARs directed staff to identify and document behaviors d/t [due to] the use of [MEDICATION(S)]. The form did not include orders for staff to monitor behaviors due to the use of trazadone. The form failed to identify a specific target behavior for efficacy monitoring for [MEDICATION(S)] and trazadone. 3. Review of R12's Face Sheet, provided on 10/14/21, showed an admitted [DATE] with medical diagnoses that included dementia, anxiety disorder, [CONDITION(S)], psychotic disorder with hallucinations, restlessness and agitation, cognitive communication disorder, and altered mental status. Review of R12's October 2021 Physician Orders included, but was not limited to, the following medications and start dates: trazadone 50 mg daily starting 07/06/21; [MEDICATION(S)] (an atypical antipsychotic medication) 50 mg daily starting 07/06/21; and [MEDICATION(S)] sprinkles (a mood stabilizer) 250 mg three times a day. R12's August, September, and October 2021 TARs directed staff to monitor each shift for Antipsychotic Side Effects, Behavior Symptoms, Behaviors, Effective. The [MEDICATION(S)] order directed staff to monitor for Behavior Symptoms and Effective. The form failed to identify a specific target behavior for efficacy monitoring for trazadone, [MEDICATION(S)], or [MEDICATION(S)] sprinkles. 4. Review of R1's Admission MDS with an ARD of 10/08/21, located in the MDS tab of the Electronic Medical Record (EMR), revealed R1 was administered an antidepressant medication daily during the assessment period. Review of R1's October 2021 Physician Orders located in the Assessments tab of the EMR, revealed the order for [MEDICATION(S)] (an antidepressant medication) 60 mg one time daily. Review of R1's October 2021 MAR revealed staff identified [MEDICATION(S)] as effective but did not document resident-specific (target) behaviors for efficacy monitoring or medication specific potential side effects of the antidepressant. 5. Review of R21's Admission MDS with an ARD of 10/06/21, revealed R21 was administered an antianxiety and an antidepressant medication daily during the assessment period. Review of R21's October 2021 Physician Orders, revealed an order for [MEDICATION(S)] (an antidepressant medication) 100 mg one time daily and [MEDICATION(S)] (an antianxiety medication) 0.5 mg three times daily as needed. Review of R21's October 2021 MAR revealed staff identified [MEDICATION(S)] and [MEDICATION(S)] as effective but did not document resident-specific (target) behaviors for efficacy monitoring or medication specific potential side effects of these psychotropics. In an interview on 10/14/21 at 11:25 AM, the Director of Nursing (DON) and the Director of Clinical Services (DCS) confirmed that the residents' MARs did not contain the required resident-specific target behaviors or medication specific side effect monitoring for the use of [CONDITION(S)] medications. In a telephone interview on 10/14/21 at 3:09 PM, Licensed Practical Nurse (LPN) 2 stated the side effects she would monitor for an antidepressant medication were lethargy, loss of appetite, [CONDITION(S)]; and for an antipsychotic medication they would be pretty much the same, lethargy, drowsiness, nausea/vomiting. When questioned regarding target symptoms, LPN2 responded Every shift has a behavior monitor that monitors side effects and symptoms. The target symptoms are supposed to be under a diagnosis in the box. When added to the MAR, the nurse is to find the reason for the diagnosis. Also, in the MAR in that area [diagnosis] you can be able to find the reason they are on it. In an interview on 10/14/21 at 3:37 PM, the Consultant Pharmacist (RPh) was asked if she reviewed resident clinical records for target symptoms for [CONDITION(S)] medication efficacy monitoring, and responded, When a resident is started on it or been on it, I make sure that there are orders with symptoms to be charted on. If I see one without symptoms, I write recommendation to DON [Director of Nursing]. When asked if the RPh reviewed records for [CONDITION(S)] efficacy monitoring, the RPh stated, I do check their MARs and that is one way I base recommendation for GDR [gradual dose reduction]. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, dated December 2016, showed: .10. When medications are prescribed for behavioral symptoms documentation will include: .b. Potential underlying causes of the behavior; .e. Specific target behaviors and expected outcomes; .h. Monitoring for efficacy and adverse consequences .

Based on observation, interview, and review of medication label, the facility failed to ensure a medication error rate of less than five percent, in that three of four Licensed Practical Nurses (LPN)1, LPN2, and LPN4 made three medication errors out of 27 medication opportunities, resulting in an 11.11% error rate. These failures placed residents (R) 1, R2 and R14, at risk to not receive the full benefit of their medication therapy. Findings include: 1. Observation on 10/12/21 at 3:32 PM, LPN1 prepared R1's medications which included [MEDICATION(S)] 3.125 milligram (mg) (a medication to treat high blood pressure and heart failure). Review of the R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After LPN1 had obtained all R1's medications, LPN1 entered R1's room and administered the medications. After LPN1 had administered the medication, he returned to the medication cart. LPN1 was asked why the [MEDICATION(S)] was not given with a meal as written on the medication label. LPN1 stated that this medication was scheduled for 8:00 AM, when it would be given with breakfast, but for some reason the order for the afternoon dose was entered into the computer for 4:00 PM, which did not coincide with a meal. R1 most recently ate at 12:30 PM and received her next meal at 5:30 PM. The resident was not observed to receive food or a snack when the medication was administered. 2. Observation on 10/14/21 at 8:01 AM, LPN4 prepared R2's medications which included [MEDICATION(S)] (a medication used to treat high blood pressure) 50 mg to be given once daily DO NOT CRUSH. LPN4 crushed the [MEDICATION(S)] medication and placed the medication in applesauce with the other crushed medications. After LPN4 returned to the medication cart, she was asked why the [MEDICATION(S)] was crushed when the label on the medication stated that it should not be crushed. LPN4 stated that R2 could not take her medication whole and therefore, it had to be crushed. LPN4 was asked if the provider had been notified about the medication order and the resident's inability to swallow it whole. She stated that she could not find documentation the provider had been notified. 3. Observation on 10/14/21 at 8:24 AM, LPN2 prepared R14's medications. The medication order read, [MEDICATION(S)] [NAME] (a medication used to treat [CONDITION(S)]) 1% OP (Ophthalmic-relating to the eye) to instill one drop into right eye three times daily. Hold tear duct for one minute. Wait three-five minutes between drops. LPN2 entered R14's room and administered the eye drop but was not observed to hold the tear duct for one minute per the medication label. LPN2 was asked, after re-reading the medication label, if she had held the resident's tear duct for one minute, as ordered. She stated, No. In an interview on 10/14/21 at 9:00 AM, the Director of Nursing (DON) was told about the medication error rate as well as the specific medication errors that were observed. She confirmed that staff did not follow the physicians' orders as written on the medications. Review of https://www.rxlist.com/[MEDICATION(S)]-drug.htm#dosage revealed, . [[MEDICATION(S)]] should be taken with food to slow the rate of absorption and reduce the incidence of orthostatic effects . Review of https://www.healthlinkbc.ca/medications/fdb7168 regarding [MEDICATION(S)] revealed, . Do not crush or chew extended-release tablets or capsules. Doing so can release all of the drug at once, increasing the risk of side effects . Review of https://www.webmd.com/drugs/2/drug-7633/[MEDICATION(S)]-ophthalmic-eye/details revealed, . Tilt your head back, look upward, and pull down the lower eyelid to make a pouch. Hold the dropper directly over your eye and place one drop into the pouch. Look downward and gently close your eyes for 1 to 2 minutes. Place one finger at the corner of your eye (near the nose) and apply gentle pressure. This will prevent the medication from draining out .

Based on interview, review of facility's policy, record review, and review of facility's investigative report, the facility failed to ensure two of three residents (Resident (R)5, and R123) reviewed for abuse, were free from physical and verbal abuse. Findings include: 1. In an interview on 10/12/21 at 12:16 PM, R5 was asked if she had ever been abused while at the facility. She said yes. R5 stated there was an aide who had a bad temper and was really bad. R5 continued to say that she appreciated all the work they (the staff) do here, but this aide was really bad. R5 was asked if she remembered which shift the incident happened. R5 stated it occurred on the night shift. During the conversation, R5 became tearful stating, the girl told me to shut up. She further stated that the aide had taken her to the bathroom, as she couldn't walk, and was treating me in a very mean way. Review of R5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/21, located in R5's Electronic Medical Record (EMR) under the Assessments tab revealed R5's Brief Interview for Mental Status (BIMS) score of 01 which indicated that R5 was severely impaired in cognition for daily decision-making. Review of the Provider Investigation Report dated 08/10/21 showed that on 08/05/21 at approximately 7:45 AM, R5 told Certified Nurse Aide (CNA) 1 that the nurse aide from last night was very rude to her and got in her face saying she could hurt her without anyone finding out. CNA1 assignment reported discoloration on the back of R5's right arm. In a written statement, dated 08/05/21, CNA1 revealed that on 08/04/21 on the evening shift, she had assisted R5 into her nightgown around 5:30 PM and did not notice any skin discolorations on her body at that time. CNA1 further stated that when she returned to the facility on [DATE] for the 7:00 AM to 7:00 PM shift, she heard R5 hollering and went to see what was wrong. Upon entry into R5's room, R5 stated that CNA2 from last night told her she could hurt her, and no one would know. When CNA1 assisted R5 to get dressed for the day, she observed discoloration on the back of R5's right shoulder. In a written statement, dated 08/05/21, CNA2 stated to the Administrator and Director of Nursing (DON) that she had been in R5's room four to five times during the 08/04/2021 7:00 PM to 08/05/2021 7:00 AM shift and had changed R5's brief three times. CNA2 further stated that R5 was already in her bedclothes when she arrived at 7:00 PM. CNA2 further stated that R5 did not assist the other CNAs when R5 needed to be changed. Review of the facility's investigation summary section documented the allegation of abuse was substantiated. Discoloration matched the outline of a handprint on R5's arm. CNA2, a staffing agency nurse aide, was reported to the state reporting agency, as well as to the contracted staffing agency. 2. Review of R123's MDS with an ARD of 07/07/21, located in R123's EMR under the Assessments tab, revealed, R123's BIMS score was 14 which indicated R123 was cognitively intact for daily decision-making. Review of R123's Provider Investigative Report, dated 08/05/21 at approximately 6:30 AM, the Administrator was notified by a Licensed Practical Nurse (LPN) 5 of alleged physical abuse by CNA3. R123 alleged that she pushed her call light button in order to have help to the restroom. The report documented R123 stated that CNA3 came into her room and proceeded to jerk the brief off of her and retape it to her belly and held her arms down as she tried to reach for her call light to get away from CNA3. A body audit was done and R123 sustained discoloration to both left and right forearms. CNA3 was escorted from the property immediately. In a written statement dated 08/05/21 at approximately 6:30 AM, CNA3 stated that she tried to check R123's brief to make sure she was dry. She stated she undid the brief after R123 told she was dry and when she put the brief back on, R123 hit CNA3 on her head and she got out of bed. CNA3 admitted to holding R123's arms to her chest as R123 tried to scratch her. CNA3 further stated that once R123 started yelling, she left the room. Review of a written statement dated 08/05/21, CNA4 stated that on 08/04/21, when she arrived for her 3:00 PM to 7:00 PM shift, R123 needed assistance a couple of times to use the restroom. CNA4 stated that R123 could transfer herself but needed someone to stand by and help if needed. CNA4 confirmed that R123 wore a brief at night but was continent during the day. CNA4 stated the resident was in a good mood that night and she did not see any visible discolorations on her arms when she left the facility at 7:00 PM. Review of the Investigation's Summary completed by the Administrator dated 08/10/21, revealed the facility substantiated the allegation of physical abuse. In an interview on 10/13/21 at 5:00 PM, the Administrator confirmed that the abuse allegations against R5 and R123 were substantiated. Review of the undated facility's policy titled, Abuse, Neglect, or Misappropriation of Resident Property Policy showed, . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm or pain or mental anguish .The facility believes that our residents have the right to be free from abuse, neglect, involuntary seclusion, or misappropriation of property. The facility will do whatever is in its control to prevent mistreatment, neglect, and abuse of our residents or misappropriation of their property .

Based on interview, record review, and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) Assessment for one (Residents (R) 15) of 16 residents was accurately coded for active diagnoses. Findings include: Review of R15's Face Sheet, provided by the facility on 10/14/21, showed an admitted [DATE] with Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R15's MDS assessments showed an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 10/13/21 at 4:01 PM, regarding documentation of the active pneumonia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [sic] Review of the October 2019 RAI manual, page I-1, showed, SECTION I: ACTIVE diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status.

Based on observation, interview, and facility policy review, the facility failed to prevent the potential transmission of Coronavirus (Covid)-19 to all residents. The facility failed to ensure staff donned Personal Protective Equipment (PPE) appropriately, used cleaning/disinfectant agents correctly for residents in Transmission Based Precautions rooms, and failed to provide a physical barrier between the Covid-19 positive isolation rooms and the remaining rooms, all located in the same unit. Findings include: The facility policy titled, Isolation-Categories of Transmission-Based Precautions dated October 2018 directed, Contact Precautions. 5. Staff .will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The facility policy titled Cleaning and Disinfection of Environmental Surfaces dated 8/2019 directed, 1.c.(1) Non-critical environmental surfaces include bed rails .bedside tables .2. Non-critical surfaces will be disinfected with an EPA (Environmental Protection Agency)-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. A. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. B. By law, all applicable label instructions on EPA-registered products must be followed. 5. Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products including: a. Recommended use-dilution. According to the Centers for Disease Control (CDC) Nursing Home Guidance published 4/30/2020, Resident Cohorting, Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19: - Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP (Health Care Personnel) with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. - Facilities that have already identified cases of COVID-19 among residents but have not developed a COVID-19 care unit, should work to create one unless the proportion of residents with COVID-19 makes this impossible (e.g., the majority of residents in the facility are already infected). - Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. - Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. During interview on 12/10/2020 at 9:30 a.m., the Director of Nursing (DON) and Executive Director (ED) stated the four (4) residents in Quarantine rooms were new admissions or readmissions to the facility. These residents were observed and monitored for 14 days for signs and symptoms of Covid. They stated the facility had an outbreak of 10 resident cases in the last two (2) weeks: on 11/20/2020 one (1) new case, on 12/1/2020 four (4) new cases, and on 12/9/2020 five (5) new cases. Ten residents had a positive [DIAGNOSES REDACTED]. The facility failed to provide a physical barrier between the Covid-19 positive isolation rooms and the remaining rooms, all located on the same unit. Observation on the unit on 12/10/2020 at 12:23 p.m. revealed 11 rooms were designated as Isolation rooms, where 10 Covid positive residents resided. In addition, three (3) rooms were designated as Quarantine rooms. The remaining 10 rooms were general population rooms for a total of 24 rooms. The unit housed a total of 25 residents and was structured in a horseshoe shape. Covid positive rooms (Isolation rooms) were located along the rear of the unit and the back corners of the side halls. No physical barriers such as temporary walls or zippered plastic barriers were noted separating the Covid positive and Covid negative rooms. During an interview on 12/10/2020 at 12:25 p.m. Registered Nurse (RN) #1 stated s/he was the nurse for only the Covid positive rooms. S/he stated the Quarantine rooms housed new admissions and they may or may not be Covid positive, and therefore the residents should be under isolation for 14 days. S/he stated full PPE (Personal Protective Equipment) was required for entry into Isolation and Quarantine rooms. S/he stated gowns and gloves should be changed between those rooms. In an interview on 12/10/2020 at 12:27 p.m. Certified Nursing Assistant (CNA) #2 stated they kept the doors closed to the Covid positive rooms and the Quarantine rooms to prevent air flow from infected people circulating within the unit. Observation at that time revealed the doors to room [ROOM NUMBER] (Covid positive Isolation room) and room [ROOM NUMBER] (Quarantine room, suspected Covid positive) were open. During interview on 12/10/2020 at 1:35 p.m., the DON stated Quarantine and Isolation were the same as far as PPE required; staff should wear full PPE including mask, face shield, gown and gloves. The DON stated the only difference was the use of hair coverings and booties which were required in the Isolation rooms but optional in the Quarantine rooms. Observations and interviews on 12/10/2020 from 12:35 p.m. until 1:27 p.m. revealed: - 12:35 p.m., CNA #2 came out of room [ROOM NUMBER], applied clean gloves and a hair covering and entered room [ROOM NUMBER] (Isolation room) without booties. -12:38 p.m. CNA #2 washed hands in room [ROOM NUMBER], entered the hallway, removed the hair covering and applied clean gloves, then entered room [ROOM NUMBER] (Isolation room) without hair covering or booties. - 12:41 p.m., CNA #2 washed hands in the resident's room, entered hallway and applied clean gloves, then entered room [ROOM NUMBER] (Isolation room) without a hair covering or booties. - 12:42 p.m. CNA #3 donned PPE including gown, gloves, mask, face shield, booties and hair covering and stood in front of the open doorway of room [ROOM NUMBER] (Isolation room) CNA #3 stated s/he was waiting for the meal to arrive so s/he left the room door open. S/he stated they should wear booties and hair coverings along with the other PPE to enter the Covid and Quarantine rooms; it was not necessary to close the doors in the Quarantine rooms, but the doors to the Isolation rooms should have closed doors. - 1:00 p.m. CNA #2 added booties and hair covering to his/her full PPE and entered room [ROOM NUMBER] (Isolation room) to deliver the noon meal. Observation from the open doorway revealed CNA #2 leaning over the end of the bed and adjusting/ repositioning the resident's feet while his/her gown touched the resident's blankets. CNA #2 then washed hands in the room, removed hair covering and booties and applied clean gloves in the hallway, did not put on booties or hair covering, and did not change his/her gown before entering room [ROOM NUMBER] (Isolation room). - 1:01 p.m. Registered Nurse (RN) #1 instructed CNA #2 to close the door for Quarantine room [ROOM NUMBER]. Observation revealed the door stood had been open since 12:25 p.m. - 1:02 p.m. CNA #4 stated Quarantine rooms were for new admissions and it was unknown if they were positive or negative for Covid. S/he stated staff should wear full PPE in the Quarantine rooms including gowns, mask, face shield, gloves, hair covering and shoe coverings, and discard all PPE when leaving the room except the face shield and mask. S/he stated residents in rooms Quarantine rooms [ROOM NUMBERS] were high fall risk residents so staff should keep the doors open. - 1:07 p.m. CNA #5 stated for Quarantine rooms, staff should wear full PPE including gown, gloves, face shield and mask. S/he stated shoe and hair coverings were optional. Upon leaving a Quarantine room staff should wash hands and change gloves. S/he stated she did not know the difference between Isolation and Quarantine, did not understand why the Quarantine rooms would require full PPE because those residents already had negative tests. - 1:09 p.m. RN #1 stated the Quarantine doors should be closed because those residents' Covid status was unknown and they should be treated as positive or suspected positive for Covid. S/he stated s/he did not know why some of the resident rooms had two signs on the doors, one saying Isolation and another saying Quarantine, and it could be confusing to the staff. Observation revealed four (4) rooms had both Isolation and Quarantine signs: Rooms 408, 413, 415 and 416. - 1:13 p.m. Observation of the DON opening the Quarantine room [ROOM NUMBER] door. S/he instructed staff in the area that the resident was a high fall risk and the door should remain open. - 1:16 p.m. CNA #2 stated s/he didn't thinks s/he touched the resident's blanket with his/her gown, just his/her hands. S/he stated s/he was educated to keep the same gown on moving from room to room unless s/he provided resident care. S/he stated the hair and shoe coverings were optional for staff to wear along with the other PPE for both Quarantine and Isolation rooms. S/he stated s/he thought Quarantine and Isolation were the same thing and didn't know why there were two signs on some of the doors, one saying Isolation and another saying Quarantine. - 1:18 p.m., Licensed Practical Nurse (LPN) #6 stated the Quarantine rooms were for new admissions for 14 days. For residents in Quarantine, staff should wear a gown, mask, and face shield. S/he stated s/she thought the signs were confusing. S/he stated if there was no Isolation sign, then the resident did not have Covid, even though they were in a Quarantine room. S/he stated the full PPE was probably not necessary since the residents did not have Covid but s/he complied because that's what s/he was told to do. - 1:27 p.m. Housekeeper (HK) #7 stated s/he was the HK for the Covid positive and Quarantine rooms. S/he stated for daily cleaning in the Covid positive rooms, s/he used the product Steriphene spray on the resident's bed rails, mobility bars and bedside tables. HK #7 stated s/he sprayed the Steriphene product on a cloth and wiped down the bedrails, bars and tables, and stated, I don't have to wait 5 (five) minutes because it dries right away, dries right up. Review of List N on the EPA website revealed Steriphene was effective for killing the Covid-19 virus according to the kill time for [DIAGNOSES REDACTED] bovis. The Steriphene product label directed a 10-minute kill time for [DIAGNOSES REDACTED] bovis. During interview on 12/1/2020 at 1:35 p.m., the DON stated Quarantine and Isolation were the same as far as PPE required; staff should wear full PPE including mask, face shield, gown and gloves. The DON stated the only difference was the use of hair coverings and booties which were required in the Isolation rooms but optional in the Quarantine rooms. S/he stated s/he placed both signs (Isolation and Quarantine) on some of the Isolation rooms to alert staff that the resident was new. The DON acknowledged staff was confused about the signs and appropriate PPE required in each type of room. The DON stated it was permissible to go between Covid positive (Isolation) rooms without changing the gown as long as no contact was made with the resident or their belongings. S/he stated CNA #2 should have changed his/her gown after the gown touched the resident's blankets. S/he stated the facility considered physical barriers in the hall to further isolate Covid positive rooms, but decided against it because they had few, intermittent positive cases; the current number of 10 cases out of 25 residents on the unit happened within the last two (2) weeks. The DON stated since the outbreak s/he increased education on Infection Control policies to the staff in the last two weeks and conducted a skills fair; the staff was required to demonstrate the donning and doffing of PPE. S/he acknowledged staff should be monitored on the unit for breaks of infection control and proper use of PPE, and the Unit Supervisors did most of the monitoring. The DON acknowledged staff may be confused about the signage and required PPE. Review of the staff education since 11/20/2020 revealed two (2) education inservices titled, Covid-19 Rapid Testing Education on 11/23/2020, and Rapid Covid Test Inservice, Infection Control Inservice from 11/29/2020 to 11/30/2020. During interview on 12/11/2020 at 8:36 a.m. the Environmental Services (ES) Manager stated the HK staff should follow the directions on the product label. S/he stated, It's definitely a problem. We need to go by the guidelines (on the can directions); if it's a five (5)-minute kill time, needs to be wet or damp for five (5) minutes on the surface. Review of the HK education on products used and contact times revealed on 9/9/2020 education titled, Proper usage of: Cleaning supplies, chemicals, time management, etc. was provided. HK #7 signed in attendance for the inservice. During a follow-up interview on 12/11/2020 at 9:11 a.m. the ES Manager stated for the Steriphene product s/he would recommend to staff to keep the product on the surface for 10 minutes because s/he wanted to get the most and best use out of it as it was intended. The ES Manager stated she would meet with the HK staff and conduct a refresher inservice, so the contact time was applied and followed according to the label. During a follow up interview on 12/11/2020 at 11:33 a.m. the DON stated s/he expected staff to keep the doors closed in the Quarantine and Isolation rooms. S/he further stated Quarantine room [ROOM NUMBER] should be kept open because the resident was a high fall risk. S/he stated the resident may require one-to-one (1:1) monitoring for falls, however it depended on availability of staff for 1:1 monitoring. The DON stated s/he and the Nursing Supervisor (NS) observed and monitored staff for proper PPE use in the Quarantine and Isolation rooms but did not use monitoring tools, and it was not scheduled. S/he stated since approximately March 2020 they did not use observation tools to monitor staff, they observed staff and if they saw anything inappropriate, they would do instant education. During interview on 12/11/2020 at 11:59 a.m., HK #8 stated staff should use Diffense Spray to clean the bedrails, mobility bars and bedside tables in resident rooms; s/he sprayed it on a cloth, wiped down the areas and let them dry. Review of the Diffense label revealed a contact time of 30 seconds, and review of the EPS List N directed the same contact time of 30 seconds. During interview on 12/11/2020 at 12:04 p.m., the NS stated s/he observed staff when s/he did rounds, usually three (3) times per shift. S/he stated if s/he happened to see staff wearing PPE incorrectly s/he would immediately educate them. The NS stated s/he did not do direct monitoring, just observations, and did not use an observation tool or observe for any certain length of time. During interview on 12/11/2020 at 12:49 p.m., the ED stated s/he expected the HK staff to follow the directions on the product label for contact (kill) times.

Based on interview and record review, the facility failed to implement abuse prevention policy related to abuse reporting for 1 of 4 residents reviewed for abuse / neglect. The facility received an allegation of abuse, and began investigating, on 7/20/20 but the 24 hour report was not submitted until 7/22/20. This contradicts facility policy related to abuse reporting. The findings included: Review of 24 Hour Report on 8/4/20 at approximately 10:30 AM revealed an allegation that Certified Nursing Assistant #1 abused Resident #1. The incident was listed as occurring 7/21/20 and the report was submitted on 7/22/20. Review of Facility Investigation on 8/4/20 at approximately 10:45 AM revealed that the facility learned of this allegation, and began investigating, on 7/20/20. Review of Abuse Prevention policy on 8/4/20 at approximately 11:20 AM revealed the facility is to Investigate and report any allegations of abuse within timeframes as required by federal requirements. Interview with Care Services Administrator on 8/4/20 at approximately 12:40 PM confirmed the delay in the 24 hour report.

Based on interview and record review, the facility failed to submit a timely report for an allegation of abuse for 1 of 4 residents reviewed for abuse / neglect. The facility received an allegation of abuse, and began investigating, on 7/20/20 but the 24 hour report was not submitted until 7/22/20. The findings included: Review of 24 Hour Report on 8/4/20 at approximately 10:30 AM revealed an allegation that Certified Nursing Assistant #1 abused Resident #1. The incident was listed as occurring 7/21/20 and the report was submitted on 7/22/20. Review of Facility Investigation on 8/4/20 at approximately 10:45 AM revealed that the facility learned of this allegation, and began investigating, on 7/20/20. Interview with Care Services Administrator on 8/4/20 at approximately 12:40 PM confirmed the delay in the 24 hour report.

Based on observation, the facility failed to ensure kitchen staff stored food appropriately according to accepted practices and that kitchen equipment was maintained to provided a sanitary work environment. Findings: During the initial tour of the kitchen on 3/4/20 at 12:08pm, it was observed that there were an open bag of Okra and a bag of mixed vegetables in the walk-in freezer that were not labeled and dated. It was observed that there were open English muffins and open croissants that were not labeled and dated. During the initial kitchen observation on 3/4/20, it was observed that the foot operated trash can at the hand washing sink was broken

Resident #4 Nutrition 03/04/20 02:37 PM Resident was admitted to facility on 11/27/19 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 03/04/20 03:01 PM Record review revealed that resident was admitted with fractured left ankle and has a wound has a wound to left lower extremity measuring 1.50X 1.00 X 0. Wound is documented to be related to irritation and rubbing of CAM boot. Current treatment includes [MEDICATION(S)] wash and wrap with cling daily. Medical record revealed that on 2/19/10 wound care physician states that the cause of legions could be [CONDITION(S)] 03/045/20 03:06 AM Resident is waiting for wound care doctor to come in to approve discharge back to Assisted living facility. 03/04/20 03:30 PM Medical Record review indicates that resident has had a weight loss of -19.91 since admission. Resident is on a regular diet. 03/05/20 11:09 PM Resident sitting in room states that she is waiting on wound doctor to come look at her wound to decide if she care for it in her home. Resident states she is excited about going home. 03/05/20 11:50 AM Medical record review reveal that residents -19. 91 weight loss was not addressed by dietician nor were interventions put in place to address weight loss. Care plan did not address there was a change in resident's status. 03/04/20 04:51 PM interview with CDM [NAME] [NAME] was asked about documentation that address weight loss, CDM states that resident's weight was not addressed due to resident was admitted to skilled on 11/27/19 weighing 218 pounds. CDM states that resident was discharged back to Assisted and when she returned, that is when the weight loss was noticed. 03/05/20 11:56 AM Interview with [NAME] [NAME] MDS coordinator was asked for documentation stating the dates of resident's discharges and admissions to facility because MDS did not reflect the information. MDS coordinator states that resident was admitted to skilled unit on 11/27/19 and has been in skilled since that date, resident has not been discharged . Weight: 11/28/19 - 218 12/1/20 - 185 1/2/20 - 189 2/4/2- - 179 3/2/20 - 174.9 03/05/20 12:27 PM PT/INR 2/10/2020 - Report changes in blood count per lab values to physician. Urinalysis and Culture and Sensitivity 1/14/2020 Results Negative 03/05/20 02:33 PM Medical record reveal resident has orders to continue OT for upper body strengthening 5 times per week for 30 days starting 2/21/20 03/05/20 02:37 PM Medical record reveals that resident takes [MEDICATION(S)] 2.5 mg 2 times daily. Resident is monitored for bleeding in gums, nose, unusual bruising, tarry black stools, pink or discolored urine and report to physician any signs or symptoms of bleeding. 03/04/20 04:45 PM

Resident #4 Nutrition 03/04/20 02:37 PM Resident was admitted to facility on 11/27/19 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 03/04/20 03:01 PM Record review revealed that resident was admitted with fractured left ankle and has a wound has a wound to left lower extremity measuring 1.50X 1.00 X 0. Wound is documented to be related to irritation and rubbing of CAM boot. Current treatment includes [MEDICATION(S)] wash and wrap with cling daily. Medical record revealed that on 2/19/10 wound care physician states that the cause of legions could be [CONDITION(S)] 03/045/20 03:06 AM Resident is waiting for wound care doctor to come in to approve discharge back to Assisted living facility. 03/04/20 03:30 PM Medical Record review indicates that resident has had a weight loss of -19.91 since admission. Resident is on a regular diet. 03/05/20 11:09 PM Resident sitting in room states that she is waiting on wound doctor to come look at her wound to decide if she care for it in her home. Resident states she is excited about going home. 03/05/20 11:50 AM Medical record review reveal that residents -19. 91 weight loss was not addressed by dietician nor were interventions put in place to address weight loss. Care plan did not address there was a change in resident's status. 03/04/20 04:51 PM interview with CDM [NAME] [NAME] was asked about documentation that address weight loss, CDM states that resident's weight was not addressed due to resident was admitted to skilled on 11/27/19 weighing 218 pounds. CDM states that resident was discharged back to Assisted and when she returned, that is when the weight loss was noticed. 03/05/20 11:56 AM Interview with [NAME] [NAME] MDS coordinator was asked for documentation stating the dates of resident's discharges and admissions to facility because MDS did not reflect the information. MDS coordinator states that resident was admitted to skilled unit on 11/27/19 and has been in skilled since that date, resident has not been discharged . Weight: 11/28/19 - 218 12/1/20 - 185 1/2/20 - 189 2/4/2- - 179 3/2/20 - 174.9 03/05/20 12:27 PM PT/INR 2/10/2020 - Report changes in blood count per lab values to physician. Urinalysis and Culture and Sensitivity 1/14/2020 Results Negative 03/05/20 02:33 PM Medical record reveal resident has orders to continue OT for upper body strengthening 5 times per week for 30 days starting 2/21/20 03/05/20 02:37 PM Medical record reveals that resident takes [MEDICATION(S)] 2.5 mg 2 times daily. Resident is monitored for bleeding in gums, nose, unusual bruising, tarry black stools, pink or discolored urine and report to physician any signs or symptoms of bleeding. 03/04/20 04:45 PM

Based on observation and interview and review of the facility's policy, the facility failed to follow appropriate infection control practices while providing treatments for pressure ulcers for Residents #122 and #172, 2 of 2 residents reviewed for pressure ulcers. The findings included: Resident #172 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of wound care on 03/05/20 at 12:34 PM revealed LPN #1, after removing resident's personal belongings, set up a barrier on the over bed table after cleaning the table with alcohol wipies. The LPN dropped a medication cup with [MEDICATION(S)] paste on the floor, picked it up and discarded it and then went back to the treatment cart in the hall to obtain additional [MEDICATION(S)] paste and then proceeded to place all wound supplies on top of the barrier. The LPN then closed the door, turned on the overhead light, pulled the curtain and donned gloves without washing her/his hands. LPN #1 then removed the soiled dressing and discarded it. After removing the gloves, washing hands and donning clean gloves, LPN #1 wiped the peri wound with 5 short wipes with the same gauze, without turning the gauze, then cleaned the wound bed with one continuous circular motion from the center outward. The LPN then applied the skin prep to the peri-wound removed the gloves washed hands, donned clean gloves and applied a border dressing. During an interview at 12:58 PM on 03/05/20, LPN #1 confirmed that s/he did not wash her/his hands before donning gloves and beginning the treatment. The LPN also confirmed the facility's policy included washing hands before and after using gloves. Resident #122 Pressure Ulcer/Injury 03/05/20 11:24 AM /04/20 04:33 PM The facility admitted Resident #172 on 02/24/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/05/20 at 12:08 PM, wound care observation revealed Licensed Practical Nurse (LPN) #2 placed a barrier on the overbed table and placed the treatment supplies on the barrier without cleaning the table before placing the barrier. LPN #2 washed her/his hands and donned gloves then assisted the Certificed Nursing Assistant (CNA) to provide bowel incontinent care after removing the soiled border dressing. LPN #2 removed the gloves, donned clean gloves, and, after turning the resident to his other side, again assisted the CNA to continue the incontinent care. While providing care, LPN #2 contaminated one gloved hand with feces, removed the glove and donned a clean glove to that hand. Upon completion of incontinent care, LPN #2 removed the gloves, donned clean gloves, and removed the calcium alginate from the wound bed. The LPN then irrigated the wound bed with normal saline and patted the wound bed 9 times using the same gauze then used a clean gauze and patted the wound bed dry twice with the same gauze. LPN #2 removed the gloves, donned clean gloves, applied [MEDICATION(S)] to the wound bed with a cotton-tipped applicator and applied calcium alginate to the wound bed. The LPN removed the gloves, donned clean gloves and applied a border dressing. LPN #2 and the CNA repositioned the resident, placed the resident's heel protectors on bilaterally, and LPN #2 closed the trash bag and discarded it in the biohazard bag in the resident's room. LPN #2 then opened an Ensure Clear, opened a straw and placed the straw in the drink and handed it to the resident before removing the gloves and gown and washing hand before leaving the room. During an interview on 03/05/20, LPN #2 confirmed the sequence of the treatment and that s/he did not wash her/his hands after removing soiled gloves and before donning clean gloves. LPN #2 confirmed that s/he patted the wound bed while cleaning it and stated that s/he just didn't know how many times. The LPN also confirmed the policy is to wash hands before and after using gloves. Review of the facility's policy, Dressings, Dry/Clean, revealed: 1. Clean bedside stand. Establish a clean field .5. Wash and dry your hands thoroughly. 6. Put on clean gloves. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly . 12. Wash and dry your hands thoroughly. 13. Put on clean gloves 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward). 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressings and secure . 18. Discard disposable items into the designated container. 19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.

FACILITY Kitchen 03/04/20 12:08 PM During initial Brief tour of the kitchen, it was observed that there was a open bag of Okra and a bag of mixed vegetable in the walk in freezer that was not labeled and dated. It was observed that there was open English muffins and open croissants that were not labeled and dated. 03/05/20 10:05 AM During kitchen observation, it was noticed that cook had his personal drink on the preparation table. 03/05/20 10:12 AM During Kitchen observation, there was no foot operative trash can

Based on observation, the facility failed to ensure kitchen staff stored food appropriately according to accepted practices and that kitchen equipment was maintained to provided a sanitary work environment. Findings: During the initial tour of the kitchen on 3/4/20 at 12:08pm, it was observed that there were an open bag of Okra and a bag of mixed vegetables in the walk-in freezer that were not labeled and dated. It was observed that there were open English muffins and open croissants that were not labeled and dated. During the initial kitchen observation on 3/4/20, it was observed that the foot operated trash can at the hand washing sink was broken

Based on observation and interview and review of the facility's policy, the facility failed to follow appropriate infection control practices while providing treatments for pressure ulcers for Residents #122 and #172, 2 of 2 residents reviewed for pressure ulcers. The findings included: Resident #172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of wound care on 03/05/20 at 12:34 PM revealed LPN #1, after removing resident's personal belongings, set up a barrier on the over bed table after cleaning the table with alcohol wipies. The LPN dropped a medication cup with [MEDICATION NAME] paste on the floor, picked it up and discarded it and then went back to the treatment cart in the hall to obtain additional [MEDICATION NAME] paste and then proceeded to place all wound supplies on top of the barrier. The LPN then closed the door, turned on the overhead light, pulled the curtain and donned gloves without washing her/his hands. LPN #1 then removed the soiled dressing and discarded it. After removing the gloves, washing hands and donning clean gloves, LPN #1 wiped the peri wound with 5 short wipes with the same gauze, without turning the gauze, then cleaned the wound bed with one continuous circular motion from the center outward. The LPN then applied the skin prep to the peri-wound removed the gloves washed hands, donned clean gloves and applied a border dressing. During an interview at 12:58 PM on 03/05/20, LPN #1 confirmed that s/he did not wash her/his hands before donning gloves and beginning the treatment. The LPN also confirmed the facility's policy included washing hands before and after using gloves. Resident #122 Pressure Ulcer/Injury 03/05/20 11:24 AM /04/20 04:33 PM The facility admitted Resident #172 on 02/24/20 with [DIAGNOSES REDACTED]. On 03/05/20 at 12:08 PM, wound care observation revealed Licensed Practical Nurse (LPN) #2 placed a barrier on the overbed table and placed the treatment supplies on the barrier without cleaning the table before placing the barrier. LPN #2 washed her/his hands and donned gloves then assisted the Certificed Nursing Assistant (CNA) to provide bowel incontinent care after removing the soiled border dressing. LPN #2 removed the gloves, donned clean gloves, and, after turning the resident to his other side, again assisted the CNA to continue the incontinent care. While providing care, LPN #2 contaminated one gloved hand with feces, removed the glove and donned a clean glove to that hand. Upon completion of incontinent care, LPN #2 removed the gloves, donned clean gloves, and removed the calcium alginate from the wound bed. The LPN then irrigated the wound bed with normal saline and patted the wound bed 9 times using the same gauze then used a clean gauze and patted the wound bed dry twice with the same gauze. LPN #2 removed the gloves, donned clean gloves, applied [MEDICATION NAME] to the wound bed with a cotton-tipped applicator and applied calcium alginate to the wound bed. The LPN removed the gloves, donned clean gloves and applied a border dressing. LPN #2 and the CNA repositioned the resident, placed the resident's heel protectors on bilaterally, and LPN #2 closed the trash bag and discarded it in the biohazard bag in the resident's room. LPN #2 then opened an Ensure Clear, opened a straw and placed the straw in the drink and handed it to the resident before removing the gloves and gown and washing hand before leaving the room. During an interview on 03/05/20, LPN #2 confirmed the sequence of the treatment and that s/he did not wash her/his hands after removing soiled gloves and before donning clean gloves. LPN #2 confirmed that s/he patted the wound bed while cleaning it and stated that s/he just didn't know how many times. The LPN also confirmed the policy is to wash hands before and after using gloves. Review of the facility's policy, Dressings, Dry/Clean, revealed: 1. Clean bedside stand. Establish a clean field .5. Wash and dry your hands thoroughly. 6. Put on clean gloves. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly . 12. Wash and dry your hands thoroughly. 13. Put on clean gloves 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward). 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressings and secure . 18. Discard disposable items into the designated container. 19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.

Based on record review and interview, the facility failed to implement the care plans for Residents #6 and #9, 2 of 2 sampled residents reviewed for Pressure Ulcers and Resident #10, 1 of 3 sampled residents reviewed for Accidents/Hazards. Weekly body audits were not completed for Residents #6 and #9. Alarms for fall prevention were not in place for Resident #10. The Findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review of the care plan for Resident #9 on 11/19/18 at 9:20 AM revealed the resident was at risk for Pressure Ulcers related to decreased mobility. The resident's goal was to be free of skin breakdown. Interventions to meet this goal included Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown. Record review of the Skin Observation Forms (weekly body audit) on 11/18/18 at 12:22 PM, with Licensed Practical Nurse (LPN) #1 present, revealed the resident had a complete body audit completed on 10/1/18, the day of admission to the facility. Further review of the record revealed no additional body audits had been done since. LPN #1 confirmed the body audit from 10/1/18 was the only body audit completed. Record review of the Treatment Record on 11/19/18 at 11:28 PM revealed treatment was initiated to the residents heel due to a blister on 10/30/18. During an interview with Registered Nurse (RN) #1 on 11/19/18 at 1:12 PM, RN #1 confirmed the resident acquired a Stage II Pressure Ulcer to the left heel on 10/30/18. During an interview with RN #1, with LPN #2 present, on 11/19/18 at 4:24 PM, RN #1 stated Resident #9 should have had a body audit done weekly to identify any potential skin breakdown. RN #1 confirmed the weekly body audits to monitor the residents skin status were not done weekly per protocol. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review of the care plan for Resident #6 on 11/19/18 at 9:20 AM revealed the resident currently had a Pressure Ulcer to the right heel and was at risk for pressure ulcers related to decreased mobility. The residents goal was to be free from further skin breakdown. Interventions for the resident included complete skin assessments. Record review of the weekly body audits on 11/19/18 at 11:00 revealed body audits were not done weekly. A complete body audit was done on 7/10/2018, the day of admission to the facility. No other body audits were completed until 9/26/2018. The body audits were done weekly from 9/26/18 - present. During an interview with Registered Nurse #1 on 11/19/18 at 3:28 PM, RN #1 confirmed body audits were not done from 7/11/18 until 9/26/2018. Review of the weekly Pressure Ulcer assessments revealed no decline in the right heel Pressure Ulcer and no new Pressure Ulcers. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Record review of the care plan for Resident #10 on 11/19/18 at 12:19 PM revealed the resident was at risk for falls related to muscle weakness. Interventions to prevent falls included using an alarm to the bed and wheelchair to monitor attempts to rise. Resident #10 was observed self propelling in his wheelchair on 11/19/18 at 11:07 AM and 12:13 PM. The alarm was not in place per the care plan. The resident was observed again on 11/20/18 at 9:27 PM self propelling in his wheelchair through the hallways. The alarm was not in place per the care plan, During an interview with Licensed Practical Nurse (LPN) #4 on 11/20/18 at 9:27 AM, LPN #4 confirmed the resident's alarm was not in place. LPN #4 stated the resident is supposed to have the alarm in place when up in his/her wheelchair. LPN #4 stated the resident had been at therapy and the alarm likely wasn't put back on after therapy.

Based on record review and interview, the facility failed to provide care to prevent the development of a Pressure Ulcer for Resident #9 and failed to provide care to prevent further Pressure Ulcers from developing for Resident #6, 2 of 2 sampled residents reviewed for Pressure Ulcers. The facility failed to monitor the skin condition of Resident #9 who developed a Pressure Ulcer. The facility failed to monitor the skin condition of Resident #6 who had an existing Pressure Ulcer to the right heel. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review of the weekly body audits (Skin Observation Form) on 11/18/18 at 12:22 PM revealed a complete body audit was completed on 10/1/18, the day the resident was admitted to the facility. The body audit revealed no issues with the residents heels. No other body audits were completed until 11/18/18. The body audit on 11/18/18 indicated the resident had a purple blister to the left heel. Record review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. The treatment orders did not indicate where the blister was located. Record review of the Wound assessments on 11/18/18 at 12:22 PM revealed no assessments of the residents heels or notes related to a blister to the heels. There were no assessments or notes to indicate the resident had acquired a Pressure Ulcer Record review of the Nurse's Notes on 11/19/18 at 11:18 AM revealed no notes related to the blister or to the treatment. Record review of the provider's Progress Notes on 11/19/18 at 11:18 AM revealed the resident was seen for routine follow up by the Nurse Practitioner on 10/31/18. The note indicated All co-morbidities are stable with current medications, per staff. The note indicated the residents's skin was free of rashes, ulcers or [MEDICAL CONDITION]. In addition, the note indicated staff were counseled to notify the provider with any new or worsening symptoms. Observation of Resident #9's heels on 11/19/18 at 2:17 PM revealed a intact, Stage II Pressure Ulcer to the left heel. During an interview with Registered Nurse (RN) #1 on 11/19/18 at 1:12 PM, RN #1 stated the floor nurse identified an intact blister to the resident's left heel on 10/30/18 and treatment was initiated. RN #1 stated based on the presentation and location of the blister it met the criteria of a Stage II Pressure Ulcer. RN #1 confirmed weekly body audits had not been done since admission until 11/18/18, the first day of the survey. In addition, RN #1 confirmed a Pressure Ulcer assessment was not completed when the wound was identified and no weekly Pressure Ulcer assessments had been done. During an interview with the Medical Director (MD) on 11/19/18 at 2:20 PM, the MD was asked if weekly body audits could have prevented the development of the resident's Pressure Ulcer. The MD stated Obviously with better monitoring it was reasonable to believe the Pressure Ulcer could have been prevented by implementing interventions to prevent skin breakdown. The MD agreed that weekly body audits may have revealed potential breakdown that could have benefited from proactive interventions. The MD stated he was rounding on residents today and Resident #9 was on his schedule. At 2:34 PM the MD was interviewed after seeing Resident #9. The MD confirmed the presence of the Stage II Pressure Ulcer. The MD also stated neither he nor the other provider covering the building were notified of any skin issues the resident was having. The MD stated he had reviewed the Medical Record and confirmed there was a lack of monitoring of the resident's skin status. The MD stated the residents heels are elevated now, but there is no documentation to indicate the staff have been doing this routinely. The MD also stated interventions could have been implemented to prevent the development of the Pressure Ulcer. The MD stated the lack of monitoring and lack of communication regarding the resident's skin status played a role in the development of the Pressure Ulcer. During an interview with RN #1, with Licensed Practical Nurse #2 present, on 11/19/18 at 4:24 PM, RN #1 stated body audits are to be done weekly by nursing. S/he stated nurses know to do this because it is flagged as a weekly task to be done in the Electronic Medical Record (EMR). RN #1 stated perhaps part of the reason for the failure to complete the body audits was due to the task not being assigned to any particular shift. RN #1 and LPN #2 stated if the body audit is not done by 1st shift it will show up on 2nd shift tasks and then 3rd shift's tasks, if not completed by 2nd shift. LPN #2 stated if the body audit is not completed and locked within a week it will no longer show up in the EMR as needing to be completed. During an interview with RN #1 on 11/20/18 at 9:20 AM, RN #1 was asked who is responsible for staging and assessing Pressure Ulcers. RN #1 replied the Director of Nursing (DON) is responsible for the staging and assessing of Pressure Ulcers. In addition, RN #1 stated the DON was responsible for weekly Pressure Ulcer assessments. RN #1 stated the DON abruptly resigned on 11/9/18 and the facility had just hired an interim DON on 11/15/18. RN #1 also stated a Pressure Ulcer assessment had been completed on the resident this morning. Review of the Pressure Ulcer assessment from 11/20/18 revealed the resident acquired a Stage II Pressure Ulcer to the left heel on 10/30/18. The wound measured 2 centimeters in length and 3 centimeters wide. The wound was intact, Purplish in color with dark blood spot in middle of blister area. Review of the facility's Pressure Ulcer policy revealed policy was to assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. The policy also indicated a comprehensive skin assessment is to be completed with each risk assessment. The policy also revealed skin status was to be monitored by evaluating, reporting and documenting potential changes in skin. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review of weekly Pressure Ulcer assessments on 11/19/18 at 10:33 AM revealed the resident was admitted with and being treated for [REDACTED]. The Resident was seen weekly by the wound physician. Record review of the weekly body audits on 11/19/18 at 11:00 AM revealed body audits were not done weekly. A complete body audit was done on 7/10/2018, the day of admission to the facility. No other body audits were completed until 9/26/2018. The body audits were done weekly from 9/26/18 - present. During an interview with Registered Nurse #1 on 11/19/18 at 3:28 PM, RN #1 confirmed weekly body audits were not done from 7/11/18 until 9/26/2018. Review of the weekly Pressure Ulcer assessments revealed no decline in the right heel Pressure Ulcer and no new Pressure Ulcers.

On the days of the Recertification and Extended Survey, based on observations, record review and interviews, the facility failed to make comprehensive assessments of resident's needs related to 7 of 7 residents reviewed for pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). The findings included: Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores, Resident #14, #1, #4, #3 and #9. Cross refers to F-281 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to promote healing and prevent infection to residents who had pressure sores, Residents #14, #1, #4, #10, #3, #2, and #9. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores, Residents #14, #1, #4, #10, #3, #2, and #9. Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. The Admission Nursing Evaluation dated 03/24/2012 indicated under the "SKIN CONDITION section that Resident #14 had two bruises on the top of head sore to the (L) (left) ear on the base of ear. (R) (right) foot on the outer apex has a quarter size black spot. Res (resident) has some sores they have cotton between bottom toes/wrap with Kerlix." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with 2 stage II pressure sores and no venous/arterial sores. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "[MEDICAL CONDITION] to (L) hand and (R) arm. Res with multiple areas of pressure ulcers." Review of the closed medical record for Resident #14 on 08/01/2012 revealed Nurse's Notes from 03/24/2012 through 07/11/2012 with limited documentation related to the resident skin concerns. Review of Resident #14's Weekly Skin Assessments completed in April, May, and June 2012 revealed documentation that the a skin concern existed there were not documented assessments of the wound to include measurement, staging, drainage, and interventions. The only wound measurement available at the time of the survey were those documented by the nurse practitioners on 06/12/2012 and 06/21/2012 and documentation in the physician's progress notes related to Resident #14's wounds. Braden Scale performed on 03/24, 03/31, 04/07, and 04/17/2012 indicated the resident was at high risk for pressure sores, 04/17/2012 was the last Braden Scale completed. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident #1's medical record revealed a Progress Note dated 06/12/2012 that stated, "Resident is frail and debilitated. She sustained a skin tear to her lower left leg, however, it is slow in healing and we are here as a followup visit. We also did review a skin body audit and found some redness on her heels and dry skin noted on her bilat. lower extremities. An area on her lower left leg measures 4 x 0.5. The wound bed is beefy. It is moist. The wound edges are somewhat macerated, however, and peeling off..." Review of the Nurse's Notes from 02/22/2012 through 07/26/2012 failed to address Resident #4 wounds until after she was seen by the Nurse Practitioner on 06/12/2012. On 06/21/2012 at 10 AM the Nurse's Note stated, "Wound Care round with ...NP new orders..." Review of Resident #1's Weekly Skin Assessment documented the 06/12 and 06/14/2012 wound assessments done by the nurse practitioner, there were no other skin assessments on the resident's medical record. A Non-Pressure Skin Condition Record documented 04/10/2012 as the first date the area on the resident left lower extremity was observed. The measurement at that time was 1.6 cm (centimeters) x 1.8 cm. The record included an assessment on 04/17/2012 with a measurement of 1.6 cm x 1.8 cm; on 04/24/2012 1.6 cm x 1.2 cm; on 05/01/2012 1.4 cm x 1.2 cm. There was no further documentation of the wound until 06/12/2012. The Braden Scale was completed on 08/01 and 11/01/2011; on 04/20/2012. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. Review of Resident #4's medical record revealed a Wound Care Visit note dated 06/12/2012 that stated, "This is a wound care visit. Nurse complains that resident has discomfort on her sacrum... On physical examination, this is an elderly female lying in her bed in no acute distress. On examination of her skin and body audit, we did find that she had bruising to bilateral forearms and lower extremities, and multiple ecchymotic areas. She did have a stage I on the right heel as well as a scab on her left heel for which both will need skin prep. She has a stage II on her sacrum that they are not aware of at this time..." Review of the Nurse's Notes from 04/02/2012 through 07/28/2012 failed to address Resident #4's wounds until after she was seen by the Nurse Practitioner on 06/12/2012. Review of Resident #4's current medical record revealed the Weekly Skin Assessment and the Wound Evaluation Flow Sheet were not filled out, the assessment forms had the resident name and room number. There were not documented assessments of the wound to include measurement, staging, drainage, and interventions. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident 10's medical record revealed a Wound Care Visit note dated 06/14/2012 that stated, "Chief Complaint: Body Audit. Resident's skin was examined today for any compromise of breakdown... Examination reveals her skin is intact except for a small area on her upper buttock sacral area. It measures approximately 0.2 to 0.3. It is barely visible... Apply Skin-Prep to the sacral wound twice a day until resolved..." Review of the Nurse's Notes from 05/10/2012 through 07/24/2012 addressed Resident #10's wound when it was identified on 05/19/2012. The skin breakdown was observed on 05/19/2012 at 2:00 PM and assessed as a stage II sacral wound that measured 3.5 x 1 centimeter. Treatment at the time included cleansing with [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days. There were no additional measurement documented until the Wound Care Visit on 06/14/2012. Review of Resident #10's current medical record revealed the Weekly Skin Assessments were done from 05/12/2012 through 06/30/2012; the Wound Evaluation Flow Sheet was not filled out. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. The facility admitted resident #3 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Scar from old PU (Pressure Ulcer) noted on bottom. Redness over scrotum." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was scored to not have any pressure sores. A Medical Nutrition Therapy Note dated 7/13/12 at 10:00 AM stated, "Per DON (Director of Nursing) res (resident) with 2 open areas to buttocks & sacrum". A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "per staff 2 open areas, one to buttock & one to sacrum". Review of the "Weekly Skin Assessment, revealed one skin assessment dated [DATE]. The skin assessment had checked the resident's skin to be pale with [MEDICAL CONDITION] present. The body figure had a circle around the coccyx/sacral area and it was marked to have been red, as well as the right heel. There were no other weekly skin assessments. The facility failed to identify pressure sores and obtain treatment in a timely manner, The skin assessments and assessment of the Braden scale was not done on a weekly basis per the company policy to monitor the at risk resident for skin impairment. There were no measurements of the wounds, The Braden Scale was not done on admission or weekly per the company policy. The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. Record review on 7/31/12 at 9:30 AM revealed a Nurse's Note dated 4/5/12 and documented as a Late Entry that stated "Stage II decubitus ulcer found to coccyx, 2 X 1.4 cm (centimeters). On 4/17/12, an assessment of the wound was documented in the Nurse's Noted stating "Stage II decubitus to coccyx. Pink granulation noted. Wound margins (and) peri wound normal for skin. Progressive healing noted. Wound slightly decreased in size. (No) drainage noted. 1.4 cm X 1.2 cm." There was no additional documentation of pressure ulcer assessments by the nursing staff.. Review of the Weekly Skin Assessments for the resident revealed skin assessments were done on 5/4/12, 5/15/12, 6/5/12, 6/8/12, and 6/22/12. There were no skin assessments for the month of July. Review of the Nurse's Notes also revealed a note dated 6/13/12 at 2:45 PM that stated "LE (late entry) 6/12/12 Complete body audit completed by (nurse practitioners). New orders received." During an interview on 8/1/12 at 7:48 AM, the Director of Nursing confirmed that Weekly Skin Assessments were missing for 2 weeks in May, 1 week in June and that there were none for the month of July. She also confirmed that the wound had been assessed and measured only twice; upon discovery and 2 weeks later on 4/17/12. In addition, she verified that the information in the medical record was not consistent regarding the date the pressure ulcer was healed. She further confirmed that the wound should have been assessed weekly and documented. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review at approximately 2:10 PM on 7/31/12 revealed a progress note by NP #1 dated 7/3/12 that stated "Upon further examination or (sic) his feet, we did notice... a blood filled blister on the heel of his right foot" and was diagnosed as a pressure ulcer. The note further directed that physical therapy be provided to the left foot only until the wound was resolved. Further review revealed the MD assessed Resident #9 on 7/12/12 and stated the resident developed the pressure ulcer performing his physical therapy exercises. The wound was described as "about the size of a quarter and soft" with "no signs infection." The MD recommended to "avoid pressure, monitor for other signs of inflammation." On 7/18/12 the MD again assessed the wound at the request of the resident. He described the wound as "silver-dollar sized area of the blister that is broken. The central part is still dark, it is ischemic, and possibly will open up but the skin is tight over that at this time." The physician further stated "The patient has diabetes and needs to be watched closely." NP #2 evaluated the resident on 7/19/12 and stated that the resident had reported tenderness on his foot and that the resident had continued to do foot slides in therapy. NP #2 described the wound as "an unstageable deep tissue injury." Measurements were given as 4 X 5 cm and she stated there was "a slight odor on his foot." NP #2 indicated that she spoke to NP #1 who reported she had visualized the blister and had " did talk to therapy regarding how he got it" and had advised "not to do any further foot slides in therapy." Recommendations at that time were for a "heel guard and boot to the right lower extremity at all times." Review of the Physician's Telephone Orders revealed an order dated 7/19/12 for "heel floating boot to RLE (Right Lower Extremity) at all times." During observation of the wound care to his heel on 7/31/12 at 2:35 PM, Resident #9 stated that he did not wear any kind of boot during the day; only at night to keep him from rubbing his heel in the bed. On 7/23/12 NP #1 evaluated the wound and recommended a change in treatment. Review of the Nursing Home Initial History & Physical the resident had chronic stasis changes in the lower extremities. Nursing recommendation was to watch for resolution of abrasions he had sustained prior to admission and for further skin breakdown. Continued review of the record revealed there were no skin assessments since admission. On 8/1/12 at 9:10 AM, record review revealed a Braden Scale for Predicting Pressure Sore Risk assessment was completed on admission with a score of 19, at risk being a score of 15-18. Review of the Nurse's notes revealed Resident #9 had voiced heel pain on 7/11/12 and received pain medication but there was no documentation that the resident's heel was assessed. There was no documentation of a pressure ulcer until 7/18/12 when the CNA reported drainage from the site and the wound was assessed by a Registered Nurse at that time. On 7/26/12 the nurse documented there was no drainage noted from the wound but no further assessment was documented in the Nurse's Notes. A wound Evaluation Flow Sheet was initiated 7/30/12 with wound measurements of 4.2 X 5.2 cm and described the exudate but was otherwise incomplete. Review of the laboratory studies done on 7/20/12 revealed the resident's [MEDICATION NAME] and [MEDICATION NAME] were both low. A note on the report signed by the NP stated "Unstageable pressure area R(ight) heel." Review of the resident's care plan revealed a care plan for current skin problems and listed a surgical wound and bruises. There was no care plan implemented for potential for skin problems on admission or for actual pressure ulcer. At 10:22 AM on 8/1/12, the Director of Nursing confirmed there was no care plan for either the pressure ulcer or the potential for skin breakdown. She further confirmed there were no skin assessments completed. The DON also verified that there was no ongoing assessments of the wound by the nursing staff and that the documentation related to the wound was incomplete. She further confirmed that the resident was not wearing a heel floating boot to the right heel at all times as had been ordered. In addition, during an interview on 8/1/12 with NP #1 revealed that she had given a telephone order the previous week to send Resident #9 to the wound clinic but did not recall which nurse she gave the order to. She further stated that she called the facility on 7/31/12 to ascertain when the resident was going back for a follow-up visit and learned that the resident had not been sent to the wound clinic. Upon arrival at the facility on 7/31/12 she gave another order for Resident #9 to be sent to the wound clinic. Additionally, NP #1 stated there was a Wound Tracking Worksheet that the facility was supposed to be utilizing but confirmed that she had not seen any of the worksheets to review. Review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]." In addition, it advises "Reassess pressure ulcers at least weekly. If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted." On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 6/12/12 and repeated on 6/21/12, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012.

On the days of the Recertification and Extended Survey, based on observations, record review and interviews, the facility failed to make comprehensive assessments of resident's needs related to 7 of 7 residents reviewed for pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). The findings included: Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores, Resident #14, #1, #4, #3 and #9. Cross refers to F-281 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to promote healing and prevent infection to residents who had pressure sores, Residents #14, #1, #4, #10, #3, #2, and #9. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores, Residents #14, #1, #4, #10, #3, #2, and #9. Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. The Admission Nursing Evaluation dated 03/24/2012 indicated under the "SKIN CONDITION section that Resident #14 had two bruises on the top of head sore to the (L) (left) ear on the base of ear. (R) (right) foot on the outer apex has a quarter size black spot. Res (resident) has some sores they have cotton between bottom toes/wrap with Kerlix." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with 2 stage II pressure sores and no venous/arterial sores. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "[MEDICAL CONDITION] to (L) hand and (R) arm. Res with multiple areas of pressure ulcers." Review of the closed medical record for Resident #14 on 08/01/2012 revealed Nurse's Notes from 03/24/2012 through 07/11/2012 with limited documentation related to the resident skin concerns. Review of Resident #14's Weekly Skin Assessments completed in April, May, and June 2012 revealed documentation that the a skin concern existed there were not documented assessments of the wound to include measurement, staging, drainage, and interventions. The only wound measurement available at the time of the survey were those documented by the nurse practitioners on 06/12/2012 and 06/21/2012 and documentation in the physician's progress notes related to Resident #14's wounds. Braden Scale performed on 03/24, 03/31, 04/07, and 04/17/2012 indicated the resident was at high risk for pressure sores, 04/17/2012 was the last Braden Scale completed. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident #1's medical record revealed a Progress Note dated 06/12/2012 that stated, "Resident is frail and debilitated. She sustained a skin tear to her lower left leg, however, it is slow in healing and we are here as a follow up visit. We also did review a skin body audit and found some redness on her heels and dry skin noted on her bilat. lower extremities. An area on her lower left leg measures 4 x 0.5. The wound bed is beefy. It is moist. The wound edges are somewhat macerated, however, and peeling off..." Review of the Nurse's Notes from 02/22/2012 through 07/26/2012 failed to address Resident #4 wounds until after she was seen by the Nurse Practitioner on 06/12/2012. On 06/21/2012 at 10 AM the Nurse's Note stated, "Wound Care round with ...NP new orders..." Review of Resident #1's Weekly Skin Assessment documented the 06/12 and 06/14/2012 wound assessments done by the nurse practitioner, there were no other skin assessments on the resident's medical record. A Non-Pressure Skin Condition Record documented 04/10/2012 as the first date the area on the resident left lower extremity was observed. The measurement at that time was 1.6 cm (centimeters) x 1.8 cm. The record included an assessment on 04/17/2012 with a measurement of 1.6 cm x 1.8 cm; on 04/24/2012 1.6 cm x 1.2 cm; on 05/01/2012 1.4 cm x 1.2 cm. There was no further documentation of the wound until 06/12/2012. The Braden Scale was completed on 08/01 and 11/01/2011; on 04/20/2012. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. Review of Resident #4's medical record revealed a Wound Care Visit note dated 06/12/2012 that stated, "This is a wound care visit. Nurse complains that resident has discomfort on her sacrum... On physical examination, this is an elderly female lying in her bed in no acute distress. On examination of her skin and body audit, we did find that she had bruising to bilateral forearms and lower extremities, and multiple ecchymotic areas. She did have a stage I on the right heel as well as a scab on her left heel for which both will need skin prep. She has a stage II on her sacrum that they are not aware of at this time..." Review of the Nurse's Notes from 04/02/2012 through 07/28/2012 failed to address Resident #4's wounds until after she was seen by the Nurse Practitioner on 06/12/2012. Review of Resident #4's current medical record revealed the Weekly Skin Assessment and the Wound Evaluation Flow Sheet were not filled out, the assessment forms had the resident name and room number. There were not documented assessments of the wound to include measurement, staging, drainage, and interventions. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident 10's medical record revealed a Wound Care Visit note dated 06/14/2012 that stated, "Chief Complaint: Body Audit. Resident's skin was examined today for any compromise of breakdown... Examination reveals her skin is intact except for a small area on her upper buttock sacral area. It measures approximately 0.2 to 0.3. It is barely visible... Apply Skin-Prep to the sacral wound twice a day until resolved..." Review of the Nurse's Notes from 05/10/2012 through 07/24/2012 addressed Resident #10's wound when it was identified on 05/19/2012. The skin breakdown was observed on 05/19/2012 at 2:00 PM and assessed as a stage II sacral wound that measured 3.5 x 1 centimeter. Treatment at the time included cleansing with [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days. There were no additional measurement documented until the Wound Care Visit on 06/14/2012. Review of Resident #10's current medical record revealed the Weekly Skin Assessments were done from 05/12/2012 through 06/30/2012; the Wound Evaluation Flow Sheet was not filled out. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. The facility admitted resident #3 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Scar from old PU (Pressure Ulcer) noted on bottom. Redness over scrotum." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was scored to not have any pressure sores. A Medical Nutrition Therapy Note dated 7/13/12 at 10:00 AM stated, "Per DON (Director of Nursing) res (resident) with 2 open areas to buttocks & sacrum". A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "per staff 2 open areas, one to buttock & one to sacrum". Review of the "Weekly Skin Assessment, revealed one skin assessment dated [DATE]. The skin assessment had checked the resident's skin to be pale with [MEDICAL CONDITION] present. The body figure had a circle around the coccyx/sacral area and it was marked to have been red, as well as the right heel. There were no other weekly skin assessments. The facility failed to identify pressure sores and obtain treatment in a timely manner, The skin assessments and assessment of the Braden scale was not done on a weekly basis per the company policy to monitor the at risk resident for skin impairment. There were no measurements of the wounds, The Braden Scale was not done on admission or weekly per the company policy. The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. Record review on 7/31/12 at 9:30 AM revealed a Nurse's Note dated 4/5/12 and documented as a Late Entry that stated "Stage II decubitus ulcer found to coccyx, 2 X 1.4 cm (centimeters). On 4/17/12, an assessment of the wound was documented in the Nurse's Noted stating "Stage II decubitus to coccyx. Pink granulation noted. Wound margins (and) peri wound normal for skin. Progressive healing noted. Wound slightly decreased in size. (No) drainage noted. 1.4 cm X 1.2 cm." There was no additional documentation of pressure ulcer assessments by the nursing staff.. Review of the Weekly Skin Assessments for the resident revealed skin assessments were done on 5/4/12, 5/15/12, 6/5/12, 6/8/12, and 6/22/12. There were no skin assessments for the month of July. Review of the Nurse's Notes also revealed a note dated 6/13/12 at 2:45 PM that stated "LE (late entry) 6/12/12 Complete body audit completed by (nurse practitioners). New orders received." During an interview on 8/1/12 at 7:48 AM, the Director of Nursing confirmed that Weekly Skin Assessments were missing for 2 weeks in May, 1 week in June and that there were none for the month of July. She also confirmed that the wound had been assessed and measured only twice; upon discovery and 2 weeks later on 4/17/12. In addition, she verified that the information in the medical record was not consistent regarding the date the pressure ulcer was healed. She further confirmed that the wound should have been assessed weekly and documented. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review at approximately 2:10 PM on 7/31/12 revealed a progress note by NP #1 dated 7/3/12 that stated "Upon further examination or (sic) his feet, we did notice... a blood filled blister on the heel of his right foot" and was diagnosed as a pressure ulcer. The note further directed that physical therapy be provided to the left foot only until the wound was resolved. Further review revealed the MD assessed Resident #9 on 7/12/12 and stated the resident developed the pressure ulcer performing his physical therapy exercises. The wound was described as "about the size of a quarter and soft" with "no signs infection." The MD recommended to "avoid pressure, monitor for other signs of inflammation." On 7/18/12 the MD again assessed the wound at the request of the resident. He described the wound as "silver-dollar sized area of the blister that is broken. The central part is still dark, it is ischemic, and possibly will open up but the skin is tight over that at this time." The physician further stated "The patient has diabetes and needs to be watched closely." NP #2 evaluated the resident on 7/19/12 and stated that the resident had reported tenderness on his foot and that the resident had continued to do foot slides in therapy. NP #2 described the wound as "an unstageable deep tissue injury." Measurements were given as 4 X 5 cm and she stated there was "a slight odor on his foot." NP #2 indicated that she spoke to NP #1 who reported she had visualized the blister and had " did talk to therapy regarding how he got it" and had advised "not to do any further foot slides in therapy." Recommendations at that time were for a "heel guard and boot to the right lower extremity at all times." Review of the Physician's Telephone Orders revealed an order dated 7/19/12 for "heel floating boot to RLE (Right Lower Extremity) at all times." During observation of the wound care to his heel on 7/31/12 at 2:35 PM, Resident #9 stated that he did not wear any kind of boot during the day; only at night to keep him from rubbing his heel in the bed. On 7/23/12 NP #1 evaluated the wound and recommended a change in treatment. Review of the Nursing Home Initial History & Physical the resident had chronic stasis changes in the lower extremities. Nursing recommendation was to watch for resolution of abrasions he had sustained prior to admission and for further skin breakdown. Continued review of the record revealed there were no skin assessments since admission. On 8/1/12 at 9:10 AM, record review revealed a Braden Scale for Predicting Pressure Sore Risk assessment was completed on admission with a score of 19, at risk being a score of 15-18. Review of the Nurse's notes revealed Resident #9 had voiced heel pain on 7/11/12 and received pain medication but there was no documentation that the resident's heel was assessed. There was no documentation of a pressure ulcer until 7/18/12 when the CNA reported drainage from the site and the wound was assessed by a Registered Nurse at that time. On 7/26/12 the nurse documented there was no drainage noted from the wound but no further assessment was documented in the Nurse's Notes. A wound Evaluation Flow Sheet was initiated 7/30/12 with wound measurements of 4.2 X 5.2 cm and described the exudate but was otherwise incomplete. Review of the laboratory studies done on 7/20/12 revealed the resident's [MEDICATION NAME] and [MEDICATION NAME] were both low. A note on the report signed by the NP stated "Unstageable pressure area R(ight) heel." Review of the resident's care plan revealed a care plan for current skin problems and listed a surgical wound and bruises. There was no care plan implemented for potential for skin problems on admission or for actual pressure ulcer. At 10:22 AM on 8/1/12, the Director of Nursing confirmed there was no care plan for either the pressure ulcer or the potential for skin breakdown. She further confirmed there were no skin assessments completed. The DON also verified that there was no ongoing assessments of the wound by the nursing staff and that the documentation related to the wound was incomplete. She further confirmed that the resident was not wearing a heel floating boot to the right heel at all times as had been ordered. In addition, during an interview on 8/1/12 with NP #1 revealed that she had given a telephone order the previous week to send Resident #9 to the wound clinic but did not recall which nurse she gave the order to. She further stated that she called the facility on 7/31/12 to ascertain when the resident was going back for a follow-up visit and learned that the resident had not been sent to the wound clinic. Upon arrival at the facility on 7/31/12 she gave another order for Resident #9 to be sent to the wound clinic. Additionally, NP #1 stated there was a Wound Tracking Worksheet that the facility was supposed to be utilizing but confirmed that she had not seen any of the worksheets to review. Review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]." In addition, it advises "Reassess pressure ulcers at least weekly. If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted." On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 6/12/12 and repeated on 6/21/12, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012. FIRST FOLLOW UP VISIT During an unannounced visit on 08/23/2012 at 5:45 PM, it was determined based on interviews, observations, review of records, and review of facility policies and procedures, that the Allegation of Compliance submitted by the facility on 08/22/2012 had been implemented by the facility was in practice as of 08/22/2012, removing the immediacy of the deficient practice. The actions listed in the Allegation of Compliance with a completion date of 08/22/2012 included the following: F272... 1. The resident sample with alleged deficient practice Residents #1, 2, 3, 4, 9, 10 were assessed on 8/1/2012 by licensed practical nurse and verified on 8/1/12 by Director of Nursing. Head to toe skin assessments were completed by Licensed Nurse and verified by Director of Nursing on 8/1/1012 for Residents # 1, 2, 3, 4, 9, 10 and all other current residents Braden Scales were completed on all current residents on 8/2/2012 by a licensed practical nurse and verified by the Director of Nursing. Any resident noted with a skin concern or a Braden Scale score of less than 12, a treatment was initiated per wound protocol; the family and physician were notified as necessary. Medical Director reviewed Residents #1, 2, 3, 4, and 9 on 8/15/12. Resident #14 and Resident #10 (D/C Date 8/2/12) has been discharged from the facility. Attending physician accessed residents #1, 2, 3, 4, and 9 on 8/21/12. 2. All residents have potential to be affected by the alleged deficient practice were identified by the licensed practical nurse and verified by the Director of Nursing, utilizing the skin assessment and Braden Scale. Any resident noted with a skin concern or a Braden Scale score of less than 12, a treatment was initiated per wound protocol; the family and physician were notified as necessary. 3. Weekly skin assessment will be conducted on all residents by the licensed nurse on an ongoing weekly basis. Braden scale will be completed on all residents by the licensed nurse weekly times 3 weeks, monthly times 4 months, quarterly, and as significant changes arise. The Director of Nursing will review and sign off on skin assessments on a weekly basis. The Director of Nursing will complete the weekly wound assessments for residents with pressure ulcers and will notify the family, Registered Dietician, and Nurse Practitioner and/or Physician per wound protocol as necessary. The NP is also a WOCN and will be rounding once per week and will be providing oversight of the Wound Management Program. The Director of Nursing will complete the weekly wound assessments for residents with pressure ulcers. The Director of Nursing will report the tracking and analysis of pressure ulcers as well as identification of trends and/or problems associated with resident care that would impact skin integrity along with interventions for improvement to the QA committee monthly for review to ensure continued compliance. The Director of Nursing was educated on the facility wound protocol on 8/3/12 by the Regional Director of Clinical Services. 4. CNA's were educated by the Regional Director of Clinical Services on 8/3/12 regarding the wound care protocol and reporting any skin issues to the Licensed nurse, and documenting the issues on the shower/skin observation report. The citation at F-272 remained at a lowered scope and severity of "F". The facility will be in compliance at F-272 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the days of the Recertification and Extended Survey, based on observations, interviews, and record review the facility failed to review and revise the comprehensive care plan for 5 of 7 residents reviewed with pressure sores (Residents #14, #1, #4, #3 and #9). The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores. Cross refers to F-281 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to promote healing and prevent infection to residents who had pressure sores. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores. Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. The Admission Nursing Evaluation dated 03/24/2012 indicated under the "SKIN CONDITION section that Resident #14 had two bruises on the top of head sore to the (L) (left) ear on the base of ear. (R) (right) foot on the outer apex has a quarter size black spot. Res (resident) has some sores they have cotton between bottom toes/wrap with Kerlix." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with 2 stage II pressure sores and no venous/arterial sores. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "[MEDICAL CONDITION] to (L) hand and (R) arm. Res with multiple areas of pressure sores." Review of the Weekly Skin Assessments included assessments conduced on 06/12/2012 and 06/21/2012 by the nurse practitioners that indicated the following skin concerns: 1) abrasion LL (left lower) back 5 x 2.8 [MEDICATION NAME]; 2) Stage III Santyl LR (lower right) back 3.5 x 1.7 3) Sacrum 1.5 (oval); 4) (R) trochar; 5) (R) scab humorous (dsg); 6) Stage I - neck; 7) Skin prep (L) heel 8) 3rd toe medial side; 9) 4th medial; 10) 3/4th medial/lateral bone...; 11) (R) eschar on foot 5.5 x 3; 12) (l) inner heel Stage I 5 x 2.5; ecchymotic areas to hands and forearms; (L) foot 2nd toe 1.5 x 1.5; 3rd toe .5 x .5; (R) great toe 1.6 x 1; 2nd toe (R) skin prep between 2nd .3 x .3 and 4th dermal toe ulcer; 4th (R) toe 1.7 x 1.4." Review of the closed Medical Record revealed a Comprehensive Plan of Care dated 03/24/2012 which addressed an unstageable area located on the resident's right outer foot near toes. On 04/15/2012 a skin tear to the right great toe was added with an intervention for protective boots. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident #1's medical record revealed a Progress Note dated 06/12/2012 that stated, "Resident is frail and debilitated. She sustained a skin tear to her lower left leg, however, it is slow in healing and we are here as a followup visit. We also did review a skin body audit and found some redness on her heels and dry skin noted on her bilat. lower extremities. An area on her lower left leg measures 4 x 0.5. The wound bed is beefy. It is moist. The wound edges are somewhat macerated, however, and peeling off..." Review of Resident #1's Plan of Care dated 11/22/2011 and updated 07/23/2012 failed to address intervention for the resident's skin care. A Skin tear dated 01/29/2012 was addressed on the Plan of Care under an identified problem with falls. The 07/23/2012 updated Plan of Care had no information related to resident's skin care needs. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. Review of Resident #4's medical record revealed a Wound Care Visit note dated 06/12/2012 that stated, "This is a wound care visit. Nurse complains that resident has discomfort on her sacrum... On physical examination, this is an elderly female lying in her bed in no acute distress. On examination of her skin and body audit, we did find that she had bruising to bilateral forearms and lower extremities, and multiple ecchymotic areas. She did have a stage I on the right heel as well as a scab on her left heel for which both will need skin prep. She has a stage II on her sacrum that they are not aware of at this time..." Review of Resident #4's Plan of Care dated 10/21/2011 and updated 05/03/2012 failed to address intervention for the resident's stage I on the left heel and the stage II on the resident's sacrum. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Scar from old PU (Pressure Ulcer) noted on bottom. Redness over scrotum." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was scored to not have had any pressure sores. A Medical Nutrition Therapy Note dated 7/13/12 at 10:00 AM stated, "Per DON (Director of Nursing) res (resident) with 2 open areas to buttocks & sacrum". A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "per staff 2 open areas, one to buttock & one to sacrum". Review of the resident's care plan dated 7/17/12, stated, "Resident is at risk for Skin Breakdown." The care plan did not speak to the resident's history of pressure sores as depicted by the Admission Nursing Assessment which stated he had a scar from an old pressure sore. The care plan was never revised to show the resident actually had skin breakdown at the time of the care plan. Another problem listed on the care plan of 7/17/12 stated, "Resident is at risk for complications secondary to incontinence." The goal was for the resident to remain clean, dry and odor free. Goals included to monitor for incontinence every 2 hours and prn, change promptly and apply a protective skin barrier to skin and to monitor for signs and symptoms of skin breakdown. The approach also stated to report to the Medical Doctor and Responsible Party. The facility failed to accurately care plan the resident for his history of pressure sores, redness to his buttocks and heels on admission, or the rash and open areas identified by the Dietician. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review at approximately 2:10 PM on 7/31/12 revealed a progress note by NP #1 dated 7/3/12 that stated "Upon further examination or (sic) his feet, we did notice... a blood filled blister on the heel of his right foot" and was diagnosed as a pressure ulcer. On 8/1/12 at 9:10 AM, record review revealed a Braden Scale for Predicting Pressure Sore Risk assessment was completed on admission with a score of 19, at risk being a score of 15-18. Review of the resident's care plan revealed a care plan for current skin problems and listed a surgical wound and bruises. There was no care plan implemented for potential for skin problems on admission or for actual pressure ulcer. At 10:22 AM on 8/1/12, the Director of Nursing confirmed there was no care plan for either the pressure ulcer or the potential for skin breakdown. On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 06/12/2012 and repeated on 06/21/2012, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012.

On the days of the Recertification and Extended Survey, based on observations, interviews, record reviews, review of the facility Skin Care Guidelines and review the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]. had pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with 2 stage II pressure sores and no venous/arterial sores. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "[MEDICAL CONDITION] to (L) hand and (R) arm. Res with multiple areas of pressure ulcers." Review of the closed medical record for Resident #14 on 08/01/2012 revealed Nurse's Notes from 03/24/2012 through 07/11/2012. The Admission Nursing Evaluation dated 03/24/2012 indicated under the "SKIN CONDITION section that Resident #14 had two bruises on the top of head sore to the (L) (left) ear on the base of ear. (R) (right) foot on the outer apex has a quarter size black spot. Res (resident) has some sores they have cotton between bottom toes/wrap with Kerlix." Documentation of the continued care of Resident #14's skin revealed the following notes: "3/30/2012 at 1 p (m) ... Antipressure boots... 4/1/12 at 2:12 PM Returned from hospital... IV (intravenous) sites (R) arm no bruising present no further skin conditions noted. 4/4/12 at 1330 Resident up in WC (wheelchair). Dsg to bilateral feet changed. Serosanguineous drainage noted... 4/6/12 at 1:15 pm... Cont (continue) with treatment to both feet and toes... 04/08/12 at 1:30 am...ABT (antibiotic) r/t (related to) UTI (urinary tract infection) and [MEDICAL CONDITION] 4/11/12 at 1400 Resident seen by MD (medical doctor). Family in room. Quality of life, wounds and therapy progress discussed with family... Weekly wound assessment completed. Multiple ... to bilateral feet in between toes, black scabbed. Wounds dressed... (R) outer foot 3.4 x 2 cm. Serosanguineous drainage noted, black necrotic tissue to wound bed. Wound margins slightly pink. We will continue tx per wound protocol at this time. No change in wound status. Bilateral heel protectors worn while in bed and at all times. 4/15/12 at 10 AM... heel protector boots in place... at 12:30 PM N. O. (new order) wound treatment... 4/16/12 at 9 PM... Dsg (dressing) intact to Bilat. feet... 4/18/12 at 11 AM... Dsg intact to Bilat. heels... 4/20/12 at 11 AM OOB (out of bed) to WC no s/s (signs/symptoms) of infection to skin tear... 4/22/12 at 1300... Bilateral feet dsg replaced. Wound care completed. Multiple... to toes and (R) outer foot. No change in healing status... 4/26/12 at 10:30 AM... no change wounds, cont. heel protectors and current POC (plan of care). 5/3/12 at 5:40 P NP (nurse practitioner) to come assess residents overall akin and feet. Saturday 5-5-12 afternoon. 5/4/12 at 11 AM... Dsg. intact to Bilat. feet. 5/8/12 at 10:30 AM... Doppler scheduled for today... 5/14/12 at 3:45 AM... boots in place... 5/22/12 at 10:30 AM... Dsg. changed to Bilat toes and feet... 5/31/12 4 PM Dr... acute exam r/t wounds on feet new orders rec'd. Dr... met with spouse and son to address concerns... 6/7/12 at 11 AM N/O Duoderm to back for two stage 2 decubiti. Change q (every) 3rd day and PRN (as needed)... at 5:30 PM Spoke briefly with MD re' (regarding) two new areas to rib cage area... 6/11/12 at 9 PM N/O (new order) U/A (urinalysis) in AM... [MEDICATION NAME] 100 mg (milligrams) po (by mouth) BID (twice a day) x 10 days due to increased WBC (white blood count) / lethargy and wounds. 6/13/12 at 2:30 pm L.E. (late entry) for 6/12/12 complete body audit; all skin issues addressed by NPs. DME (durable medical equipment) company called regarding air mattress inflation... 6/17/12 at 2:30 p Resident bed not staying inflated to the correct capacity, so I called the equipment company and left voicemail for them to come fix. 6/21/12 at 10 AM Wounds rounds with NP cont. with current Tx's wounds unchanged from previous week, resume warm compress to (L) (left) ear x 5 days then BID PRN. New order foot cradle... Review of the Weekly Skin Assessments for Resident #14 revealed assessments performed on the following dates: "4/2/12... Bruises on top of head, black spot (R) foot, sacrum red. 4/9/12 and 4/16/12 no new areas 4/23/12 no new areas others being tx (treated) 4/30/12 no new areas 5/7/12 dsg to sacral bilat heels ulcers 5/14/12 no concern 5/21/12 Lt. Ankle Dsg 5/28/12 red area to buttock Tx. in progress wound to right lateral foot Tx in progress 6/4/12 small open areas noted between toes, tx provided as ordered. 6/12/12 and 6/21/12 (assessment performed by the nurse practitioners) 1) abrasion LL (left lower) back 5 x 2.8 duoderm; 2) Stage III Santyl LR (lower right) back 3.5 x 1.7 3) Sacrum 1.5 (oval); 4) (R) trochan; 5) (R) scab humorous (dsg); 6) Stage I - neck; 7) Skin prep (L) heel 8) 3rd toe medial side; 9) 4th medial; 10) 3/4th medial/lateral bone...; 11) (R) eschar on foot 5.5 x 3; 12) (l) inner heel Stage I 5 x 2.5; ecchymotic areas to hands and forearms; (L) foot 2nd toe 1.5 x 1.5; 3rd toe .5 x .5; (R) great toe 1.6 x 1; 2nd toe (R) skin prep between 2nd .3 x .3 and 4th dermal toe ulcer; 4th (R) toe 1.7 x 1.4." The only wound measurement available at the time of the survey were those documented by the nurse practitioners on 06/12/2012 and 06/21/2012 and documentation in the progress notes related to Resident #14's wounds. Review of the closed Medical Record revealed Braden Scale performed 03/24, 03/31, 04/07, and 04/17/2012 indicating the resident was at high risk for pressure sores. Review of Physician Followup notes revealed the following visits: 04/02/2012... Lower extremities: There is no [MEDICAL CONDITION] noted... He did have multiple areas of deep tissue injuries between his toes as well as on the sides of his feet. These are being treated and they were on him on admission. There was not foul odor; however, on the right side of his right foot on his pinkie toe, there was an area that seemed to be a larger deep tissue injury with redness around it. It did appear to be erythemic, but no drainage was noted. His areas between his toes appeared to have somewhat of a darkened area. They almost all appeared to have some form of scab over them... I do believe if he continues in his decline, it will be on his best interest to consider hospice care as he is having a fast decline... 05/03/2012... Lower extremities... he did have multiple bandages on his lower extremities upon further assessment. I did use wound cleanser to help remove the dressings that were dried to his feet. I did note, on his right foot, he has very poor skin turgor. There is a 1-cm (centimeter) round pressure area on the right outer aspect of his right toe. It appears to be scabbed over. No drainage noted. They are applying Skin-Prep. He has a cracked area in between his toes, between his third and fourth toe that appears to be somewhat reddened around it. On his fourth toe, on the lateral side, there is a 0.5 cm round area on the upper portion of his fourth toe and a 0.25 cm round area on the lower portion. Both appear to be somewhat reddened around them and having some slough noted to them... On the outer aspect of his right foot on his pinky toe, he did have a very large area approximately 3.5 x 3.5 x 4 cm... It appears to have a large black area where it had been closed and they have been applying Skin-Prep... His right heel also was somewhat boggy... On his sacrum, he has a very prominent tailbone and there is an area on the sacrum and coccyx where the bones stick out. The skin appears to be very thin. It was reddened as well as blanching. It has very high risk for breakdown and it may be some deep tissue injury at this time... At this time, we will put him on antibiotics for the [MEDICAL CONDITION] I have contacted... a wound specialist to evaluate his skin... 05/05/2012... provider has asked me to see the resident related to nonhealing foot wounds... he has eschar area on his right lateral foot as well as the right. He has a eschar areas on his right lateral foot by the fifth toe... The wound overall measures approximately 1.5 to 2 cm. He has a scabbed area on his fifth toe and between each toe on both feet he has kissing dermal wounds with creamy centers. Each... measuring between 0.3 to 0.5 in diameter... a wound on the medial aspect of his right great toe... measures 0.5 to 0.75. The wound bed is pink to light red. It is moist. It is oval in shape... He also has a scabbed area on the left calcaneus... It measures approximately 0.5 cm... 06/12/2012... Resident #14 was assessed by the Nurse Practitioner, Skin Specialist who documented the continued decline of the residents wounds. 06/14/2012... I did inform her on the multiple decubitus throughout his body... She was quite tearful and upset... consult hospice... Review of the Physician's Orders related to wound treatment revealed the following: "3/30/12 Clean... (R) outer foot with wound cleaner, apply solosite to wound bed. Cover with [MEDICATION NAME] border 4 x 4 dsg. Apply solosite to pressure areas to toes bilateral feet, Gauze in between toes. Change daily and PRN until healed... 4/5/12 Cleanse (R) Great Toe with wound cleaner Apply solosite to wound cleaner with Meplix Border Gauze. 5/5/12 DC Solosite to all foot wound. Apply dry gauze between toes and (R) lateral foot wound, wrap with Kerlix (R) foot qd (every day) and PRN. Wear protective footwear. 5/31/12 Apply, ABT (antibiotic) ointment to open area between the toes separated by cotton. Apply ABT ointment to area behind (L) ear, Diet: NCS (no concentrated sweets), DC gauze between toes. 6/7/12 Duoderm dressing to stage 2 decubiti on back. Two areas noted. Change q 3 days and PRN. Air Mattress R/T pressure areas. 6/12/12 (L) ear wound/abscess - cleanse with NS (normal saline) or wound cleanser. Apply [MEDICATION NAME], even with 2 x 2 gauze. Change qd and prn. Warm soak compress to (L) ear wound 10 min (minutes) tid x 3 days. Wound Care to lower (R) back - cleanse with NS or wound cleanser apply Santyl, cover with sl (slight) moistened NS gauze, cover with foam change qd and prn. Wound care to sacrum - cleanse with NS or wound cleanser, apply duoderm change q 3 days and prn. Apply skin prep to (R) trochanter, (L) heel, neck - q shift. Wound care to (L) inner heel - apply skin prep q shift. Skin prep to (R) lateral foot eschar q shift. Wound care to open wounds on (R) foot - NS or wound cleanser apply Hydrogel with dampened gauze, skin prep to dried scabs... 6/14/12 hospice consult r/t decline, multiple wounds... 7/9/2012 Admit to Hospice..." Review of the closed Medical Record revealed no Treatment Records (wound care) for June or July 2012. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident #1's medical record revealed a Progress Note dated 06/12/2012 that stated, "Resident is frail and debilitated. She sustained a skin tear to her lower left leg, however, it is slow in healing and we are here as a followup visit. We also did review a skin body audit and found some redness on her heels and dry skin noted on her bilat. lower extremities. An area on her lower left leg measures 4 x 0.5. The wound bed is beefy. It is moist. The wound edges are somewhat macerated, however, and peeling off..." Review of the Nurse's Notes from 02/22/2012 through 07/26/2012 failed to address Resident #4 wounds until after she was seen by the Nurse Practitioner on 06/12/2012. On 06/21/2012 at 10 AM the Nurse's Note stated, "Wound Care round with ...NP new orders..." Review of Resident #1's Weekly Skin Assessment documented the 06/12 and 06/14/2012 wound assessments done by the nurse practitioner, there were no other skin assessments on the resident's medical record. A Non-Pressure Skin Condition Record documented 04/10/2012 as the first date the area on the resident left lower extremity was observed. The measurement at that time was 1.6 cm (centimeters) x 1.8 cm. The record included an assessment on 04/17/2012 with a measurement of 1.6 cm x 1.8 cm; on 04/24/2012 1.6 cm x 1.2 cm; on 05/01/2012 1.4 cm x 1.2 cm. There was no further documentation of the wound until 06/12/2012. The Braden Scale was completed on 08/01 and 11/01/2011; on 04/20/2012. Review of the 07/01/2012 - 07/31/2012 Treatment Record for Resident #1 indicated that the wound treatment for 07/17 and 07/25/2012 was not signed as done; documentation indicated the resident refused treatment on 07/12 and 07/18/2012. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. Review of Resident #4's medical record revealed a Wound Care Visit note dated 06/12/2012 that stated, "This is a wound care visit. Nurse complains that resident has discomfort on her sacrum... On physical examination, this is an elderly female lying in her bed in no acute distress. On examination of her skin and body audit, we did find that she had bruising to bilateral forearms and lower extremities, and multiple ecchymotic areas. She did have a stage I on the right heel as well as a scab on her left heel for which both will need skin prep. She has a stage II on her sacrum that they are not aware of at this time..." Review of the Nurse's Notes from 04/02/2012 through 07/28/2012 failed to address Resident #4 wounds until after she was seen by the Nurse Practitioner on 06/12/2012. On 07/22/2012 at 9:00 AM the Nurse's Note stated, "... no s/s of infection to wound to sacrum area". A Nurse's Note dated 07/24/2012 at 0815 stated, "...wound on sacrum is with minimal drainage, no redness around wound bed noted..." Review of Resident #4's current medical record revealed the Weekly Skin Assessment and the Wound Evaluation Flow Sheet were not filled out, the assessment forms had the resident name and room number. There were not documented assessments of the wound to include measurement, staging, drainage, and interventions. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. Review of the 06/01/2012 - 06/30/2012 Treatment Record for Resident #4 indicated that the wound treatment for 06/19/2012 was not signed as done. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident 10's medical record revealed a Wound Care Visit note dated 06/14/2012 that stated, "Chief Complaint: Body Audit. Resident's skin was examined today for any compromise of breakdown... Examination reveals her skin is intact except for a small area on her upper buttock sacral area. It measures approximately 0.2 to 0.3. It is barely visible... Apply Skin-Prep to the sacral wound twice a day until resolved..." Review of the Nurse's Notes from 05/10/2012 through 07/24/2012 addressed Resident #10's wound when it was identified on 05/19/2012. The skin breakdown was observed on 05/19/2012 at 2:00 PM and assessed as a stage II sacral wound that measured 3.5 x 1 centimeter. Treatment at the time included cleansing with [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days. There were no additional measurement documented until the Wound Care Visit on 06/14/2012. Review of Resident #10's current medical record revealed the Weekly Skin Assessment were done from 05/12/2012 through 06/30/2012; the Wound Evaluation Flow Sheet was not filled out. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. Review of the 05/10/2012 - 05/31/2012 Treatment Record for Resident #10 indicated that the wound treatment for 06/22, 06/25 and 06/31/2012 were not signed as done. The June 2012 Treatment Record was not available at the time of the survey. The facility admitted resident #3 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Scar from old PU (Pressure Ulcer) noted on bottom. Redness over scrotum." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was scored to not have any pressure sores. A Medical Nutrition Therapy Note dated 7/13/12 at 10:00 AM stated, "Per DON (Director of Nursing) res (resident) with 2 open areas to buttocks & sacrum". A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "per staff 2 open areas, one to buttock & one to sacrum". Review of the Physician's Telephone Orders, revealed an order on 7/19/12, "EPC cream to groin & sacrum/coccyx Stage II decub, q (every shift) & PRN (as needed) with incontinence episodes". A second order dated 7/20/12 stated, ..."epc cream to groin/coccyx and along vertebrae on back q shift & prn incontinence episodes." Review of the "Weekly Skin Assessment, revealed one skin assessment dated [DATE]. The skin assessment had checked the resident's skin to be pale with [MEDICAL CONDITION] present. The body figure had a circle around the coccyx/sacral area and it was marked to have been red as well as the right heel. There was no other weekly skin assessments. Review of the Braden Scale for Predicting Pressure Sore Risk had one evaluation date of 7/10/12 that was scored a 12. The score key stated, "10-12 High Risk". Instructions on the top of the form stated, "To be completed upon admission, weekly x (times) 3, then quarterly and PRN. The first time the Braden Scale was completed was one week after admission and had not been done since. At the time of the survey the The facility failed to identify wounds, notify the physician and obtain treatment in a timely manner. Review of the medical record revealed no mention the resident had pressure sores/decubitus ulcers, other than the Telephone Orders and Dietary Notes. The weekly skin assessments were not done, there were no measurements of the wounds, The Braden Scale was not done on admission or weekly per the company policy. The open areas were documented on 7/13/12 by the Registered Dietician and again on 7/16/12 by the Dietician. The family complained the resident had been left unchanged for 14 hours and had a rash and sore on 7/17/12. There were no orders for treatment until 7/19 and 7/20/12. There was no evidence the physician had been notified until 7/19/12 when an order had been obtained for treatment to the decubitus. The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. Record review on 7/31/12 at 9:30 AM revealed a Nurse's Note dated 4/5/12 and documented as a Late Entry that stated "Stage II decubitus ulcer found to coccyx, 2 X 1.4 cm (centimeters). On 4/17/12, an assessment of the wound was documented in the Nurse's Noted stating "Stage II decubitus to coccyx. Pink granulation noted. Wound margins (and) peri wound normal for skin. Progressive healing noted. Wound slightly decreased in size. (No) drainage noted. 1.4 cm X 1.2 cm." There was no further documentation in the Nurse's Notes to indicate the wounds were being assessed by the nurses. Review of the Weekly Skin Assessments for the resident revealed skin assessments were done on 5/4/12, 5/15/12, 6/5/12, 6/8/12, and 6/22/12. There were missing skin assessments for 2 weeks in May, 1 week in June and there were no skin assessments for the month of July. Review of the Nurse's Notes also revealed a note dated 6/13/12 at 2:45 PM that stated "LE (late entry) 6/12/12 Complete body audit completed by (nurse practitioners)." During an interview on 8/1/12 at 7:48 AM, the Director of Nursing confirmed that Weekly Skin Assessments were missing in May and June and that there were none for July. She also confirmed that the wound had been assessed and measured only twice; upon discovery and 2 weeks later on 4/17/12. In addition, she verified that the information in the medical record was not consistent regarding the date the pressure ulcer was healed. She further confirmed that the wound should have been assessed weekly and documented. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review at approximately 2:10 PM on 7/31/12 revealed a progress note by NP #1 dated 7/3/12 that stated "Upon further examination or (sic) his feet, we did notice... a blood filled blister on the heel of his right foot" and was diagnosed as a pressure ulcer. Further review revealed the MD assessed Resident #9 on 7/12/12 and the wound was described as "about the size of a quarter and soft" with "no signs infection." On 7/18/12 the MD again assessed the wound at the request of the resident. He described the wound as "silver-dollar sized area of the blister that is broken. The central part is still dark, it is ischemic, and possibly will open up but the skin is tight over that at this time." The physician further stated "The patient has diabetes and needs to be watched closely." NP #2 described the wound as "an unstageable deep tissue injury" on 7/19/12 and measurements were given as 4 X 5 cm and she stated there was "a slight odor on his foot." Review of the Nurse's Notes revealed a note, timed and dated 8:15 AM 7/18/12, that stated the wound measured 5 x 3 cm. There was no documentation in the Nurse's Notes that the foot had an odor. Review of the Nursing Home Initial History & Physical revealed the resident had chronic stasis changes in the lower extremities and Diabetes. Nursing recommendation was to "watch ... for further skin breakdown." Continued review of the record revealed there were no skin assessments since admission. On 8/1/12 at 9:10 AM, record review revealed a Braden Scale for Predicting Pressure Sore Risk assessment was completed on admission with a score of 19, a score of 15-18 being at risk. Review of the Nurse's notes revealed Resident #9 had complained of heel pain on 7/11/12 and received pain medication but there was no documentation that the resident's heel was assessed. There was no documentation of the pressure ulcer in the Nurse's Notes until 7/18/12 when a staff member reported drainage on there dressing and the wound was assessed by a Registered Nurse. On 7/26/12 the nurse documented there was no drainage noted from the wound but no further assessment was documented in the Nurse's Notes. A wound Evaluation Flow Sheet was initiated 7/30/12 with wound measurements of 4.2 X 5.2 cm and described the exudate but was otherwise incomplete. Review of the resident's care plan revealed a care plan for a surgical wound and bruises but no care plan for potential for skin problems or for the actual pressure ulcer. At 10:22 AM on 8/1/12, the Director of Nursing confirmed there was no care plan for either the pressure ulcer or the potential for skin breakdown. She further confirmed there were no skin assessments completed. The Director of Nursing also verified that there were no ongoing assessments of the wound by the nursing staff and that the documentation related to the wound was incomplete. During an interview on 8/1/12, NP #1 revealed that she had given a telephone order the previous week to send Resident #9 to the wound clinic. She also stated that the order was never written and the resident was not evaluated by the wound clinic. Additionally, NP #1 stated there was a Wound Tracking Worksheet that the facility was supposed to be utilizing but confirmed that she had not seen any of the worksheets to review. During the interview, NP #1 stated that NP #2 voiced concerns and reported finding pressure ulcers that she did not know about. At that time, in mid-June, the 2 Nurse Practitioners and the Director of Nursing completed body audits on all the residents in the building at that time secondary to the Nurse Practitioners concerns. Review of the facility policy Clinical Guideline: Skin Integrity indicated that "All residents will be assessed/observed for risk of skin breakdown (Braden Scale) within 24 hours of admission then weekly x 3 weeks, then quarterly and as necessitated by change in condition. Facility develops a routine to review residents with wounds or at risk on a weekly basis... DNS or designee... monitor the skin integrity. Wound status is monitored on a weekly basis. Documentation and Care Interventions for Skin Integrity: Assessment/Observation is to be completed within the first twenty-four hours of admission/weekly x 3 weeks/ quarterly/significant change of condition. If identified risk present the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan... Documentation of Weekly Skin Assessments/Observations: Licensed nurse will be responsible for performing this skin assessment/observation using Braden Scale... Monitoring Compliance: The following elements are in place to demonstrate satisfactory compliance with guideline. Wound Evaluation Flow Sheet is being used. DNS or designee evaluates wounds on a weekly basis. Physical observation reflects all care plan interventions are implemented and in place. Skin integrity guidelines are in place for assessment, interventions and nutritional support..." Review of the Wound Evaluation Flow Sheet indicated the sheet was to be completed by the nurse upon identification of pressure ulcer/wound and at least weekly from date of identification. The sheet included information related to the site and location; measurements, exudate, wound bed, periwound and a section for comments. Review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]." In addition, it advises "Reassess pressure ulcers at least weekly. If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted." On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 06/12/2012 and repeated on 06/21/2012, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012.

On the days of the Recertification and Extended Survey, based on observations, interviews, record reviews, review of the facility Skin Care Guidelines and review the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]. pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with 2 stage II pressure sores and no venous/arterial sores. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "[MEDICAL CONDITION] to (L) hand and (R) arm. Res with multiple areas of pressure ulcers." Review of the closed medical record for Resident #14 on 08/01/2012 revealed Nurse's Notes from 03/24/2012 through 07/11/2012. The Admission Nursing Evaluation dated 03/24/2012 indicated under the "SKIN CONDITION section that Resident #14 had two bruises on the top of head sore to the (L) (left) ear on the base of ear. (R) (right) foot on the outer apex has a quarter size black spot. Res (resident) has some sores they have cotton between bottom toes/wrap with Kerlix." Documentation of the continued care of Resident #14's skin revealed the following notes: "3/30/2012 at 1 p (m) ... Antipressure boots... 4/1/12 at 2:12 PM Returned from hospital... IV (intravenous) sites (R) arm no bruising present no further skin conditions noted. 4/4/12 at 1330 Resident up in WC (wheelchair). Dsg to bilateral feet changed. Serosanguineous drainage noted... 4/6/12 at 1:15 pm... Cont (continue) with treatment to both feet and toes... 04/08/12 at 1:30 am...ABT (antibiotic) r/t (related to) UTI (urinary tract infection) and [MEDICAL CONDITION] 4/11/12 at 1400 Resident seen by MD (medical doctor). Family in room. Quality of life, wounds and therapy progress discussed with family... Weekly wound assessment completed. Multiple ... to bilateral feet in between toes, black scabbed. Wounds dressed... (R) outer foot 3.4 x 2 cm. Serosanguineous drainage noted, black necrotic tissue to wound bed. Wound margins slightly pink. We will continue tx per wound protocol at this time. No change in wound status. Bilateral heel protectors worn while in bed and at all times. 4/15/12 at 10 AM... heel protector boots in place... at 12:30 PM N. O. (new order) wound treatment... 4/16/12 at 9 PM... Dsg (dressing) intact to Bilat. feet... 4/18/12 at 11 AM... Dsg intact to Bilat. heels... 4/20/12 at 11 AM OOB (out of bed) to WC no s/s (signs/symptoms) of infection to skin tear... 4/22/12 at 1300... Bilateral feet dsg replaced. Wound care completed. Multiple... to toes and (R) outer foot. No change in healing status... 4/26/12 at 10:30 AM... no change wounds, cont. heel protectors and current POC (plan of care). 5/3/12 at 5:40 P NP (nurse practitioner) to come assess residents overall akin and feet. Saturday 5-5-12 afternoon. 5/4/12 at 11 AM... Dsg. intact to Bilat. feet. 5/8/12 at 10:30 AM... Doppler scheduled for today... 5/14/12 at 3:45 AM... boots in place... 5/22/12 at 10:30 AM... Dsg. changed to Bilat toes and feet... 5/31/12 4 PM Dr... acute exam r/t wounds on feet new orders rec'd. Dr... met with spouse and son to address concerns... 6/7/12 at 11 AM N/O [MEDICATION NAME] to back for two stage 2 decubiti. Change q (every) 3rd day and PRN (as needed)... at 5:30 PM Spoke briefly with MD re' (regarding) two new areas to rib cage area... 6/11/12 at 9 PM N/O (new order) U/A (urinalysis) in AM... [MEDICATION NAME] 100 mg (milligrams) po (by mouth) BID (twice a day) x 10 days due to increased WBC (white blood count) / lethargy and wounds. 6/13/12 at 2:30 pm L.E. (late entry) for 6/12/12 complete body audit; all skin issues addressed by NPs. DME (durable medical equipment) company called regarding air mattress inflation... 6/17/12 at 2:30 p Resident bed not staying inflated to the correct capacity, so I called the equipment company and left voicemail for them to come fix. 6/21/12 at 10 AM Wounds rounds with NP cont. with current Tx's wounds unchanged from previous week, resume warm compress to (L) (left) ear x 5 days then BID PRN. New order foot cradle... Review of the Weekly Skin Assessments for Resident #14 revealed assessments performed on the following dates: "4/2/12... Bruises on top of head, black spot (R) foot, sacrum red. 4/9/12 and 4/16/12 no new areas 4/23/12 no new areas others being tx (treated) 4/30/12 no new areas 5/7/12 dsg to sacral bilat heels ulcers 5/14/12 no concern 5/21/12 Lt. Ankle Dsg 5/28/12 red area to buttock Tx. in progress wound to right lateral foot Tx in progress 6/4/12 small open areas noted between toes, tx provided as ordered. 6/12/12 and 6/21/12 (assessment performed by the nurse practitioners) 1) abrasion LL (left lower) back 5 x 2.8 [MEDICATION NAME]; 2) Stage III Santyl LR (lower right) back 3.5 x 1.7 3) Sacrum 1.5 (oval); 4) (R) trochan; 5) (R) scab humorous (dsg); 6) Stage I - neck; 7) Skin prep (L) heel 8) 3rd toe medial side; 9) 4th medial; 10) 3/4th medial/lateral bone...; 11) (R) eschar on foot 5.5 x 3; 12) (l) inner heel Stage I 5 x 2.5; ecchymotic areas to hands and forearms; (L) foot 2nd toe 1.5 x 1.5; 3rd toe .5 x .5; (R) great toe 1.6 x 1; 2nd toe (R) skin prep between 2nd .3 x .3 and 4th dermal toe ulcer; 4th (R) toe 1.7 x 1.4." The only wound measurement available at the time of the survey were those documented by the nurse practitioners on 06/12/2012 and 06/21/2012 and documentation in the progress notes related to Resident #14's wounds. Review of the closed Medical Record revealed Braden Scale performed 03/24, 03/31, 04/07, and 04/17/2012 indicating the resident was at high risk for pressure sores. Review of Physician Followup notes revealed the following visits: 04/02/2012... Lower extremities: There is no [MEDICAL CONDITION] noted... He did have multiple areas of deep tissue injuries between his toes as well as on the sides of his feet. These are being treated and they were on him on admission. There was not foul odor; however, on the right side of his right foot on his pinkie toe, there was an area that seemed to be a larger deep tissue injury with redness around it. It did appear to be erythemic, but no drainage was noted. His areas between his toes appeared to have somewhat of a darkened area. They almost all appeared to have some form of scab over them... I do believe if he continues in his decline, it will be on his best interest to consider hospice care as he is having a fast decline... 05/03/2012... Lower extremities... he did have multiple bandages on his lower extremities upon further assessment. I did use wound cleanser to help remove the dressings that were dried to his feet. I did note, on his right foot, he has very poor skin turgor. There is a 1-cm (centimeter) round pressure area on the right outer aspect of his right toe. It appears to be scabbed over. No drainage noted. They are applying Skin-Prep. He has a cracked area in between his toes, between his third and fourth toe that appears to be somewhat reddened around it. On his fourth toe, on the lateral side, there is a 0.5 cm round area on the upper portion of his fourth toe and a 0.25 cm round area on the lower portion. Both appear to be somewhat reddened around them and having some slough noted to them... On the outer aspect of his right foot on his pinky toe, he did have a very large area approximately 3.5 x 3.5 x 4 cm... It appears to have a large black area where it had been closed and they have been applying Skin-Prep... His right heel also was somewhat boggy... On his sacrum, he has a very prominent tailbone and there is an area on the sacrum and coccyx where the bones stick out. The skin appears to be very thin. It was reddened as well as blanching. It has very high risk for breakdown and it may be some deep tissue injury at this time... At this time, we will put him on antibiotics for the [MEDICAL CONDITION] I have contacted... a wound specialist to evaluate his skin... 05/05/2012... provider has asked me to see the resident related to nonhealing foot wounds... he has eschar area on his right lateral foot as well as the right. He has a eschar areas on his right lateral foot by the fifth toe... The wound overall measures approximately 1.5 to 2 cm. He has a scabbed area on his fifth toe and between each toe on both feet he has kissing dermal wounds with creamy centers. Each... measuring between 0.3 to 0.5 in diameter... a wound on the medial aspect of his right great toe... measures 0.5 to 0.75. The wound bed is pink to light red. It is moist. It is oval in shape... He also has a scabbed area on the left calcaneus... It measures approximately 0.5 cm... 06/12/2012... Resident #14 was assessed by the Nurse Practitioner, Skin Specialist who documented the continued decline of the residents wounds. 06/14/2012... I did inform her on the multiple decubitus throughout his body... She was quite tearful and upset... consult hospice... Review of the Physician's Orders related to wound treatment revealed the following: "3/30/12 Clean... (R) outer foot with wound cleaner, apply solosite to wound bed. Cover with [MEDICATION NAME] border 4 x 4 dsg. Apply solosite to pressure areas to toes bilateral feet, Gauze in between toes. Change daily and PRN until healed... 4/5/12 Cleanse (R) Great Toe with wound cleaner Apply solosite to wound cleaner with Meplix Border Gauze. 5/5/12 DC Solosite to all foot wound. Apply dry gauze between toes and (R) lateral foot wound, wrap with Kerlix (R) foot qd (every day) and PRN. Wear protective footwear. 5/31/12 Apply, ABT (antibiotic) ointment to open area between the toes separated by cotton. Apply ABT ointment to area behind (L) ear, Diet: NCS (no concentrated sweets), DC gauze between toes. 6/7/12 [MEDICATION NAME] dressing to stage 2 decubiti on back. Two areas noted. Change q 3 days and PRN. Air Mattress R/T pressure areas. 6/12/12 (L) ear wound/abscess - cleanse with NS (normal saline) or wound cleanser. Apply [MEDICATION NAME], even with 2 x 2 gauze. Change qd and prn. Warm soak compress to (L) ear wound 10 min (minutes) tid x 3 days. Wound Care to lower (R) back - cleanse with NS or wound cleanser apply Santyl, cover with sl (slight) moistened NS gauze, cover with foam change qd and prn. Wound care to sacrum - cleanse with NS or wound cleanser, apply [MEDICATION NAME] change q 3 days and prn. Apply skin prep to (R) trochanter, (L) heel, neck - q shift. Wound care to (L) inner heel - apply skin prep q shift. Skin prep to (R) lateral foot eschar q shift. Wound care to open wounds on (R) foot - NS or wound cleanser apply Hydrogel with dampened gauze, skin prep to dried scabs... 6/14/12 hospice consult r/t decline, multiple wounds... 7/9/2012 Admit to Hospice..." Review of the closed Medical Record revealed no Treatment Records (wound care) for June or July 2012. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident #1's medical record revealed a Progress Note dated 06/12/2012 that stated, "Resident is frail and debilitated. She sustained a skin tear to her lower left leg, however, it is slow in healing and we are here as a followup visit. We also did review a skin body audit and found some redness on her heels and dry skin noted on her bilat. lower extremities. An area on her lower left leg measures 4 x 0.5. The wound bed is beefy. It is moist. The wound edges are somewhat macerated, however, and peeling off..." Review of the Nurse's Notes from 02/22/2012 through 07/26/2012 failed to address Resident #4 wounds until after she was seen by the Nurse Practitioner on 06/12/2012. On 06/21/2012 at 10 AM the Nurse's Note stated, "Wound Care round with ...NP new orders..." Review of Resident #1's Weekly Skin Assessment documented the 06/12 and 06/14/2012 wound assessments done by the nurse practitioner, there were no other skin assessments on the resident's medical record. A Non-Pressure Skin Condition Record documented 04/10/2012 as the first date the area on the resident left lower extremity was observed. The measurement at that time was 1.6 cm (centimeters) x 1.8 cm. The record included an assessment on 04/17/2012 with a measurement of 1.6 cm x 1.8 cm; on 04/24/2012 1.6 cm x 1.2 cm; on 05/01/2012 1.4 cm x 1.2 cm. There was no further documentation of the wound until 06/12/2012. The Braden Scale was completed on 08/01 and 11/01/2011; on 04/20/2012. Review of the 07/01/2012 - 07/31/2012 Treatment Record for Resident #1 indicated that the wound treatment for 07/17 and 07/25/2012 was not signed as done; documentation indicated the resident refused treatment on 07/12 and 07/18/2012. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. Review of Resident #4's medical record revealed a Wound Care Visit note dated 06/12/2012 that stated, "This is a wound care visit. Nurse complains that resident has discomfort on her sacrum... On physical examination, this is an elderly female lying in her bed in no acute distress. On examination of her skin and body audit, we did find that she had bruising to bilateral forearms and lower extremities, and multiple ecchymotic areas. She did have a stage I on the right heel as well as a scab on her left heel for which both will need skin prep. She has a stage II on her sacrum that they are not aware of at this time..." Review of the Nurse's Notes from 04/02/2012 through 07/28/2012 failed to address Resident #4 wounds until after she was seen by the Nurse Practitioner on 06/12/2012. On 07/22/2012 at 9:00 AM the Nurse's Note stated, "... no s/s of infection to wound to sacrum area". A Nurse's Note dated 07/24/2012 at 0815 stated, "...wound on sacrum is with minimal drainage, no redness around wound bed noted..." Review of Resident #4's current medical record revealed the Weekly Skin Assessment and the Wound Evaluation Flow Sheet were not filled out, the assessment forms had the resident name and room number. There were not documented assessments of the wound to include measurement, staging, drainage, and interventions. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. Review of the 06/01/2012 - 06/30/2012 Treatment Record for Resident #4 indicated that the wound treatment for 06/19/2012 was not signed as done. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was coded with no pressure sores. The Quarterly MDS dated [DATE] coded the resident with no skin concerns. A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "blister/wounds to (L) L (lower) (E) extremity..." Review of Resident 10's medical record revealed a Wound Care Visit note dated 06/14/2012 that stated, "Chief Complaint: Body Audit. Resident's skin was examined today for any compromise of breakdown... Examination reveals her skin is intact except for a small area on her upper buttock sacral area. It measures approximately 0.2 to 0.3. It is barely visible... Apply Skin-Prep to the sacral wound twice a day until resolved..." Review of the Nurse's Notes from 05/10/2012 through 07/24/2012 addressed Resident #10's wound when it was identified on 05/19/2012. The skin breakdown was observed on 05/19/2012 at 2:00 PM and assessed as a stage II sacral wound that measured 3.5 x 1 centimeter. Treatment at the time included cleansing with [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days. There were no additional measurement documented until the Wound Care Visit on 06/14/2012. Review of Resident #10's current medical record revealed the Weekly Skin Assessment were done from 05/12/2012 through 06/30/2012; the Wound Evaluation Flow Sheet was not filled out. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. Review of the 05/10/2012 - 05/31/2012 Treatment Record for Resident #10 indicated that the wound treatment for 06/22, 06/25 and 06/31/2012 were not signed as done. The June 2012 Treatment Record was not available at the time of the survey. The facility admitted resident #3 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Scar from old PU (Pressure Ulcer) noted on bottom. Redness over scrotum." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was scored to not have any pressure sores. A Medical Nutrition Therapy Note dated 7/13/12 at 10:00 AM stated, "Per DON (Director of Nursing) res (resident) with 2 open areas to buttocks & sacrum". A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "per staff 2 open areas, one to buttock & one to sacrum". Review of the Physician's Telephone Orders, revealed an order on 7/19/12, "EPC cream to groin & sacrum/coccyx Stage II decub, q (every shift) & PRN (as needed) with incontinence episodes". A second order dated 7/20/12 stated, ..."epc cream to groin/coccyx and along vertebrae on back q shift & prn incontinence episodes." Review of the "Weekly Skin Assessment, revealed one skin assessment dated [DATE]. The skin assessment had checked the resident's skin to be pale with [MEDICAL CONDITION] present. The body figure had a circle around the coccyx/sacral area and it was marked to have been red as well as the right heel. There was no other weekly skin assessments. Review of the Braden Scale for Predicting Pressure Sore Risk had one evaluation date of 7/10/12 that was scored a 12. The score key stated, "10-12 High Risk". Instructions on the top of the form stated, "To be completed upon admission, weekly x (times) 3, then quarterly and PRN. The first time the Braden Scale was completed was one week after admission and had not been done since. At the time of the survey the The facility failed to identify wounds, notify the physician and obtain treatment in a timely manner. Review of the medical record revealed no mention the resident had pressure sores/decubitus ulcers, other than the Telephone Orders and Dietary Notes. The weekly skin assessments were not done, there were no measurements of the wounds, The Braden Scale was not done on admission or weekly per the company policy. The open areas were documented on 7/13/12 by the Registered Dietician and again on 7/16/12 by the Dietician. The family complained the resident had been left unchanged for 14 hours and had a rash and sore on 7/17/12. There were no orders for treatment until 7/19 and 7/20/12. There was no evidence the physician had been notified until 7/19/12 when an order had been obtained for treatment to the decubitus. The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. Record review on 7/31/12 at 9:30 AM revealed a Nurse's Note dated 4/5/12 and documented as a Late Entry that stated "Stage II decubitus ulcer found to coccyx, 2 X 1.4 cm (centimeters). On 4/17/12, an assessment of the wound was documented in the Nurse's Noted stating "Stage II decubitus to coccyx. Pink granulation noted. Wound margins (and) peri wound normal for skin. Progressive healing noted. Wound slightly decreased in size. (No) drainage noted. 1.4 cm X 1.2 cm." There was no further documentation in the Nurse's Notes to indicate the wounds were being assessed by the nurses. Review of the Weekly Skin Assessments for the resident revealed skin assessments were done on 5/4/12, 5/15/12, 6/5/12, 6/8/12, and 6/22/12. There were missing skin assessments for 2 weeks in May, 1 week in June and there were no skin assessments for the month of July. Review of the Nurse's Notes also revealed a note dated 6/13/12 at 2:45 PM that stated "LE (late entry) 6/12/12 Complete body audit completed by (nurse practitioners)." During an interview on 8/1/12 at 7:48 AM, the Director of Nursing confirmed that Weekly Skin Assessments were missing in May and June and that there were none for July. She also confirmed that the wound had been assessed and measured only twice; upon discovery and 2 weeks later on 4/17/12. In addition, she verified that the information in the medical record was not consistent regarding the date the pressure ulcer was healed. She further confirmed that the wound should have been assessed weekly and documented. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review at approximately 2:10 PM on 7/31/12 revealed a progress note by NP #1 dated 7/3/12 that stated "Upon further examination or (sic) his feet, we did notice... a blood filled blister on the heel of his right foot" and was diagnosed as a pressure ulcer. Further review revealed the MD assessed Resident #9 on 7/12/12 and the wound was described as "about the size of a quarter and soft" with "no signs infection." On 7/18/12 the MD again assessed the wound at the request of the resident. He described the wound as "silver-dollar sized area of the blister that is broken. The central part is still dark, it is ischemic, and possibly will open up but the skin is tight over that at this time." The physician further stated "The patient has diabetes and needs to be watched closely." NP #2 described the wound as "an unstageable deep tissue injury" on 7/19/12 and measurements were given as 4 X 5 cm and she stated there was "a slight odor on his foot." Review of the Nurse's Notes revealed a note, timed and dated 8:15 AM 7/18/12, that stated the wound measured 5 x 3 cm. There was no documentation in the Nurse's Notes that the foot had an odor. Review of the Nursing Home Initial History & Physical revealed the resident had chronic stasis changes in the lower extremities and Diabetes. Nursing recommendation was to "watch ... for further skin breakdown." Continued review of the record revealed there were no skin assessments since admission. On 8/1/12 at 9:10 AM, record review revealed a Braden Scale for Predicting Pressure Sore Risk assessment was completed on admission with a score of 19, a score of 15-18 being at risk. Review of the Nurse's notes revealed Resident #9 had complained of heel pain on 7/11/12 and received pain medication but there was no documentation that the resident's heel was assessed. There was no documentation of the pressure ulcer in the Nurse's Notes until 7/18/12 when a staff member reported drainage on there dressing and the wound was assessed by a Registered Nurse. On 7/26/12 the nurse documented there was no drainage noted from the wound but no further assessment was documented in the Nurse's Notes. A wound Evaluation Flow Sheet was initiated 7/30/12 with wound measurements of 4.2 X 5.2 cm and described the exudate but was otherwise incomplete. Review of the resident's care plan revealed a care plan for a surgical wound and bruises but no care plan for potential for skin problems or for the actual pressure ulcer. At 10:22 AM on 8/1/12, the Director of Nursing confirmed there was no care plan for either the pressure ulcer or the potential for skin breakdown. She further confirmed there were no skin assessments completed. The Director of Nursing also verified that there were no ongoing assessments of the wound by the nursing staff and that the documentation related to the wound was incomplete. During an interview on 8/1/12, NP #1 revealed that she had given a telephone order the previous week to send Resident #9 to the wound clinic. She also stated that the order was never written and the resident was not evaluated by the wound clinic. Additionally, NP #1 stated there was a Wound Tracking Worksheet that the facility was supposed to be utilizing but confirmed that she had not seen any of the worksheets to review. During the interview, NP #1 stated that NP #2 voiced concerns and reported finding pressure ulcers that she did not know about. At that time, in mid-June, the 2 Nurse Practitioners and the Director of Nursing completed body audits on all the residents in the building at that time secondary to the Nurse Practitioners concerns. Review of the facility policy Clinical Guideline: Skin Integrity indicated that "All residents will be assessed/observed for risk of skin breakdown (Braden Scale) within 24 hours of admission then weekly x 3 weeks, then quarterly and as necessitated by change in condition. Facility develops a routine to review residents with wounds or at risk on a weekly basis... DNS or designee... monitor the skin integrity. Wound status is monitored on a weekly basis. Documentation and Care Interventions for Skin Integrity: Assessment/Observation is to be completed within the first twenty-four hours of admission/weekly x 3 weeks/ quarterly/significant change of condition. If identified risk present the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan... Documentation of Weekly Skin Assessments/Observations: Licensed nurse will be responsible for performing this skin assessment/observation using Braden Scale... Monitoring Compliance: The following elements are in place to demonstrate satisfactory compliance with guideline. Wound Evaluation Flow Sheet is being used. DNS or designee evaluates wounds on a weekly basis. Physical observation reflects all care plan interventions are implemented and in place. Skin integrity guidelines are in place for assessment, interventions and nutritional support..." Review of the Wound Evaluation Flow Sheet indicated the sheet was to be completed by the nurse upon identification of pressure ulcer/wound and at least weekly from date of identification. The sheet included information related to the site and location; measurements, exudate, wound bed, periwound and a section for comments. Review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]." In addition, it advises "Reassess pressure ulcers at least weekly. If the condition of the patient or of the wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted." On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 06/12/2012 and repeated on 06/21/2012, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012. FIRST FOLLOW UP VISIT During an unannounced visit on 08/23/2012 at 5:45 PM, it was determined based on interviews, observations, review of records, and review of facility policies and procedures, that the Allegation of Compliance submitted by the facility on 08/22/2012 had been implemented by the facility was in practice as of 08/22/2012, removing the immediacy of the deficient practice. The actions listed in the Allegation of Compliance with a completion date of 08/22/2012 included the following: F281... 1. The resident sample with alleged deficient practice Residents #1, 2, 3, 4, 9, 10 were assessed by licensed practical nurse and verified by Director of Nursing. Head to toe skin assessments were completed on 8/1/2012 for Residents # 1,2,3,4,9,10 and all other current residents. Braden Scales were completed on all current residents on 8/2/2012 by a licensed practical nurse and verified by the Director of Nursing. Any resident noted with a skin concern or a Braden Scale score of less than 12, a treatment was initiated per wound protocol; the family and physician were notified as necessary. If Physician interventions or order is prescribed the nurse will note the order, and transcribe the directive to the T.A.R. (Treatment Administration Record). Family will be notified, and treatment will provided as ordered by physician by licensed nurse.

On the days of the Recertification and Extended Survey, based on observations, interviews, record reviews, and review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED].#14, #1, #4, #10, #3, #2, and #9). In addition, Resident #9, 1 of 3 residents with wound treatments observed, failed to receive pressure sore treatment per physician instructions. The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores (Resident #14, #1, #4, #3 and #9). Cross refers to F-281 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to promote healing and prevent infection to residents who had pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. Nursing documentation on 03/24/2012 revealed that Resident #14 was admitted to the facility with two bruises on the top of his head and a sore at the base of the left ear. The right outer apex of his right foot had a "quarter size" black spot. His toes were described as "has some sores" with cotton between and his bottom toes was wrap with Kerlix. The first wound measurement was obtained/documented on 04/11/2012; this was a measurement of the right outer foot wound. On 06/07/2012 the nursing documentation stated two stage 2 decubitus on the back. There were no measurements or assessment of the area. On 06/13/2012 and 06/17/2012 nursing documentation speaks to a problem with the resident's air mattress not staying inflated with no documented resolution. The only wound measurements for Resident #14, the facility was able to provide other than the one measurement of the right outer foot, were those documented by the nurse practitioner on 06/12/2012 and 06/21/2012. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the closed medical record for Resident #14 on 08/01/2012 revealed Nurse's Notes from 03/24/2012 through 07/11/2012. The Admission Nursing Evaluation dated 03/24/2012 indicated under the "SKIN CONDITION section that Resident #14 had two bruises on the top of head sore to the (L) (left) ear on the base of ear. (R) (right) foot on the outer apex has a quarter size black spot. Res (resident) has some sores they have cotton between bottom toes/wrap with Kerlix." Documentation of the continued care of Resident #14's skin revealed the following notes: "3/30/2012 at 1 p (m) ... Antipressure boots... 4/1/12 at 2:12 PM Returned from hospital... IV (intravenous) sites (R) arm no bruising present no further skin conditions noted. 4/4/12 at 1330 Resident up in WC (wheelchair). Dsg to bilateral feet changed. Serosanguineous drainage noted... 4/6/12 at 1:15 pm... Cont (continue) with treatment to both feet and toes... 04/08/12 at 1:30 am...ABT (antibiotic) r/t (related to) UTI (urinary tract infection) and [MEDICAL CONDITION] 4/11/12 at 1400 Resident seen by MD (medical doctor). Family in room. Quality of life, wounds and therapy progress discussed with family... Weekly wound assessment completed. Multiple ... to bilateral feet in between toes, black scabbed. Wounds dressed... (R) outer foot 3.4 x 2 cm. Serosanguineous drainage noted, black necrotic tissue to wound bed. Wound margins slightly pink. We will continue tx per wound protocol at this time. No change in wound status. Bilateral heel protectors worn while in bed and at all times. 4/15/12 at 10 AM... heel protector boots in place... at 12:30 PM N. O. (new order) wound treatment... 4/16/12 at 9 PM... Dsg (dressing) intact to Bilat. feet... 4/18/12 at 11 AM... Dsg intact to Bilat. heels... 4/20/12 at 11 AM OOB (out of bed) to WC no s/s (signs/symptoms) of infection to skin tear... 4/22/12 at 1300... Bilateral feet dsg replaced. Wound care completed. Multiple... to toes and (R) outer foot. No change in healing status... 4/26/12 at 10:30 AM... no change wounds, cont. heel protectors and current POC (plan of care). 5/3/12 at 5:40 P NP (nurse practitioner) to come assess residents overall skin and feet. Saturday 5-5-12 afternoon. 5/4/12 at 11 AM... Dsg. intact to Bilat. feet. 5/8/12 at 10:30 AM... Doppler scheduled for today... 5/14/12 at 3:45 AM... boots in place... 5/22/12 at 10:30 AM... Dsg. changed to Bilat toes and feet... 5/31/12 4 PM Dr... acute exam r/t wounds on feet new orders rec'd. Dr... met with spouse and son to address concerns... 6/7/12 at 11 AM N/O [MEDICATION NAME] to back for two stage 2 decubiti. Change q (every) 3rd day and PRN (as needed)... at 5:30 PM Spoke briefly with MD re' (regarding) two new areas to rib cage area... 6/11/12 at 9 PM N/O (new order) U/A (urinalysis) in AM... [MEDICATION NAME] 100 mg (milligrams) po (by mouth) BID (twice a day) x 10 days due to increased WBC (white blood count) / lethargy and wounds. 6/13/12 at 2:30 pm L.E. (late entry) for 6/12/12 complete body audit; all skin issues addressed by NPs. DME (durable medical equipment) company called regarding air mattress inflation... 6/17/12 at 2:30 p Resident bed not staying inflated to the correct capacity, so I called the equipment company and left voicemail for them to come fix. 6/21/12 at 10 AM Wounds rounds with NP cont. with current Tx's wounds unchanged from previous week, resume warm compress to (L) (left) ear x 5 days then BID PRN. New order foot cradle... Review of the Weekly Skin Assessments performed on the following dates for Resident #14 revealed no wound measurements until 06/12/2012 when a skin assessment was done by the nurse practitioner: "4/2/12... Bruises on top of head, black spot (R) foot, sacrum red. 4/9/12 and 4/16/12 no new areas 4/23/12 no new areas others being tx (treated) 4/30/12 no new areas 5/7/12 dsg to sacral bilat heels ulcers 5/14/12 no concern 5/21/12 Lt. Ankle Dsg 5/28/12 red area to buttock Tx. in progress wound to right lateral foot Tx in progress 6/4/12 small open areas noted between toes, tx provided as ordered. 6/12/12 and 6/21/12 (assessment performed by the nurse practitioners) 1) abrasion LL (left lower) back 5 x 2.8 [MEDICATION NAME]; 2) Stage III Santyl LR (lower right) back 3.5 x 1.7 3) Sacrum 1.5 (oval); 4) (R) trochar; 5) (R) scab humorous (dsg); 6) Stage I - neck; 7) Skin prep (L) heel 8) 3rd toe medial side; 9) 4th medial; 10) 3/4th medial/lateral bone...; 11) (R) eschar on foot 5.5 x 3; 12) (l) inner heel Stage I 5 x 2.5; ecchymotic areas to hands and forearms; (L) foot 2nd toe 1.5 x 1.5; 3rd toe .5 x .5; (R) great toe 1.6 x 1; 2nd toe (R) skin prep between 2nd .3 x .3 and 4th dermal toe ulcer; 4th (R) toe 1.7 x 1.4." The only wound measurements provided by the facility were those documented by the nurse practitioners on 06/12/2012 and 06/21/2012 and documentation in the progress notes related to Resident #14's wounds. Review of the closed Medical Record revealed Braden Scale performed 03/24, 03/31, 04/07, and 04/17/2012 indicating the resident was at high risk for pressure sores. Review of the closed Medical Record revealed a Comprehensive Plan of Care dated 03/24/2012 which addressed an unstageable area located on the resident's right outer foot near toes. On 04/15/2012 a skin tear to the right great toe was added with an intervention for protective boots. No other wounds or interventions were care planned. Review of Physician Followup notes revealed the following visits: 04/02/2012... Lower extremities: There is no [MEDICAL CONDITION] noted... He did have multiple areas of deep tissue injuries between his toes as well as on the sides of his feet. These are being treated and they were on him on admission. There was not foul odor; however, on the right side of his right foot on his pinkie toe, there was an area that seemed to be a larger deep tissue injury with redness around it. It did appear to be erythemic, but no drainage was noted. His areas between his toes appeared to have somewhat of a darkened area. They almost all appeared to have some form of scab over them... I do believe if he continues in his decline, it will be on his best interest to consider hospice care as he is having a fast decline... 05/03/2012... Lower extremities... he did have multiple bandages on his lower extremities upon further assessment. I did use wound cleanser to help remove the dressings that were dried to his feet. I did note, on his right foot, he has very poor skin turgor. There is a 1-cm (centimeter) round pressure area on the right outer aspect of his right toe. It appears to be scabbed over. No drainage noted. They are applying Skin-Prep. He has a cracked area in between his toes, between his third and fourth toe that appears to be somewhat reddened around it. On his fourth toe, on the lateral side, there is a 0.5 cm round area on the upper portion of his fourth toe and a 0.25 cm round area on the lower portion. Both appear to be somewhat reddened around them and having some slough noted to them... On the outer aspect of his right foot on his pinky toe, he did have a very large area approximately 3.5 x 3.5 x 4 cm... It appears to have a large black area where it had been closed and they have been applying Skin-Prep... His right heel also was somewhat boggy... On his sacrum, he has a very prominent tailbone and there is an area on the sacrum and coccyx where the bones stick out. The skin appears to be very thin. It was reddened as well as blanching. It has very high risk for breakdown and it may be some deep tissue injury at this time... At this time, we will put him on antibiotics for the [MEDICAL CONDITION] I have contacted... a wound specialist to evaluate his skin... 05/05/2012... provider has asked me to see the resident related to nonhealing foot wounds... he has eschar area on his right lateral foot as well as the right. He has a eschar areas on his right lateral foot by the fifth toe... The wound overall measures approximately 1.5 to 2 cm. He has a scabbed area on his fifth toe and between each toe on both feet he has kissing dermal wounds with creamy centers. Each... measuring between 0.3 to 0.5 in diameter... a wound on the medial aspect of his right great toe... measures 0.5 to 0.75. The wound bed is pink to light red. It is moist. It is oval in shape... He also has a scabbed area on the left calcaneus... It measures approximately 0.5 cm... 06/12/2012... Resident #14 was assessed by the Nurse Practitioner, Skin Specialist who documented the continued decline of the residents wounds. 06/14/2012... I did inform her (the resident's spouse) on the multiple decubitus throughout his body... She was quite tearful and upset... consult hospice... Review of the physician's orders [REDACTED]. "3/30/12 Clean... (R) outer foot with wound cleaner, apply solosite to wound bed. Cover with [MEDICATION NAME] border 4 x 4 dsg. Apply solosite to pressure areas to toes bilateral feet, Gauze in between toes. Change daily and PRN until healed... 4/5/12 Cleanse (R) Great Toe with wound cleaner Apply solosite to wound cleaner with Meplix Border Gauze. 5/5/12 DC Solosite to all foot wound. Apply dry gauze between toes and (R) lateral foot wound, wrap with Kerlix (R) foot qd (every day) and PRN. Wear protective footwear. 5/31/12 Apply, ABT (antibiotic) ointment to open area between the toes separated by cotton. Apply ABT ointment to area behind (L) ear, Diet: NCS (no concentrated sweets), DC gauze between toes. 6/7/12 [MEDICATION NAME] dressing to stage 2 decubiti on back. Two areas noted. Change q 3 days and PRN. Air Mattress R/T pressure areas. 6/12/12 (L) ear wound/abscess - cleanse with NS (normal saline) or wound cleanser. Apply [MEDICATION NAME], even with 2 x 2 gauze. Change qd and prn. Warm soak compress to (L) ear wound 10 min (minutes) tid x 3 days. Wound Care to lower (R) back - cleanse with NS or wound cleanser apply Santyl, cover with sl (slight) moistened NS gauze, cover with foam change qd and prn. Wound care to sacrum - cleanse with NS or wound cleanser, apply [MEDICATION NAME] change q 3 days and prn. Apply skin prep to (R) trochanter, (L) heel, neck - q shift. Wound care to (L) inner heel - apply skin prep q shift. Skin prep to (R) lateral foot eschar q shift. Wound care to open wounds on (R) foot - NS or wound cleanser apply Hydrogel with dampened gauze, skin prep to dried scabs... 6/14/12 hospice consult r/t decline, multiple wounds... 7/9/2012 Admit to Hospice..." Review of the closed Medical Record for Resident #14 revealed no Treatment Records (wound care) for June or July 2012. The facility was unable to provide the wound care records for June or July 2012. Resident #1 with a Non-Pressure Skin Condition Record documented 04/10/2012 as the first date the area on the resident left lower extremity was observed. The measurement at that time was 1.6 cm (centimeters) x 1.8 cm. The record included an assessment on 04/17/2012 with a measurement of 1.6 cm x 1.8 cm; on 04/24/2012 1.6 cm x 1.2 cm; on 05/01/2012 1.4 cm x 1.2 cm. There was no further documentation of the wound until 06/12/2012 when it was assessed and measured by the nurse practitioner as an area on the lower left leg measuring 4 cm x 0.5 cm. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of Resident #1's medical record revealed a Progress Note dated 06/12/2012 that stated, "Resident is frail and debilitated. She sustained a skin tear to her lower left leg, however, it is slow in healing and we are here as a followup visit. We also did review a skin body audit and found some redness on her heels and dry skin noted on her bilat. lower extremities. An area on her lower left leg measures 4 x 0.5. The wound bed is beefy. It is moist. The wound edges are somewhat macerated, however, and peeling off..." Review of the Nurse's Notes from 02/22/2012 through 07/26/2012 failed to address Resident #4 wounds until 06/12/2012 when she was seen by the Nurse Practitioner. On 06/21/2012 at 10 AM the Nurse's Note stated, "Wound Care round with ...NP new orders..." Review of Resident #1's Plan of Care dated 11/22/2011 and updated 07/23/2012 failed to address intervention for the resident's skin care. A Skin tear dated 01/29/2012 was addressed on the Plan of Care under an identified problem with falls. The 07/23/2012 updated Plan of Care had no information related to resident's skin care needs. Review of Resident #1's Weekly Skin Assessment documented the 06/12 and 06/14/2012 wound assessments done by the nurse practitioner, there were no other skin assessments on the resident's medical record. A Non-Pressure Skin Condition Record documented 04/10/2012 as the first date the area on the resident left lower extremity was observed. The measurement at that time was 1.6 cm (centimeters) x 1.8 cm. The record included an assessment on 04/17/2012 with a measurement of 1.6 cm x 1.8 cm; on 04/24/2012 1.6 cm x 1.2 cm; on 05/01/2012 1.4 cm x 1.2 cm. There was no further documentation of the wound until 06/12/2012. The Braden Scale for Resident #1 was completed on 08/01 and 11/01/2011; on 04/20/2012. No other Braden Scale assessment were provided by the facility. Review of the 07/01/2012 - 07/31/2012 Treatment Record for Resident #1 indicated that the wound treatment for 07/17 and 07/25/2012 was not signed as done; documentation indicated the resident refused treatment on 07/12 and 07/18/2012. During an observation on 07/31/2012 of Resident #1's wound treatment to the left lower extremity the Licensed Practical Nurse stated that she did not measure the wounds, she just did the treatments. Resident #4 with a stage II pressure wound that was discovered by the nurse practitioner after the nurse complained to her that the resident had discomfort on her sacrum. The nurse practitioner's note stated, "...stage II on her sacrum that they are not aware of at this time..." The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of Resident #4's medical record revealed a Wound Care Visit note dated 06/12/2012 that stated, "This is a wound care visit. Nurse complains that resident has discomfort on her sacrum... On physical examination, this is an elderly female lying in her bed in no acute distress. On examination of her skin and body audit, we did find that she had bruising to bilateral forearms and lower extremities, and multiple ecchymotic areas. She did have a stage I on the right heel as well as a scab on her left heel for which both will need skin prep. She has a stage II on her sacrum that they are not aware of at this time..." Review of the Nurse's Notes from 04/02/2012 through 07/28/2012 failed to address Resident #4 wounds until after she was seen by the Nurse Practitioner on 06/12/2012. On 07/22/2012 at 9:00 AM the Nurse's Note stated, "... no s/s of infection to wound to sacrum area". A Nurse's Note dated 07/24/2012 at 0815 stated, "...wound on sacrum is with minimal drainage, no redness around wound bed noted..." Review of Resident #4's Plan of Care dated 10/21/2011 and updated 05/03/2012 failed to address intervention for the resident's stage I on the left heel and the stage II on the resident's sacrum. Review of Resident #4's current medical record revealed the Weekly Skin Assessment and the Wound Evaluation Flow Sheet were not filled out, the assessment forms had the resident name and room number. There were not documented assessments of the wound to include measurement, staging, drainage, and interventions. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. Review of the 06/01/2012 - 06/30/2012 Treatment Record for Resident #4 indicated that the wound treatment for 06/19/2012 was not signed as done. During an observation on 07/30/2012 of Resident #4's wound treatment to the sacrum the Registered Nurse stated that she did not record the wound measure, did not write the measurement down. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of Resident 10's medical record revealed a Wound Care Visit note dated 06/14/2012 that stated, "Chief Complaint: Body Audit. Resident's skin was examined today for any compromise of breakdown... Examination reveals her skin is intact except for a small area on her upper buttock sacral area. It measures approximately 0.2 to 0.3. It is barely visible... Apply Skin-Prep to the sacral wound twice a day until resolved..." Review of the Nurse's Notes from 05/10/2012 through 07/24/2012 addressed Resident #10's wound when it was identified on 05/19/2012. The skin breakdown was observed on 05/19/2012 at 2:00 PM and assessed as a stage II sacral wound that measured 3.5 x 1 centimeter. Treatment at the time included cleansing with [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days. There were no additional measurements documented until the Wound Care Visit on 06/14/2012. Review of Resident #10's current medical record revealed the Weekly Skin Assessment were done from 05/12/2012 through 06/30/2012; the Wound Evaluation Flow Sheet was not filled out. The Braden Scale was completed on 02/25, 08/12, 10/17/2011; 04/04 and 07/03/2012. Review of the 05/10/2012 - 05/31/2012 Treatment Record for Resident #10 indicated that the wound treatment for 06/22, 06/25 and 06/31/2012 were not signed as done. The facility was unable to provide the June 2012 Treatment Record. Resident #10 was observed on all days of the survey dressed appropriately sitting in the lobby visiting with her family. The facility admitted resident #3 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Scar from old PU (Pressure Ulcer) noted on bottom. Redness over scrotum." Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always incontinent of bowel and bladder. The resident was scored to not have any pressure sores. A Medical Nutrition Therapy Note dated 7/13/12 at 10:00 AM stated, "Per DON (Director of Nursing) res (resident) with 2 open areas to buttocks & sacrum". A Nutritional Risk assessment dated [DATE] stated under the section Skin Condition/[MEDICAL CONDITION], "per staff 2 open areas, one to buttock & one to sacrum". Review of the Physician's Telephone Orders, revealed an order on 7/19/12, "EPC cream to groin & sacrum/coccyx Stage II decub, q (every shift) & PRN (as needed) with incontinence episodes". A second order dated 7/20/12 stated, ..."epc cream to groin/coccyx and along vertebrae on back q shift & prn incontinence episodes." Review of the "Weekly Skin Assessment, revealed one skin assessment dated [DATE]. The skin assessment had checked the resident's skin to be pale with [MEDICAL CONDITION] present. The body figure had a circle around the coccyx/sacral area and it was marked to have been red as well as the right heel. There were no other weekly skin assessments. Review of the Braden Scale for Predicting Pressure Sore Risk had one evaluation date of 7/10/12 that was scored a 12. The score key stated, "10-12 High Risk". Instructions on the top of the form stated, "To be completed upon admission, weekly x (times) 3, then quarterly and PRN. The first time the Braden Scale was completed was one week after admission and had not been done since. At the time of the survey the Braden Scale and the Weekly Skin Assessments should have been done a total of four (4) times. Review of the Resident's Care plan dated 7/17/12, stated, "Resident is at risk for Skin Breakdown." The care plan was never revised to show the resident actually had skin breakdown at the time of the care plan. Another problem listed on the care plan of 7/17/12 stated, "Resident is at risk for complications secondary to incontinence." The goal was for the resident to remain clean, dry and odor free. Goals included to monitor for incontinence every 2 hours and prn, change promptly and apply a protective skin barrier to skin and to monitor for signs and symptoms of skin breakdown. The approach also stated to report to the Medical Doctor and Responsible Party. A Grievance was filed with the facility on 7/17/12 by the family of the resident. The Grievance stated, "...her father had not been changed in 14 hours.....this has been going on for a while. She says he has a rash and sore and she can't get that better if they don't change him..." The facility failed to identify wounds, notify the physician and obtain treatment in a timely manner. Review of the medical record revealed no mention the resident had pressure sores/decubitus ulcers, other than the Admission Nursing Assessment of 7/4/12, Telephone Orders of 7/19/12 and 7/20/12,and Dietary Notes of 7/13/12 and 7/16/12. . The weekly skin assessments were not done, there were no measurements of the wounds, The Braden Scale was not done on admission or weekly per the company policy. The open areas were documented on 7/13/12 by the Registered Dietician and again on 7/16/12 by the Dietician. The family complained the resident had been left unchanged for 14 hours on 7/17/12. There were no orders for treatment until 7/19 and 7/20/12. There was no evidence the physician had been notified until 7/19/12 when an order had been obtained for treatment to the decubitus. Nurse Practitioner (NP) #1 was interviewed on 8/1/12 at 11:05 AM regarding pressure sores in the facility. She stated she had given an order for [REDACTED]. When asked about the body audits she stated the audits had been incomplete. The NP stated she and the other NP had made rounds in the facility in June and checked every resident for skin issues and measured wounds. The NP stated the wounds should have been tracked and showed the surveyors a blank Wound Tracking Sheet. She stated, "I usually see Stage III and IV's. We should still be notified of Stages I and II's. We knew about some wounds but we found some." The NP's stated they had concerns of finding wounds that were not documented. Nurse Practitioner #2 was interviewed on 8/1/12 at 12:00 PM. She stated there was a concern related to wound care. She stated she had discussed the decline with the Administrator. One resident was identified to have had 15 pressure sores. The NP stated the facility's previous DON stated the nurses had not been signing for dressing changes and didn't have time to do the dressing changes. The DON was going back and signing behind the nurses. The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. Record review on 7/31/12 at 9:30 AM revealed a Nurse's Note dated 4/5/12 and documented as a Late Entry that stated "Stage II decubitus ulcer found to coccyx, 2 X 1.4 cm (centimeters). On 4/17/12, an assessment of the wound was documented in the Nurse's Noted stating "Stage II decubitus to coccyx. Pink granulation noted. Wound margins (and) peri wound normal for skin. Progressive healing noted. Wound slightly decreased in size. (No) drainage noted. 1.4 cm X 1.2 cm." There was no further documentation of pressure ulcer assessments. Review of the Nurse Practitioner's progress notes dated 4/2/12 and 5/16/12 there was no indication that the nurse practitioner or the physician were aware of the pressure ulcer. Review of the Weekly Skin Assessments for the resident revealed skin assessments were done on 5/4/12, 5/15/12, 6/5/12, 6/8/12, and 6/22/12. There were no skin assessments for the month of July. Review of the Nurse's Notes also revealed a note dated 6/13/12 at 2:45 PM that stated "LE (late entry) 6/12/12 Complete body audit completed by (nurse practitioners). New orders received." The 5/4/12 skin assessment stated "Stage II decubitus" and stated the treatment orders. The Skin Assessment for 5/15/12 stated "Stage II Decubitus on buttocks. Treatment continues as ordered." On 7/31/12 at 10:57 AM, review of the Medical Nutrition Therapy Notes revealed a note dated 5/30/12 at 3:30 PM that stated "Res(ident) (with) Stage II PU (pressure ulcer) to buttocks healing per assessments." Review of the care plan revealed the care plan was initiated on 4/3/12 and indicated that the stage II pressure ulcer was healed on 5/6/12. During an interview on 8/1/12 at 7:48 AM, the Director of Nursing confirmed that Weekly Skin Assessments were missing for 2 weeks in May, 1 week in June and that there were none for the month of July. She also confirmed that the wound had been assessed and measured only twice; upon discovery and 2 weeks later on 4/17/12. In addition, she verified that the information in the medical record was not consistent regarding the date the pressure ulcer was healed. She further confirmed that the wound should have been assessed weekly and documented. During an interview on 8/1/12, NP #1 verified that the MD or the NP should be notified of any new pressure ulcer. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review at approximately 2:10 PM on 7/31/12 revealed a progress note by NP #1 dated 7/3/12 that stated "Upon further examination or (sic) his feet, we did notice... a blood filled blister on the heel of his right foot" and was diagnosed as a pressure ulcer. The note further directed that physical therapy be provided to the left foot only until the wound was resolved. Further review revealed the MD assessed Resident #9 on 7/12/12 and stated the resident developed the pressure ulcer performing his physical therapy exercises. The wound was described as "about the size of a quarter and soft" with "no signs infection." The MD recommended to "avoid pressure, monitor for other signs of inflammation." On 7/18/12 the MD again assessed the wound at the request of the resident. He described the wound as "silver-dollar sized area of the blister that is broken. The central part is still dark, it is ischemic, and possibly will open up but the skin is tight over that at this time." The physician further stated "The patient has diabetes and needs to be watched closely." NP #2 evaluated the resident on 7/19/12 and stated that the resident had reported tenderness on his foot and that the resident had continued to do foot slides in therapy. NP #2 described the wound as "an unstageable deep tissue injury." Measurements were given as 4 X 5 cm and she stated there was "a slight odor on his foot." NP #2 indicated that she spoke to NP #1 who reported she had visualized the blister and had " did talk to therapy regarding how he got it" and had advised "not to do any further foot slides in therapy." Recommendations at that time were for a "heel guard and boot to the right lower extremity at all times." Review of the Physician's Telephone Orders revealed an order dated 7/19/12 for "heel floating boot to RLE (Right Lower Extremity) at all times." During observation of the wound care to his heel on 7/31/12 at 2:35 PM, Resident #9 stated that he did not wear any kind of boot during the day; only at night to keep him from rubbing his heel in the bed. On 7/23/12 NP #1 evaluated the wound and recommended a change in treatment. Review of the Nursing Home Initial History & Physical the resident had chronic stasis changes in the lower extremities. Nursing recommendation was to watch for resolution of abrasions he had sustained prior to admission and for further skin breakdown. Continued review of the record revealed there were no skin assessments since admission. On 8/1/12 at 9:10 AM, record review revealed a Braden Scale for Predicting Pressure Sore Risk assessment was completed on admission with a score of 19, at risk being a score of 15-18. Review of the Nurse's notes revealed Resident #9 had voiced heel pain on 7/11/12 and received pain medication but there was no docume

On the days of the Recertification and Extended Survey, based on observations, interviews, and record reviews, the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores (Resident #14, #1, #4, #3 and #9). Cross refers to F-281 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to promote healing and prevent infection to residents who had pressure sores, in accordance with recognized standards of practice (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-314 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-496 as it relates to the failure of the facility to verify certification before the date of hire for four of eleven Certified Nursing Assistants reviewed as part of the extended survey. Cross refers to F-499 as it relates to the failure of the facility to verify that 3 of 8 nurses were in good standing with the State of South Carolina Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. During an interview on 08/01/2012 at 11:45 AM, the Administrator stated that the facility was aware of concerns related to pressure ulcers in June, 2012. At that time the Nurse Practitioners, with the Director of Nursing, had performed complete body audits on all residents in the facility due to concerns the Nurse Practitioners had that they were identifying new pressure ulcers of which they had no knowledge. She was unable to provide documentation of the audit. During the interview, the Administrator confirmed, that based on the findings of the Survey, the program had not been effective. On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 06/12/2012 and repeated on 06/21/2012, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012.

On the days of the Recertification and Extended Survey, based on observations, interviews, and record reviews, the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores (Resident #14, #1, #4, #3 and #9). Cross refers to F-281 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to promote healing and prevent infection to residents who had pressure sores, in accordance with recognized standards of practice (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-314 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-496 as it relates to the failure of the facility to verify certification before the date of hire for four of eleven Certified Nursing Assistants reviewed as part of the extended survey. Cross refers to F-499 as it relates to the failure of the facility to verify that 3 of 8 nurses were in good standing with the State of South Carolina Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. During an interview on 08/01/2012 at 11:45 AM, the Administrator stated that the facility was aware of concerns related to pressure ulcers in June, 2012. At that time the Nurse Practitioners, with the Director of Nursing, had performed complete body audits on all residents in the facility due to concerns the Nurse Practitioners had that they were identifying new pressure ulcers of which they had no knowledge. She was unable to provide documentation of the audit. During the interview, the Administrator confirmed, that based on the findings of the Survey, the program had not been effective. On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 06/12/2012 and repeated on 06/21/2012, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012. FIRST FOLLOW UP VISIT During an unannounced visit on 08/23/2012 at 5:45 PM, it was determined based on interviews, observations, review of records, and review of facility policies and procedures, that the Allegation of Compliance submitted by the facility on 08/22/2012 had been implemented by the facility was in practice as of 08/22/2012, removing the immediacy of the deficient practice. The actions listed in the Allegation of Compliance with a completion date of 08/22/2012 included the following: F490... 1. An experienced Medical Records Technician has been hired to maintain continuity in resident records. A Staff Development Coordinator position has been posted and the facility is currently actively recruiting for this position. An experienced, seasoned HCA has been transferred from another facility to uphold and maintain standards to manage quality care to all residents. Healthcare Administrator was educated on the Administrative Policy and Procedure by the Vice President of Operations on 8/2/2012. 2. An experienced Director of Nursing has been employed as Interim Director of Nursing, with potential to be transitioned to Director of Nursing position for continuity of care. The Interim Director of Nursing was educated on the Administrative Policy and Procedure by the Vice President of Operations on 8/2/2012. 3. The CEO had met with the facility management staff on 8/8/2012 at Summit Hills Facility. The CEO met with staff including the Administrator, Interim Director of Nursing, Medical Social Worker, Activities Director, Vice President of Operations, the Attending Physician, and the Medical Director. The purpose of the meetings was to set expectations of quality care, and maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. 4. The company recruited and hired additional Regional Director of Clinical on 7/26/2012. A Regional Director of Clinical Services or Vice President of Operations will conduct a minimum of weekly review to ensure continued compliance of the AOC, all areas of deficiencies noted on most recent survey, QA process, and continue to review the root cause analysis of systems to achieve the highest practical, physical, mental, and psychosocial wellbeing of each resident. All Healthcare staff has been educated on accountability, quality measures and expectations including reorientation of all employees via in-service on 8/21/12. 5. The Administrator will review and report findings related to effective use of resources to the QA committee monthly for continued compliance and make changes as needed on an ongoing basis. The citation at F-490 remained at a lowered scope and severity of "F". The facility will be in compliance at F-490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the days of the Recertification and Extended Survey, based on observations, interviews, and record reviews the facility failed to implement a plan of action and follow up on concerns related to pressure sore treatment. The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores (Resident #14, #1, #4, #3 and #9). Cross refers to F-281 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to promote healing and prevent infection to residents who had pressure sores, in accordance with recognized standards of practice (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-314 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-490 as it relates to the failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. During an interview on 08/01/2012 at approximately 2:30 PM, the Nursing Home Administrator stated the facility had not implemented a plan of action related to pressure ulcers. She stated an audit had been done for all residents in the facility to assess for pressure ulcers but stated she was unable to locate any documentation of the audit. She further stated the facility had implemented a new protocol entitled "Clinical Guideline: Skin Integrity." In addition, the administrator verified that, based on the findings of the survey, the program had not been effective and confirmed there was no plan for evaluating the effectiveness of the program. The Administrator further revealed that there were no other deficiencies identified by the QAA Committee that were pertinent to the concerns identified during the survey. On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 06/12/2012 and repeated on 06/21/2012, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012.

On the days of the Recertification and Extended Survey, based on observations, interviews, and record reviews the facility failed to implement a plan of action and follow up on concerns related to pressure sore treatment. The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores (Resident #14, #1, #4, #3 and #9). Cross refers to F-281 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to promote healing and prevent infection to residents who had pressure sores, in accordance with recognized standards of practice (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-314 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-490 as it relates to the failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. During an interview on 08/01/2012 at approximately 2:30 PM, the Nursing Home Administrator stated the facility had not implemented a plan of action related to pressure ulcers. She stated an audit had been done for all residents in the facility to assess for pressure ulcers but stated she was unable to locate any documentation of the audit. She further stated the facility had implemented a new protocol entitled "Clinical Guideline: Skin Integrity." In addition, the administrator verified that, based on the findings of the survey, the program had not been effective and confirmed there was no plan for evaluating the effectiveness of the program. The Administrator further revealed that there were no other deficiencies identified by the QAA Committee that were pertinent to the concerns identified during the survey. On 08/01/2012 at 2:15 PM the Administrator and the Director of Nurses were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/28/2012 when the facility failed to follow through with skin assessments started on 06/12/2012 and repeated on 06/21/2012, related to validated concerns of wounds not identified and assessed, wound care not documented and/or provided, and failing to revise or review care plans of at risk residents. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-272, F-280, F-281, F-314, F-490 and F-520 at a scope and severity of "L" remained ongoing at the time the survey was completed on 08/02/2012. FIRST FOLLOW UP VISIT During an unannounced visit on 08/23/2012 at 5:45 PM, it was determined based on interviews, observations, review of records, and review of facility policies and procedures, that the Allegation of Compliance submitted by the facility on 08/22/2012 had been implemented by the facility was in practice as of 08/22/2012, removing the immediacy of the deficient practice. The actions listed in the Allegation of Compliance with a completion date of 08/22/2012 included the following: F520... 1. The QA committee was restructured to encompass all levels of care with separate focus and to determine patterns that would affect all levels of care and service. This will include review, update, and implementation changes to improve quality of care as identified by the team. A monthly calendar has been scheduled for one year. 2. High risk residents will be identified through Braden Scale. Any resident with a score of <12 on the Braden Scale will have the following initiated: Assessment for actual or potential areas of skin breakdown, i.e. bony prominence; food preferences; nutritional consult - weight. These will be reviewed minimum monthly. 3. The Clinical OPS team along the Medical Director will participate in the monthly QA process to ensure continued compliance and make changes to the process as needed. The Clinical OPS team will participate for three months or until a pattern oc compliance is established. The Medical Director will attend QA meeting monthly as a standard operating procedure. The citation at F-520 remained at a lowered scope and severity of "F". The facility will be in compliance at F-520 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the days of the survey, based on interviews, record review, review of the facility Symptomatic Protocol and review of Perry, A. G. and Potter, P. A., Clinical Nursing Skills & Techniques, 7th Edition, St Louis, Mosby Elsevier, 2010, the facility failed to notify the physician(s) of changes in condition for Residents #2, #4, #5, #13, and #14, 5 of 9 residents reviewed for physician notification and failed to notify the Medical Doctor (MD) or Nurse Practitioner (NP) of the emergence of a stage II decubitus ulcer, unresponsive episodes, [MEDICAL CONDITION], possible [MEDICAL CONDITION] activity, low blood sugars and episodes of hypotensive blood pressures for Resident #2. The findings included: The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. Record review of the Nurse's Notes on 7/31/12 at 9:30 AM revealed a Nurse's Note timed and dated 9:00 AM 4/5/12 that stated "Late Entry. Stage II decubitus ulcer found to coccyx. 2 X 1.4 cm (centimeters). Pink granulation present. Res(ident) reports (no) pain. Area cleaned (and) dsg (dressing) applied. Care plan updated." There was no documentation that the physician or the resident's responsible party were notified. During an interview on 8/1/12 at 7:48 AM, the Director of Nursing (DON) confirmed there was no documentation of notification and further verified that the Physician (MD) and/or Nurse Practitioner (NP) progress notes did not indicate that they were aware that Resident #2 had a pressure ulcer. Further review of the Nurse's Notes revealed a note timed and dated 11:00 AM 4/10/12 that the resident "had another unresponsive episode ... lasted approx(imately) 1 1/2 min(utes)." There was no documentation in the Nurse's Notes of an earlier episode or that the physician had been notified of either episode until 3:30 PM when a different nurse documented "Resident seen by GNP (Geriatric Nurse Practitioner). Acute visit r/t (related to) episode of AMS (altered mental status)..." These findings were confirmed by the Director of Nursing during an interview on 8/1/12 at approximately 7:48 AM. Additional review of the Nurse's Notes revealed a 4/22/12 note at 12:00 PM that stated "Some confusion (and) [MEDICAL CONDITION] noted. Normal for resident." There was no documentation from 4/5/12 to 4/22/12 that the resident had experienced any [MEDICAL CONDITION] or that this was normal for the resident. Further review revealed a 5/12/12 at 1:20 PM that the resident stated "A man named Meaphis Jackson robbed her, tied her to tree for 5 to 6 hrs (hours) stole her jewelry, but had a good heart because he didn't shoot her. (After) talking to resident awhile, she stated " I was just kidding"." A 6/1/12 note stated "Res(ident) confused (at) present - verbalizes being in hotel where employees have "fine jewels"." There was no documentation the physician was notified of any of the episodes of [MEDICAL CONDITION] from 4/5/12 to 6/2/12. During an interview on 8/1/12 that began at 7:48 AM, the Director of Nursing confirmed these findings. Record review further revealed a Nurse's Note dated 7/15/12 5 PM that stated "CNA (Certified Nursing Assistant) reported to this nurse that she thought resident was having a [MEDICAL CONDITION]. Upon assessment of resident there were (no) s/s (signs or symptoms) of [MEDICAL CONDITION] activity." There was no documentation of the symptoms observed by the CNA and no documentation that the physician was notified. During an interview on 8/1/12 at approximately 8:10 AM, the Director of Nursing confirmed the findings and stated that she would have expected the nurse to perform and document a full assessment and notify the physician. She verified that a full assessment was not performed based on the documentation. Review of the Vital Signs and Weight Record revealed 34 episodes when the residents diastolic Blood Pressure (BP) was less than 60 mmHg (millimeters of Mercury), April 1,2,(2 episodes), 14, 20, 24, 26 (2 episodes) and 27; May 3, 9, 12, 16 (2 episodes), 17, 19 (2 episodes), 20, 21, 26 (2 episodes) and 28; June 4, 16, 17, 18, 22; and July 14, 20 (2 episodes), 22, and 30. In addition, 8 of these episodes also had a recorded systolic Blood pressure at or below 90 mmHg. The Nurse's Notes revealed the RN (Registered Nurse) charge nurse was notified on 5/12/12 of a BP of 85/54 mmHg but there was no documentation that the MD was notified. Review of the 4/2/12 Nurse Practitioner's (NP) note revealed she was aware of the low BP on 4/2/12 of 80/52 mmHg and had increased her [MEDICATION NAME] to 5 mg (milligrams) three times per day for orthostatic [MEDICAL CONDITION]. The note also indicated that the resident had known orthostatic hypertension and that the nurse practitioners would review the resident's blood pressures in one week. There were no documented low blood pressures within the next week; the next documented low BP was 96/53 mmHg on 4/14/12 and there was no documentation that the MD or NP was notified. In addition, review of a Nurse's Note dated and timed 5/15/12 9 AM, "...Res(ident) also had a [MEDICAL CONDITION] episode while being transferred back to bed...Resident [MEDICAL CONDITION] episode lasted < (less than) 1 min(ute). There were no vital signs recorded at the time of the episode. There was no documentation the MD or NP was notified. A 5/16/12 note by the MD revealed he was aware of the blood pressure on the 16 th of 83/54 mmHg but stated is was "generally much better." There was no documentation in the MD's progress note that he was aware of the [MEDICAL CONDITION] episode the day before. There is no indication that the MD or the NP had been notified of episodes of low blood pressures except on 4/2/12 and 5/16 and the resident remained on [MEDICATION NAME] 5 mg. three times per day. Review of Clinical Nursing Skills & Techniques, 7th Edition, Chapter 5, page 90 revealed "[MEDICAL CONDITION] occurs when the SBP (systolic blood pressure) falls to 90 mm Hg or below. ...for the majority of people low BP is an abnormal finding associated with illness..." and "Orthostatic changes in vital signs are good indicators of blood volume depletion." The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the closed medical record revealed Nurse's Notes dated 04/21/2012 that documented the following: 6:25 AM Res fsbs (fingerstick blood sugar) was 56 was given 1 ml per symptomatic protocol. FSBS was 68 @ 6:35 AM, Res becoming more alert, will cont (continue) to monitor. Resident #14 was administered [MEDICATION NAME] per the symptomatic protocol on 04/21/2012 without physician notification of the treatment. On 06/28/2012 at 4:00 PM his blood sugar was 65, he refused to swallow orange juice and would open his eyes only when his name was called. At 4:38 PM his blood sugar was rechecked and found to be 51 at which time. Again [MEDICATION NAME] was not given, the physician was called. An order was given to call 911 and for 37 minutes no interventions were put in place related to the resident's low blood sugars. Review of the History and Physical for the 06/29/2012 hospital admission stated, "... when EMS got there, and rechecked his sugar, it was 4 or 1, we are not exactly sure, and he was transported by EMS to the hospital for further evaluation..." The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurse's Note dated 05/07/2012 that documented the following: "7:35 AM Went in Residents room to check B/P (blood pressure) to give meds 120/68, 94, 20, 97.2 nonverbal opened eyes body cold BS (blood sugar) checked results 42 IM [MEDICATION NAME] gave per Symptomatic Protocol. 7:40 AM BS rechecked 59... 7:55 AM Spoke with Responsible Party (RP) which stated just monitor her I do not want her sent to hospital. 8:00 AM BS 77 8:15 AM BS 97...Spoke with RP to update her on status... Resident #4 was administered [MEDICATION NAME] per the symptomatic protocol on 05/07/2012 without documentation of physician notification of the treatment or the families desire to not admit the resident to the hospital. Review of the Symptomatic Protocol page 2 of 2 last revised 8/1/7 stated, "... 22. [DIAGNOSES REDACTED]/INSULIN REACTION Administer sweetened beverage and/or GLUCOSTAT. May Administer GLUCOGON 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability, or altered level of consciousness) and/or blood sugar below 55. May repeat [MEDICATION NAME] once PRN. SPECIAL INSTRUCTIONS a. Determine blood sugar by finger-stick. b. Administer treatment(s) as necessary. c. Re-check glucose 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. e. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the medical record revealed a lab report for a [MEDICATION NAME] Time (PT) and a INR (International Normalized Ratio) on 6/20/12. The INR results were 0.93. A hand written note on the lab report stated, "Why on-call 0 (not) called? ...0 (not) Calling labs same day unacceptable." The PT/INR results were used to determine the dosage of blood thinner to be given to the resident. The report was signed and dated on 6/21/12. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review of the medical record revealed a lab report for a PT/INR on 6/20/12. The PT results were 19.8 (high). A hand written note on the lab report circled the date of 6/20/12 and a line drawn down to the note 0 called timely. The note was dated 6/21/12.

On the days of the survey based on record review, interviews and review of the facility Symptomatic Protocol, the facility failed to provide necessary care and services for 3 of nine sampled residents reviewed. The facility Symptomatic Protocol was not followed regarding low blood sugars for Residents #14 and #4; the physician was not called and/or treatment initiated per the protocol. In additions the facility failed to provide ongoing assessment and followup with physician for identified unresponsive episodes, [MEDICAL CONDITION], possible [MEDICAL CONDITION] activity, and episodes of hypotensive blood pressures for Resident #2. The findings included: The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed a note timed and dated 11:00 AM 4/10/12 that the resident "had another unresponsive episode ... lasted approx(imately) 1 1/2 min(utes)." There was no documentation in the Nurse's Notes of an earlier episode or that the physician had been notified of either episode until 3:30 PM when a different nurse documented "Resident seen by GNP (Geriatric Nurse Practitioner). Acute visit r/t (related to) episode of AMS (altered mental status)..." These findings were confirmed by the Director of Nursing during an interview on 8/1/12 at approximately 7:48 AM. Additional review of the Nurse's Notes revealed a 4/22/12 note at 12:00 PM that stated "Some confusion (and) [MEDICAL CONDITION] noted. Normal for resident." There was no documentation from 4/5/12 to 4/22/12 that the resident had experienced any [MEDICAL CONDITION] or that this was normal for the resident. Further review revealed a 5/12/12 at 1:20 PM that the resident stated "A man named Meaphis Jackson robbed her, tied her to tree for 5 to 6 hrs (hours) stole her jewelry, but had a good heart because he didn't shoot her. (After) talking to resident awhile, she stated " I was just kidding"." A 6/1/12 note stated "Res(ident) confused (at) present - verbalizes being in hotel where employees have "fine jewels"." There was no documentation the physician was notified of any of the episodes of [MEDICAL CONDITION] from 4/5/12 to 6/2/12. During an interview on 8/1/12 that began at 7:48 AM, the Director of Nursing confirmed these findings. Record review further revealed a Nurse's Note dated 7/15/12 5 PM that stated "CNA (Certified Nursing Assistant) reported to this nurse that she thought resident was having a [MEDICAL CONDITION]. Upon assessment of resident there were (no) s/s (signs or symptoms) of [MEDICAL CONDITION] activity." There was no documentation of the symptoms observed by the CNA and no documentation that the physician was notified. During an interview on 8/1/12 at approximately 8:10 AM, the Director of Nursing confirmed the findings and stated that she would have expected the nurse to perform and document a full assessment and notify the physician. She verified that a full assessment was not performed based on the documentation. Review of the Vital Signs and Weight Record revealed 34 episodes when the residents diastolic Blood Pressure (BP) was less than 60 mmHg (millimeters of Mercury), April 1,2,(2 episodes), 14, 20, 24, 26 (2 episodes) and 27; May 3, 9, 12, 16 (2 episodes), 17, 19 (2 episodes), 20, 21, 26 (2 episodes) and 28; June 4, 16, 17, 18, 22; and July 14, 20 (2 episodes), 22, and 30. In addition, 8 of these episodes also had a recorded systolic Blood pressure at or below 90 mmHg. The Nurse's Notes revealed the RN (Registered Nurse) charge nurse was notified on 5/12/12 of a BP of 85/54 mmHg but there was no documentation that the MD was notified. Review of the 4/2/12 Nurse Practitioner's (NP) note revealed she was aware of the low BP on 4/2/12 of 80/52 mmHg and had increased her [MEDICATION NAME] to 5 mg (milligrams) three times per day for orthostatic [MEDICAL CONDITION]. The note also indicated that the resident had known orthostatic hypertension and that the nurse practitioners would review the resident's blood pressures in one week. There were no documented low blood pressures within the next week; the next documented low BP was 96/53 mmHg on 4/14/12 and there was no documentation that the MD or NP was notified. In addition, review of a Nurse's Note dated and timed 5/15/12 9 AM, "...Res(ident) also had a [MEDICAL CONDITION] episode while being transferred back to bed...Resident [MEDICAL CONDITION] episode lasted < (less than) 1 min(ute). There were no vital signs recorded at the time of the episode. There was no documentation the MD or NP was notified. A 5/16/12 note by the MD revealed he was aware of the blood pressure on the 16 th of 83/54 mmHg but stated is was "generally much better." There was no documentation in the MD's progress note that he was aware of the [MEDICAL CONDITION] episode the day before. There is no indication that the MD or the NP had been notified of episodes of low blood pressures except on 4/2/12 and 5/16 and the resident remained on [MEDICATION NAME] 5 mg. three times per day. Review of Clinical Nursing Skills & Techniques, 7th Edition, Chapter 5, page 90 revealed "[MEDICAL CONDITION] occurs when the SBP (systolic blood pressure) falls to 90 mm Hg or below. ...for the majority of people low BP is an abnormal finding associated with illness..." and "Orthostatic changes in vital signs are good indicators of blood volume depletion." The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the closed medical record revealed Nurse's Notes dated 04/21/2012 that documented the following: 6:25 AM Res fsbs (fingerstick blood sugar) was 56 was given 1 ml per symptomatic protocol. FSBS was 68 @ 6:35 AM, Res becoming more alert, will cont (continue) to monitor. Resident #14 was administered [MEDICATION NAME] per the symptomatic protocol on 04/21/2012 without physician notification of the treatment. On 06/28/2012 at 4:00 PM his blood sugar was 65, he refused to swallow orange juice and would open his eyes only when his name was called. At 4:38 PM his blood sugar was rechecked and found to be 51 at which time. Again [MEDICATION NAME] was not given, the physician was called. An order was given to call 911 and for 37 minutes no interventions were put in place related to the resident's low blood sugars. Review of the History and Physical for the 06/29/2012 hospital admission stated, "... when EMS got there, and rechecked his sugar, it was 4 or 1, we are not exactly sure, and he was transported by EMS to the hospital for further evaluation..." Review of the History and Physical for the 06/29/2012 admission stated, "... For whatever reason, the patient has a history that he will have hypoglycemic symptoms at a blood sugar much higher than average. The protocol calls for the nurses to not call the on-call physician from the nursing home until his blood sugar gets down to 55. The patient gives symptoms well before than and it is being left to get down to the blood sugar 55 before he has been given any medication or food to eat. The patient had an episode today where his blood sugar dropped low. It was registered in the 60's. He, at that point in time,was continued to be observed because their protocol does not call (sic) to call the MD until the blood sugar is 55 or less. At which point, they waited another hour when EMS got there, and rechecked his sugar, it was 4 or 1, we are not exactly sure, and he was transported by EMS to the hospital for further evaluation..." The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurse's Note dated 05/07/2012 that documented the following: "7:35 AM Went in Residents room to check B/P (blood pressure) to give meds 120/68, 94, 20, 97.2 nonverbal opened eyes body cold BS (blood sugar) checked results 42 IM [MEDICATION NAME] gave per Symptomatic Protocol. 7:40 AM BS rechecked 59... 7:55 AM Spoke with Responsible Party (RP) which stated just monitor her I do not want her sent to hospital. 8:00 AM BS 77 8:15 AM BS 97...Spoke with RP to update her on status... Resident #4 was administered [MEDICATION NAME] per the symptomatic protocol on 05/07/2012 without documentation of physician notification of the treatment or the families desire to not admit the resident to the hospital. Review of the Symptomatic Protocol page 2 of 2 last revised 8/1/7 stated, "... 22. [DIAGNOSES REDACTED]/INSULIN REACTION Administer sweetened beverage and/or GLUCOSTAT. May Administer GLUCOGON 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability, or altered level of consciousness) and/or blood sugar below 55. May repeat [MEDICATION NAME] once PRN. SPECIAL INSTRUCTIONS a. Determine blood sugar by finger-stick. b. Administer treatment(s) as necessary. c. Re-check glucose 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. e. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." In an interview on 08/02/2012 at 3:40 PM the Physician stated who expected the staff to notify him of any concerns with blood sugars and follow the protocol.

On the days of the survey based on record review, interviews and review of the facility Symptomatic Protocol, the facility failed to provide necessary care and services for 3 of nine sampled residents reviewed. The facility Symptomatic Protocol was not followed regarding low blood sugars for Residents #14 and #4; the physician was not called and/or treatment initiated per the protocol. In additions the facility failed to provide ongoing assessment and followup with physician for identified unresponsive episodes, [MEDICAL CONDITION], possible [MEDICAL CONDITION] activity, and episodes of hypotensive blood pressures for Resident #2. The findings included: The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed a note timed and dated 11:00 AM 4/10/12 that the resident "had another unresponsive episode ... lasted approx(imately) 1 1/2 min(utes)." There was no documentation in the Nurse's Notes of an earlier episode or that the physician had been notified of either episode until 3:30 PM when a different nurse documented "Resident seen by GNP (Geriatric Nurse Practitioner). Acute visit r/t (related to) episode of AMS (altered mental status)..." These findings were confirmed by the Director of Nursing during an interview on 8/1/12 at approximately 7:48 AM. Additional review of the Nurse's Notes revealed a 4/22/12 note at 12:00 PM that stated "Some confusion (and) [MEDICAL CONDITION] noted. Normal for resident." There was no documentation from 4/5/12 to 4/22/12 that the resident had experienced any [MEDICAL CONDITION] or that this was normal for the resident. Further review revealed a 5/12/12 at 1:20 PM that the resident stated "A man named Meaphis Jackson robbed her, tied her to tree for 5 to 6 hrs (hours) stole her jewelry, but had a good heart because he didn't shoot her. (After) talking to resident awhile, she stated " I was just kidding"." A 6/1/12 note stated "Res(ident) confused (at) present - verbalizes being in hotel where employees have "fine jewels"." There was no documentation the physician was notified of any of the episodes of [MEDICAL CONDITION] from 4/5/12 to 6/2/12. During an interview on 8/1/12 that began at 7:48 AM, the Director of Nursing confirmed these findings. Record review further revealed a Nurse's Note dated 7/15/12 5 PM that stated "CNA (Certified Nursing Assistant) reported to this nurse that she thought resident was having a [MEDICAL CONDITION]. Upon assessment of resident there were (no) s/s (signs or symptoms) of [MEDICAL CONDITION] activity." There was no documentation of the symptoms observed by the CNA and no documentation that the physician was notified. During an interview on 8/1/12 at approximately 8:10 AM, the Director of Nursing confirmed the findings and stated that she would have expected the nurse to perform and document a full assessment and notify the physician. She verified that a full assessment was not performed based on the documentation. Review of the Vital Signs and Weight Record revealed 34 episodes when the residents diastolic Blood Pressure (BP) was less than 60 mmHg (millimeters of Mercury), April 1,2,(2 episodes), 14, 20, 24, 26 (2 episodes) and 27; May 3, 9, 12, 16 (2 episodes), 17, 19 (2 episodes), 20, 21, 26 (2 episodes) and 28; June 4, 16, 17, 18, 22; and July 14, 20 (2 episodes), 22, and 30. In addition, 8 of these episodes also had a recorded systolic Blood pressure at or below 90 mmHg. The Nurse's Notes revealed the RN (Registered Nurse) charge nurse was notified on 5/12/12 of a BP of 85/54 mmHg but there was no documentation that the MD was notified. Review of the 4/2/12 Nurse Practitioner's (NP) note revealed she was aware of the low BP on 4/2/12 of 80/52 mmHg and had increased her [MEDICATION NAME] to 5 mg (milligrams) three times per day for orthostatic [MEDICAL CONDITION]. The note also indicated that the resident had known orthostatic hypertension and that the nurse practitioners would review the resident's blood pressures in one week. There were no documented low blood pressures within the next week; the next documented low BP was 96/53 mmHg on 4/14/12 and there was no documentation that the MD or NP was notified. In addition, review of a Nurse's Note dated and timed 5/15/12 9 AM, "...Res(ident) also had a [MEDICAL CONDITION] episode while being transferred back to bed...Resident [MEDICAL CONDITION] episode lasted < (less than) 1 min(ute). There were no vital signs recorded at the time of the episode. There was no documentation the MD or NP was notified. A 5/16/12 note by the MD revealed he was aware of the blood pressure on the 16 th of 83/54 mmHg but stated is was "generally much better." There was no documentation in the MD's progress note that he was aware of the [MEDICAL CONDITION] episode the day before. There is no indication that the MD or the NP had been notified of episodes of low blood pressures except on 4/2/12 and 5/16 and the resident remained on [MEDICATION NAME] 5 mg. three times per day. Review of Clinical Nursing Skills & Techniques, 7th Edition, Chapter 5, page 90 revealed "[MEDICAL CONDITION] occurs when the SBP (systolic blood pressure) falls to 90 mm Hg or below. ...for the majority of people low BP is an abnormal finding associated with illness..." and "Orthostatic changes in vital signs are good indicators of blood volume depletion." The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the closed medical record revealed Nurse's Notes dated 04/21/2012 that documented the following: 6:25 AM Res fsbs (fingerstick blood sugar) was 56 was given 1 ml per symptomatic protocol. FSBS was 68 @ 6:35 AM, Res becoming more alert, will cont (continue) to monitor. Resident #14 was administered [MEDICATION NAME] per the symptomatic protocol on 04/21/2012 without physician notification of the treatment. On 06/28/2012 at 4:00 PM his blood sugar was 65, he refused to swallow orange juice and would open his eyes only when his name was called. At 4:38 PM his blood sugar was rechecked and found to be 51 at which time. Again [MEDICATION NAME] was not given, the physician was called. An order was given to call 911 and for 37 minutes no interventions were put in place related to the resident's low blood sugars. Review of the History and Physical for the 06/29/2012 hospital admission stated, "... when EMS got there, and rechecked his sugar, it was 4 or 1, we are not exactly sure, and he was transported by EMS to the hospital for further evaluation..." Review of the History and Physical for the 06/29/2012 admission stated, "... For whatever reason, the patient has a history that he will have hypoglycemic symptoms at a blood sugar much higher than average. The protocol calls for the nurses to not call the on-call physician from the nursing home until his blood sugar gets down to 55. The patient gives symptoms well before than and it is being left to get down to the blood sugar 55 before he has been given any medication or food to eat. The patient had an episode today where his blood sugar dropped low. It was registered in the 60's. He, at that point in time,was continued to be observed because their protocol does not call (sic) to call the MD until the blood sugar is 55 or less. At which point, they waited another hour when EMS got there, and rechecked his sugar, it was 4 or 1, we are not exactly sure, and he was transported by EMS to the hospital for further evaluation..." The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurse's Note dated 05/07/2012 that documented the following: "7:35 AM Went in Residents room to check B/P (blood pressure) to give meds 120/68, 94, 20, 97.2 nonverbal opened eyes body cold BS (blood sugar) checked results 42 IM [MEDICATION NAME] gave per Symptomatic Protocol. 7:40 AM BS rechecked 59... 7:55 AM Spoke with Responsible Party (RP) which stated just monitor her I do not want her sent to hospital. 8:00 AM BS 77 8:15 AM BS 97...Spoke with RP to update her on status... Resident #4 was administered [MEDICATION NAME] per the symptomatic protocol on 05/07/2012 without documentation of physician notification of the treatment or the families desire to not admit the resident to the hospital. Review of the Symptomatic Protocol page 2 of 2 last revised 8/1/7 stated, "... 22. [DIAGNOSES REDACTED]/INSULIN REACTION Administer sweetened beverage and/or GLUCOSTAT. May Administer GLUCOGON 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability, or altered level of consciousness) and/or blood sugar below 55. May repeat [MEDICATION NAME] once PRN. SPECIAL INSTRUCTIONS a. Determine blood sugar by finger-stick. b. Administer treatment(s) as necessary. c. Re-check glucose 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. e. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." In an interview on 08/02/2012 at 3:40 PM the Physician stated who expected the staff to notify him of any concerns with blood sugars and follow the protocol.

On the days of the Recertification, Complaint and Extended Survey, based on observations, record review, interview and review of the facility's policy on Medication Administration, Immediate Jeopardy was identified on 11/08/2011 related to the facility staff's failure to administer medications per the physician's orders [REDACTED].#21, #22, #23, and #24 failed to receive controlled substances as ordered; Resident #7 documented to receive the wrong dose of medication on the Medication Administration Record. In addition, the facility failed to adhere to accepted standards of practice for two of two sampled residents reviewed with Sliding Scale Insulin. Nursing Staff failed to administer the physician ordered amount of Sliding Scale Insulin as per Finger Stick Blood Sugar results for Residents #2 and #7. (2 of 2 sampled residents reviewed for professional standards related to administration of sliding scale insulin) The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Resident #16 was discharged on [DATE] to an acute care hospital. Resident #16's closed medical record was reviewed due to a complaint received by the Department of Health and Environmental Control, that a Benzodiazepine medication was found during a Toxicology Screen at a hospital on [DATE]. In an interview on 10/31/2011 at 11:45 AM, the Director of Nurses (DON) stated that Resident #16's family member informed the facility of the positive Toxicology Screen and that the resident was not prescribed any Benzodiazepines. The facility did not have or attempt to obtain proof of the toxicology report. Review of the Clean Catch Urine Toxicology Screen dated 9/17/2011 at 9:49 PM revealed Resident #16 was "POS" (positive) for Benzodiazepines. Review of the physician's orders [REDACTED]. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of Resident #17's Admission Physician order [REDACTED]. In addition, Resident #17 was prescribed [MEDICATION NAME] 5/325 mg three times daily scheduled at 8 AM, 2 PM and 8 PM. Review of the Narcotic Log for [MEDICATION NAME] 5/325 revealed the medication label on the Narcotic Log sheet stated, "[MEDICATION NAME]-[MEDICATION NAME] 5-325 ([MEDICATION NAME]) mg TA 180 EA (each) QTY (quantity) REM (remaining) 900... C 23..." Handwritten on the Narcotic Log indicated "Date Received 9/28/2011; Qty Received 120; Qty Dispensed 120. The medication label did not match the handwritten information on the Narcotic Log. Resident #17 should have received a minimum of 47 doses of [MEDICATION NAME] 5/325 mg between 10/14 at 8 PM and 10/31 at 8 AM. Per the Narcotic Log, Resident #17 received 19 of the 47 doses. Review of the Narcotic Logs for [MEDICATION NAME] revealed the medication label on the Narcotic Log sheet stated, "[MEDICATION NAME] ([MEDICATION NAME]) 1 mg Tablet 30... C 56..." Handwritten on the Narcotic Log "[MEDICATION NAME] 0.5 mg give q (every) A.M. The 0.5 mg was crossed off and 1 mg written and initialed. There was no date received, no quantity received. Handwritten showed "QTY Dispensed 20 - 1/2 tabs". Between 10/18 and 10/31, Resident #17 should have received 13 doses of the 0.5 mg tablet, however Resident #17 only received 11 doses. Resident #17 should have received 12 doses of the 1 mg [MEDICATION NAME] between 10/18 and 10/30, however the resident only received 7 doses. Review of the Medication Administration Record dated October 2011 revealed Resident #17's [MEDICATION NAME] was initialed as given three times daily with the exception of 2 doses in which the resident refused on 10/23 and 10/27. In addition, [MEDICATION NAME] was initialed as given every morning and every evening. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of the Physician Telephone Order dated 8/19/2011 revealed [MEDICATION NAME] 0.25 ml (0.5 mg) twice daily was prescribed. Review of the Narcotic Logs for [MEDICATION NAME] ([MEDICATION NAME]) revealed four (4) sheets. Sheet one (1) start date on 8/9/2011 with a typed medication label on the Narcotic Log sheet that stated, "[MEDICATION NAME] 2MG/1MG ORAL CO 30 ML QTY REM:0... 07/20/11... Take 0.25ML (0.5MG) BY MOUTH EVERY 4 HOURS AS NEEDED FOR AGITATION ... REFILL AFTER 08/06/11... C 10...". Sheet two (2) begin date 9/9/11 was handwritten "... [MEDICATION NAME] 2 mg/ml 0.25 ml po (by mouth) BID (twice a day) for agitation. Sheet three (3) begin date 9/25/11 handwritten "[MEDICATION NAME] liquid 0.25 ml". Sheet four (4) begin date 10/14/2011 handwritten "... [MEDICATION NAME] liquid 0.25 ml". [MEDICATION NAME] 0.25 ml twice daily prn was prescribed prior to 8/19/2011. On 8/19/2011 the resident was switched to a scheduled dose twice daily. Resident #19 was prescribed a total of 0.5 milliliters of [MEDICATION NAME] a day. A 30 ml bottle was dispensed to the facility and two doses were given prior to 8/19/11 leaving 29.5 ml. Resident #19's [MEDICATION NAME] bottle should have been completed on 10/17/11. A total of 29 missed doses were noted or 7.25 ml accounting for 15 days worth of medication. Review of the Medication Administration Record documentation for October 2011 revealed Resident #19's [MEDICATION NAME] was initialed as given twice daily except for the following date 10/2/2011 at 6 PM, when the resident refused; 10/11/2011 when the resident refused and was combative with increased agitation; 10/27/2011 when the resident refused. The facility admitted Resident #20 with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. Review of the Narcotic Log sheet for [MEDICATION NAME] (Klonopin) revealed two (2) sheets. Sheet one (1) start date on 9/27/2011 with a typed medication label on the Narcotic Log sheet that stated, "[MEDICATION NAME] 0.5 MG TABLETS 75 EA (each) QTY REM:375... 09/20/11... TAKE 2 AND 1/2 TABS (1.25 MG) BY MOUTH AT BEDTIME FOR ANXIETY...REFILL AFTER 10/16/11... C 95... handwritten Qty. Dispensed 60 whole tabs". Eleven (11) tablets remained on this sheet on 10/31/2011. Sheet two (2) begin date 9/27/2011 was handwritten "... [MEDICATION NAME] 0.25 mg give 1 1/2 tab along with (2) whole 0.5 tabs... QTY 30 1/2 tabs". Both logs were started on 9/27/11 at 8 PM. On 9/28 the resident received 0.5 mg only. On 9/29/2011 and 9/30/2011 - Resident #20 received 1 mg. No Klonopin was given between 10/1/2011 and 10/3/2011. On 10/4/2011 Resident #20 received 1 mg. On 10/10/2011 she received 0.25 mg. On 10/11/2011 she was given 0.5 mg; on 10/15/2011 and 10/16/2011 she received 0.25 mg only. On 10/28/2011 the resident received 0.5 mg. No Klonopin was given on 10/29/2011. On 10/30/2011 the resident received 0.5 mg. During an interview on 10/31/2011, Registered Nurse (RN) #3 stated that she had been administering 2 - 0.25 mg tablets to Resident #20 instead of the prescribed 1.25 mg dose. RN #1 stated that she "didn't know" what the correct combination of tablets was to be administered to the resident. RN #3 also stated that during medication pass, the nurse was to check the medication administration record and the actual medication, dispense the tablet and initial the Medication Administration Record (MAR) as given. For controlled substances, the nurses were to sign the Narcotic Log at the time the drug was administered. RN #3 stated that at shift change both nurses counted the narcotics and then signed the sheet. RN #3 confirmed the blanks on the Narcotic Log for 10/31/2011 and stated that she had not signed for her shift as of 2 PM (10/31/2011). The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated 9/21/2011 revealed Resident #21 was prescribed Narco 5/325 mg by mouth three times daily, scheduled at 8 AM, 2 PM and 8 PM and three times daily as needed for pain. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] 5-325 ([MEDICATION NAME]) revealed three (3) sheets. Sheet one (1) start date on 10/01/2011 with a typed medication label on the Narcotic Log sheet that stated, "... [MEDICATION NAME]-[MEDICATION NAME] 5-325MG TA 90 EA (each) QTY REM:990... 09/22/11... TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED ...REFILL AFTER 10/05/11... C 43... handwritten Qty. Dispensed 90". Sheet two (2) a continuation of sheet one documenting medication dispensed from 10/10/2011 through 10/31/2011. Sheet three (3) stat date on 10/12/2011 with a typed medication label on the Narcotic Log sheet that stated, "[MEDICATION NAME]-[MEDICATION NAME] 5-325MG TA 90 EA (each) QTY REM:900... 10/08/11... TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED ...REFILL AFTER 10/21/11... C 43... handwritten Qty. Dispensed 90". Scheduled and as needed medications were documented on the same Narcotic Log sheet. Resident #21 failed to receive one (1) dose of [MEDICATION NAME] on 10/7/2011, 10/10/2011, and 10/16/2011; she failed to receive two (2) doses of [MEDICATION NAME] on 10/12/2011. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated 10/19/2011 revealed Resident #22 was prescribed [MEDICATION NAME] 10 mg ER (Extended Release), three times daily scheduled at 6 AM, 2 PM and 10 PM. Resident #22 did not have an as needed dose of [MEDICATION NAME] ordered. Review of the Narcotic Log sheet for [MEDICATION NAME] REFORMULATED 10MG TAB SR ([MEDICATION NAME] Sustained Release) revealed one (1) sheet start date on 10/19/2011 with a typed medication label on the Narcotic Log sheet that stated, "... [MEDICATION NAME] REFORMULATED 10MG TAB SR 90 EA (each) QTY REM:0... 10/19/11... TAKE 1 TAB BY MOUTH THREE TIMES DAILY FOR PAIN **DO NOT CRUSH OR CHEW** ...REFILL AFTER 11/14/11... N 47... handwritten Qty. Dispensed 90". No date was recorded when the tablets were received. The log was started on 10/19/2011. On 10/21/11, Resident #22 received the scheduled 10 PM dose. Then on 10/22/11 at 12 AM, the resident received another dose of [MEDICATION NAME]. The resident also received the 6 AM dose and then received an 8 PM dose (two hours before the scheduled time). On 10/24, Resident #22 received an 8 PM dose instead of a 10 PM dose of [MEDICATION NAME]. On 10/30, the 6 AM dose was not received. Resident #22 should have received 32 doses of [MEDICATION NAME] between 10/19 at 9 PM and 10/31 at 6 AM. The resident did not receive 2 scheduled doses and had 4 wrong administration times. Review of the MAR dated October 2011 revealed Resident #22's [MEDICATION NAME] SR was initialed as given three times daily at 6 AM, 2 PM and 10 PM. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders dated 10/18/2011 revealed Resident #23 was prescribed [MEDICATION NAME]/[MEDICATION NAME] 1 mg every night and [MEDICATION NAME] 2.5/500 mg every 8 hours scheduled at 6 AM, 2 PM and 10 PM. Review of the Narcotic Log sheet for [MEDICATION NAME] 1MG TABLET ([MEDICATION NAME]) revealed one (1) sheet with a typed medication label on the Narcotic Log sheet that stated, "... [MEDICATION NAME] 1MG TABLET 30 EA (each) QTY REM:30... 10/20/11... TAKE 1 TAB BY MOUTH AT BEDTIME FOR ANXIETY/AGITATION ...REFILL AFTER 11/15/11... C 68... handwritten Qty. Dispensed 30". No date was recorded when the medication was received, however the Narcotic Log sheet was started on 10/20/11 (2 days after the order was written). The resident did not receive a dose of [MEDICATION NAME] on 10/24/2011. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] 2.5-500MG ([MEDICATION NAME]) revealed one (1) sheet with a typed label on the Narcotic Log sheet that stated, "[MEDICATION NAME]-[MEDICATION NAME] 2.5-500MG 90 EA QTY REM:90... 10/20/2011... TAKE 1 TAB BY MOUTH EVERY 8 HOURS FOR NECK OR JOINT PAIN ...REFIL AFTER 11/15/11... C 64... handwritten QTY. Dispensed 90". No date was recorded when the medication was received, however the card was started on 10/20/11 (2 days after the order was written). Resident #23 should have received 30 doses of [MEDICATION NAME] between 10/19 and 10/31/2011; he only received 21 tablets. Review of the MAR for October 2011 revealed the resident refused the 2 PM dose of [MEDICATION NAME] on 10/20, 10/22, 10/23, 10/24 and 10/25. (Only the 10/22 dose was wasted per the Narcotic Log). 10/26 was left blank. All other scheduled doses were recorded as given. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Admission physician's orders [REDACTED]. On 9/28/2011 the order for [MEDICATION NAME] was changed to [MEDICATION NAME] 0.5 mg at bedtime. Review of MAR for 10/1/2011 through 10/31/2011 documented the resident received "[MEDICATION NAME] 0.5MG TABLET (for [MEDICATION NAME]) TAKE 1/2 TAB BY MOUTH AT BEDTIME". Review of the Narcotic Log Sheet for [MEDICATION NAME] 0.5MG TABLET revealed, "[MEDICATION NAME] 0.5MG TABLET 30 EA QTY REM:150... 9/28/11... REFIL AFTER 10/24/2011... C 07... handwritten Qty. Dispensed 30 ...Date Received 9/28/11". The nursing staff document on the October 2011 MAR that Resident #7 received [MEDICATION NAME] .25MG instead of the ordered [MEDICATION NAME] .5MG tablet at bedtime. Resident #7 received per documentation on the Narcotic Log sheet [MEDICATION NAME] .5MG at bedtime. Earlier record review on 10/10/2011 at approximately 5:20 PM revealed a September 2011 Documentation Record which included an entry for FSBS (Finger stick blood sugar) AC (Before Meals) + HS (Bedtime) (with) SSI (sliding scale insulin) , [MEDICATION NAME], 175-249= 1 unit..." According to the Documentation Record, Resident #7 had (2) Blood Sugar results that required 1 unit of Insulin coverage with no documentation that the coverage was provided by the nursing staff. The following are those results: 9/22/2011 4:30 PM Blood Sugar 176 9/27/2011 9:00 PM Blood Sugar 244. During an interview on 10/10/2011 at 5:35 PM, Licensed Practical Nurse (LPN #2) verified the above findings after reviewing the record. The facility admitted Resident #24 on 10/11/11 with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders dated 10/12/2011 revealed the resident was prescribed [MEDICATION NAME] 5/325 three times daily scheduled at 8 AM, 2 PM and 8 PM. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] 5-325MG ([MEDICATION NAME]) revealed one (1) sheet with a typed label on the Narcotic Log sheet that stated, "[MEDICATION NAME]-[MEDICATION NAME] 5-325MG TA 45 EA QTY REM:1035 SUB FOR [MEDICATION NAME] 10/21/2011... *DOSE CHANGE* TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED FOR PAIN ...REFIL AFTER 11/03/11... C 36... handwritten QTY. Dispensed 45". The card was started on 10/24/11. No [MEDICATION NAME] was given on 10/25 or 10/26. The resident received a 2 AM as needed dose of [MEDICATION NAME] on 10/27. No scheduled doses were given. No other [MEDICATION NAME] had been given since 10/27/11. Resident #24 received 1 out of 17 scheduled doses of [MEDICATION NAME] between 10/23 and 10/31/11. Review of the MAR for October 2011 revealed the resident's [MEDICATION NAME] was initialed as given three times daily at the scheduled times. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/10/2011 at 12:28 PM revealed a Documentation Record for October 2011 that included an entry for "[MEDICATION NAME] FSBS (Fingerstick Blood Sugar) before meals and Bedtime. If (less than) 70= 0 units, 70-150= 0 units, 151-200= 2 units...". According to the Documentation Record, Resident #2 had (4) Blood Sugar results that required 2 units of Insulin coverage with no documentation that the coverage was provided by the nursing staff. The following are those results: 10/2/2011 12:00 Noon Blood Sugar 174 10/3/2011 8:00 PM Blood Sugar 158 10/5/2011 12:00 Noon Blood Sugar 161 10/6/2011 12:00 Noon Blood Sugar 163 During an interview on 10/10/11 at 12:40 PM, Licensed Practical Nurse (LPN) #1 verified the above findings after reviewing the record. On 10/31/2011 between 2 PM and 4 PM, the Director of Nurses (DON) confirmed the above Narcotic Logs, MARs and physician's orders [REDACTED]. Even though the Narcotic Log sheets and the actual drug counts were correct, there was a noted excess of controlled substances for the above residents. The DON confirmed that there was an excess of controlled substances for the residents. She agreed that the facility nurses were not giving the prescribed controlled substances to the residents as ordered. The DON also confirmed that she was aware of possible medication errors but stated that she did not have any direct evidence. The DON confirmed again that Resident #20 was not receiving the ordered dose of Klonopin. The DON also confirmed that Resident #19's bottle of liquid [MEDICATION NAME] should have been completed in the beginning of October 2011. The DON confirmed that the facility staff was signing the MARs indicating that the medications were given, however, the narcotic sheets indicated no medication had been dispensed. Review of the facility's policy on Pharmacy Services and Procedures Manual revealed: "Prior to Medication Administration: Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route at the correct rate, at the correct time for the correct resident. Facility staff should confirm that the MAR reflects the most recent medication order... Medication Administration: Facility staff should: Identify the resident; administer medications within timeframes specified by Facility policy; document the administration of controlled substances in accordance with applicable law... After Medication Administration: Facility should: document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms; dispose of unused medications in accordance with Facility policy..." Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #1 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to assure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520 Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 "...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-281 was lowered in scope and severity from "L" to "F".

On the days of the Recertification, Complaint and Extended Survey, based on record review, interview, and review of the policy provided by the facility entitled "Documentation Standards", Substandard Quality of Care and Immediate Jeopardy was identified on [DATE] related to the administration of controlled substances for 7 of 8 residents on scheduled controlled substances and 1 of 1 resident that received a controlled medication in error. Resident #16 received a Benzodiazepine without a physician's orders [REDACTED].#21, #22, #23, and #24's controlled substances were not administered per the physician's orders [REDACTED]. Resident #2 did not receive [MEDICATION NAME] as ordered. There was also no documentation of a pulse having been checked prior to the administration of [MEDICATION NAME] with orders which stated the medication "lower(s) HR (Heart Rate) may hold if below 40", Resident #7 did not receive [MEDICATION NAME] as ordered and there was no documentation of Blood Pressure checks prior to the administration of a Blood Pressure medication for Resident #4 with orders to hold for certain parameters. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Resident #16 was discharged on [DATE] to an acute care hospital. Review of the Nurse's Notes revealed on [DATE] (no time given), Licensed Practical Nurse (LPN) #3 documented "Resident went to hospital per transport per request of family members. BP ,[DATE], P 76, R 18, T 97.2. Skin W+D (warm and dry). (Patient) did not c/o (complain) until family came at 5 PM. Tylenol tabs 2 given to pt prior to family visit per request of pt (patient) per request of back pain." LPN #3 was noted to work ,[DATE] PM shift. Review of the Clean Catch Urine Toxicology Screen dated [DATE] at 9:49 PM revealed Resident #16 was "POS" (positive) for Benzodiazepines. Review of the physician's orders [REDACTED]. During an interview on [DATE] at 11:45 AM, the Director of Nurses (DON) stated that Resident #16's family member informed the facility of the positive urine toxicology sample. She also confirmed that Resident #16 was not prescribed any Benzodiazepines. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of Resident #17's Admission Physician order [REDACTED]. In addition, Resident #17 was prescribed [MEDICATION NAME] ,[DATE] mg three times daily scheduled at 8 AM, 2 PM and 8 PM. Review of the Narcotic Log for [MEDICATION NAME] ,[DATE] revealed the medication label on the Narcotic Log sheet stated, "[MEDICATION NAME]-[MEDICATION NAME] ,[DATE] ([MEDICATION NAME]) mg TA 180 EA (each) QTY (quantity) REM (remaining) 900... C 23..." Handwritten on the Narcotic Log indicated "Date Received [DATE]; Qty Received 120; Qty Dispensed 120. The medication label did not match the handwritten information on the Narcotic Log. Resident #17 should have received a minimum of 47 doses of [MEDICATION NAME] ,[DATE] mg between ,[DATE] at 8 PM and ,[DATE] at 8 AM. Per the Narcotic Log, Resident #17 received 19 of the 47 doses. Review of the Narcotic Logs for [MEDICATION NAME] revealed the medication label on the Narcotic Log sheet stated, "[MEDICATION NAME] ([MEDICATION NAME]) 1 mg Tablet 30... C 56..." Handwritten on the Narcotic Log "[MEDICATION NAME] 0.5 mg give q (every) A.M. The 0.5 mg was crossed off and 1 mg written and initialed. There was no date received, no quantity received. Handwritten showed "QTY Dispensed 20 - ,[DATE] tabs". Between ,[DATE] and ,[DATE], Resident #17 should have received 13 doses of the 0.5 mg tablet, however Resident #17 only received 11 doses. Resident #17 should have received 12 doses of the 1 mg [MEDICATION NAME] between ,[DATE] and ,[DATE], however the resident only received 7 doses. Review of the Medication Administration Record dated [DATE] revealed Resident #17's [MEDICATION NAME] was initialed as given three times daily with the exception of 2 doses in which the resident refused on ,[DATE] and ,[DATE]. In addition, [MEDICATION NAME] was initialed as given every morning and every evening. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of the Physician Telephone Order dated [DATE] revealed [MEDICATION NAME] 0.25 ml (0.5 mg) twice daily was prescribed. Review of the Narcotic Logs for [MEDICATION NAME] ([MEDICATION NAME]) revealed four (4) sheets. Sheet one (1) start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, "[MEDICATION NAME] 2MG/1MG ORAL CO 30 ML QTY REM:0... [DATE]... Take 0.25ML (0.5MG) BY MOUTH EVERY 4 HOURS AS NEEDED FOR AGITATION ... REFILL AFTER [DATE]... C 10...". Sheet two (2) begin date [DATE] was handwritten "... [MEDICATION NAME] Intonsol 2mg/ml 0.25 ml po (by mouth) BID (twice a day) for agitation. Sheet three (3) begin date [DATE] handwritten "[MEDICATION NAME] liquid 0.25 ml". Sheet four (4) begin date [DATE] handwritten "... [MEDICATION NAME] liquid 0.25 ml". [MEDICATION NAME] 0.25 ml twice daily prn was prescribed prior to [DATE]. On [DATE] the resident was switched to a scheduled dose twice daily. Resident #19 was prescribed a total of 0.5 milliliters of [MEDICATION NAME] a day. A 30 ml bottle was dispensed to the facility and two doses were given prior to [DATE] leaving 29.5 ml. Resident #19's [MEDICATION NAME] bottle should have been completed on [DATE]. A total of 29 missed doses were noted or 7.25 ml accounting for 15 days worth of medication. Review of the Medication Administration Record (MAR) documentation for [DATE] revealed Resident #19's [MEDICATION NAME] was initialed as given twice daily except for the following date [DATE] at 6 PM, when the resident refused; [DATE] when the resident refused and was combative with increased agitation; [DATE] when the resident refused. Review of the Nurses Notes revealed on ,[DATE] the resident was noted with "increased agitation... resident yelling at staff and hitting them." There was no documentation related to the resident's increased agitation on ,[DATE] per the MAR. The facility admitted Resident #20 with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. Review of the Narcotic Log sheet for [MEDICATION NAME] (Klonopin) revealed two (2) sheets. Sheet one (1) start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, "[MEDICATION NAME] 0.5MG TABLETS 75 EA (each) QTY REM:375... [DATE]... TAKE 2 AND ,[DATE] TABS (1.25MG) BY MOUTH AT BEDTIME FOR ANXIETY...REFILL AFTER [DATE]... C 95... handwritten Qty. Dispensed 60 whole tabs". Eleven (11) tablets remained on this sheet on [DATE]. Sheet two (2) begin date [DATE] was handwritten "... [MEDICATION NAME] 0.25mg give 1 ,[DATE] tab along with (2) whole 0.5 tabs... QTY 30 ,[DATE] tabs". Both logs were started on [DATE] at 8 PM. On ,[DATE] the resident received 0.5 mg only. On [DATE] and [DATE] - Resident #20 received 1 mg. No Klonopin was given between [DATE] and [DATE]. On [DATE] Resident #20 received 1 mg. On [DATE] she received 0.25 mg. On [DATE] she was given 0.5 mg; on [DATE] and [DATE] she received 0.25 mg only. On [DATE] the resident received 0.5 mg. No Klonopin was given on [DATE]. On [DATE] the resident received 0.5 mg. During an interview on [DATE], Registered Nurse (RN) #3 stated that she had been administering 2 - 0.25 mg tablets to Resident #20 instead of the prescribed 1.25 mg dose. RN #3 stated that she "didn't know" what the correct combination of tablets was to be administered to the resident. RN #3 also stated that during medication pass, the nurse was to check the medication administration record and the actual medication, dispense the tablet and initial the Medication Administration Record (MAR) as given. For controlled substances, the nurses were to sign the Narcotic Log at the time the drug was administered. RN #3 stated that at shift change both nurses counted the narcotics and then signed the sheet. RN #3 confirmed the blanks on the Narcotic Log for [DATE] and stated that she had not signed for her shift as of 2 PM ([DATE]). Review of the Nurses Notes revealed on ,[DATE] the resident was "observed removing food from other residents..." On ,[DATE], "resident is sitting at nurses station yelling, trying to hit and kick staff." On ,[DATE], the resident was "up in wheelchair with hand raised to the sky calling for God to make her whole and that she wanted to be with her husband." On ,[DATE], "resident yelling that she wanted to see her deceased husband. [MEDICATION NAME] 125 mg given for increased agitation. Resident was awake all night." During an interview on [DATE] the DON, confirmed that Resident #20 had increased agitation during the month of October. She stated that last Saturday she was working and had to administer [MEDICATION NAME] to the resident for increased agitation. The DON also confirmed that no nurses notes were documented during the month of [DATE]. The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated [DATE] revealed Resident #21 was prescribed [MEDICATION NAME] ,[DATE] mg by mouth three times daily, scheduled at 8 AM, 2 PM and 8 PM and three times daily as needed for pain. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] ([MEDICATION NAME]) revealed three (3) sheets. Sheet one (1) start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, "... [MEDICATION NAME]-[MEDICATION NAME] ,[DATE]MG TA 90 EA (each) QTY REM:990... [DATE]... TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED ...REFILL AFTER [DATE]... C 43... handwritten Qty. Dispensed 90". Sheet two (2) a continuation of sheet one documenting medication dispensed from [DATE] through [DATE]. Sheet three (3) start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, "[MEDICATION NAME]-[MEDICATION NAME] ,[DATE]MG TA 90 EA (each) QTY REM:900... [DATE]... TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED ...REFILL AFTER [DATE]... C 43... handwritten Qty. Dispensed 90". Scheduled and as needed medications were documented on the same Narcotic Log sheet. Resident #21 failed to receive one (1) dose of [MEDICATION NAME] on [DATE], [DATE], and [DATE]; she failed to receive two (2) doses of [MEDICATION NAME] on [DATE]. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated [DATE] revealed Resident #22 was prescribed [MEDICATION NAME] 10 mg ER (Extended Release), three times daily scheduled at 6 AM, 2 PM and 10 PM. Resident #22 did not have an as needed dose of [MEDICATION NAME] ordered. Review of the Narcotic Log sheet for [MEDICATION NAME] REFORMULATED 10MG TAB SR ([MEDICATION NAME] Sustained Release) revealed one (1) sheet start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, "... [MEDICATION NAME] REFORMULATED 10MG TAB SR 90 EA (each) QTY REM:0... [DATE]... TAKE 1 TAB BY MOUTH THREE TIMES DAILY FOR PAIN **DO NOT CRUSH OR CHEW** ...REFILL AFTER [DATE]... N 47... handwritten Qty. Dispensed 90". No date was recorded when the tablets were received. The log was started on [DATE]. On [DATE], Resident #22 received the scheduled 10 PM dose. Then on [DATE] at 12 AM, the resident received another dose of [MEDICATION NAME]. The resident also received the 6 AM dose and then received an 8 PM dose (two hours before the scheduled time). On ,[DATE], Resident #22 received an 8 PM dose instead of a 10 PM dose of [MEDICATION NAME]. On ,[DATE], the 6 AM dose was not received. Resident #22 should have received 32 doses of [MEDICATION NAME] between ,[DATE] at 9 PM and ,[DATE] at 6 AM. The resident did not receive 2 scheduled doses and had 4 wrong administration times. Review of the MAR dated [DATE] revealed Resident #22's [MEDICATION NAME] SR was initialed as given three times daily at 6 AM, 2 PM and 10 PM. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders dated [DATE] revealed Resident #23 was prescribed [MEDICATION NAME]/[MEDICATION NAME] 1 mg every night and [MEDICATION NAME] 2XXX,[DATE] mg every 8 hours scheduled at 6 AM, 2 PM and 10 PM. Review of the Narcotic Log sheet for [MEDICATION NAME] 1MG TABLET ([MEDICATION NAME]) revealed one (1) sheet with a typed medication label on the Narcotic Log sheet that stated, "... [MEDICATION NAME] 1MG TABLET 30 EA (each) QTY REM:30... [DATE]... TAKE 1 TAB BY MOUTH AT BEDTIME FOR ANXIETY/AGITATION ...REFILL AFTER [DATE]... C 68... handwritten Qty. Dispensed 30". No date was recorded when the medication was received, however the Narcotic Log sheet was started on [DATE] (2 days after the order was written). The resident did not receive a dose of [MEDICATION NAME] on [DATE]. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] 2XXX,[DATE]MG ([MEDICATION NAME]) revealed one (1) sheet with a typed label on the Narcotic Log sheet that stated, "[MEDICATION NAME]-[MEDICATION NAME] 2XXX,[DATE]MG 90 EA QTY REM:90... [DATE]... TAKE 1 TAB BY MOUTH EVERY 8 HOURS FOR NECK OR JOINT PAIN ...REFIL AFTER [DATE]... C 64... handwritten QTY. Dispensed 90". No date was recorded when the medication was received, however the card was started on [DATE] (2 days after the order was written). Resident #23 should have received 30 doses of [MEDICATION NAME] between ,[DATE] and [DATE]; he only received 21 tablets. Review of the MAR for [DATE] revealed the resident refused the 2 PM dose of [MEDICATION NAME] on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. (Only the ,[DATE] dose was wasted per the Narcotic Log). ,[DATE] was left blank. All other scheduled doses were recorded as given. Review of the Nurses Notes revealed on ,[DATE] the resident was "belligerent" and kept removing the cervical spine collar. On ,[DATE] and ,[DATE] the resident's "dementia was apparent." On ,[DATE] the resident complained of elbow pain and "a PRN was given." However, no as needed medication was initialed as given on the MAR or recorded on the Narcotic Log. On ,[DATE] the resident again complained of pain and Tylenol 325 mg was given at 7 AM. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders dated [DATE] revealed the resident was prescribed [MEDICATION NAME] ,[DATE] three times daily scheduled at 8 AM, 2 PM and 8 PM. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE]MG ([MEDICATION NAME]) revealed one (1) sheet with a typed label on the Narcotic Log sheet that stated, "[MEDICATION NAME]-[MEDICATION NAME] ,[DATE]MG TA 45 EA QTY REM:1035 SUB FOR [MEDICATION NAME] [DATE]... *DOSE CHANGE* TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED FOR PAIN ...REFIL AFTER [DATE]... C 36... handwritten QTY. Dispensed 45". The card was started on [DATE]. No [MEDICATION NAME] was given on ,[DATE] or ,[DATE]. The resident received a 2 AM as needed dose of [MEDICATION NAME] on ,[DATE]. No scheduled doses were given. No other [MEDICATION NAME] had been given since [DATE]. Resident #24 received 1 out of 17 scheduled doses of [MEDICATION NAME] between ,[DATE] and [DATE]. Review of the MAR for [DATE] revealed the resident's [MEDICATION NAME] was initialed as given three times daily at the scheduled times. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 12:00 Noon revealed a Discharge Summary from the hospital dated [DATE] with a Discharge Medication List which included "[MEDICATION NAME] 0.1 mg (milligrams) q (every) 8 hours prn (as needed) systolic blood pressure greater than 180". Review of the "Active Inpatient Medications" list from the hospital revealed a typed entry for [MEDICATION NAME] HCL 0.1 mg (1 tablet) PO (By Mouth) every 12 hours. Under the frequency of "every 12 hours" was handwritten "PRN syst(olic) (greater than) 180". The box to "Continue" the medication had been checked. Review of Physician's admission orders [MEDICATION NAME] HCL 0.1 mg = (1) tab (tablet) q 12 (hours)". There was no further documentation to indicate the medication had been ordered PRN (as needed) and there were no times listed for the medication to be given. Review of the [DATE] Documentation Record revealed the same entry for [MEDICATION NAME] as listed previously with nothing to indicate the medication was PRN or any time frames for the medication to be given. According to the Documentation Record, the [MEDICATION NAME] had not been administered at all from [DATE] through [DATE]. Review of physician's orders [REDACTED]. Review of the October Documentation Record revealed [MEDICATION NAME] 0.1 mg had been given twice daily from [DATE] through the morning dose on [DATE] (except for a circled morning dose [DATE]). There was no documentation of blood pressures having been taken prior to giving the [MEDICATION NAME]. Review of Physician's Telephone Orders for September and [DATE] revealed there were no other orders relative to [MEDICATION NAME] administration. During an interview on [DATE] at 12:40 PM, Licensed Practical Nurse (LPN) #1 verified the above findings after reviewing the records with the surveyor. When asked, she stated it looked like the [MEDICATION NAME] should have been given for a Systolic Blood Pressure greater than 180. Review of Daily Skilled Nurse's Note(s) along with the Vital Signs Record for September and [DATE] revealed no indication that the resident's blood pressure had been greater than 180 systolic. During a phone interview on [DATE] at 1:20 PM, the above record review information was relayed to the Nurse Practitioner for the facility. She was asked what she thought the Physician intended as far as what the correct order for the [MEDICATION NAME] should have been upon admission. She stated that since [MEDICATION NAME] was a rapid acting blood pressure medication, she thought that it would not have been ordered as a scheduled medication. During a phone interview on [DATE] at 2:05 PM, the above record review information was relayed to the resident's Physician. When asked which order was correct and what had been intended for the order, the Physician stated that the [MEDICATION NAME] should have been given PRN. He stated that as long as there was no order from him to change the [MEDICATION NAME] to scheduled, it should have been PRN. Resident #2 did not have a pulse checked prior to the administration of [MEDICATION NAME] with orders that the medication may be held if the heart rate was below 40. Review of Admission physician's orders [REDACTED].= 0.5 of 25 mg (1) q 12 (hours)". Next to the entry was handwritten "lower(s) HR may hold if below 40". Review of the Documentation Record for [DATE] revealed the medication had been given 12 times in September without any documentation of a pulse having been checked prior to administration. Review of the [DATE] cumulative physician's orders [REDACTED]. There was nothing on the orders to indicate the medication should be held for a heart rate less than 40. Review of the Documentation Record for [DATE] also revealed no indication that the medication should be held for a heart rate less than 40. There was no documentation of a pulse having been checked prior to the administration of [MEDICATION NAME] for 18 doses in October. During an interview on [DATE] at 12:45 PM, LPN #1 verified the above findings after reviewing the record. She stated she knew to take the pulse prior to giving the [MEDICATION NAME]. She stated she did not document this. She stated that usually the medication was held for a pulse less than 60. She verified a pulse had not been documented prior to giving the medications. On [DATE] the Director of Nursing (DON) stated there was no particular facility policy related to checking for a pulse or blood pressure prior to administering medications. She provided a policy entitled "Documentation Standards" which stated that ..."Vital Signs (Temp, Pulse, Resp, B/P) will be documented daily within the body of the Medicare charting and the vital signs flow sheet. Licensed staff will refer to the medical record to insure that the physician orders [REDACTED]. During a phone interview on [DATE] at approximately 1:15 PM, the facility Nurse Practitioner was asked what it meant when the order said "may hold" if heart rate is less than 40. She stated she expected that pulse would be taken prior to giving the medication and if it was less than 40 the medication would be held. She was told that the order to "may hold" was on the September admission orders [REDACTED]. She stated that she thinks that sometimes when the orders are transcribed by the Pharmacy, that they sometimes drop parts of the order. During a phone interview on [DATE] at approximately 2:05 PM, the resident's Physician was asked about the order that the [MEDICATION NAME] may be held if the heart rate was less than 40. He stated he would expect that a pulse would be checked prior to the administration of the medication. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 8:30 AM revealed Admission Physician order [REDACTED]. Continued review of physician's orders [REDACTED]. Review of Daily Skilled Nurse's Note(s) revealed an entry dated [DATE] at 1:30 AM which stated "Pharmacy called R/T (related to) allergies [REDACTED]. MD (Physician) will be called in AM". Review of the Documentation Record for [DATE] on [DATE] revealed the nurse's initials for the medication [MEDICATION NAME] had been circled indicating the medication had not been given for 12 doses from the evening of [DATE] until [DATE]. There were also 3 blanks for that time period where the nurse did not initial for the medication at all. On the back of the Documentation Record were 3 notations that referenced the [MEDICATION NAME]. One dated [DATE] at 10:00 AM stated "[MEDICATION NAME]----Clarification faxed to pharmacy r/t (no) true allergy". A second dated [DATE] at 8:00 AM stated "[MEDICATION NAME]-not in see above [DATE]". The third was dated [DATE], which stated "Faxed stat order for [MEDICATION NAME] 12.5. Did not send". The Documentation Record revealed that the medication had been initialed as having been given starting [DATE] with the evening dose and also showed that while at times the medication was circled for the morning dose, the evening dose had been initialed as having been given. Review of Nurses Notes for [DATE] and the backs of the Documentation Record did not indicate why the Nurses initials had been circled except as noted above for 3 doses. The Director of Nursing verified the circles and blanks on the Documentation Record on [DATE] at 8:45 AM. She stated that the Pharmacy had initially sent only (15) ,[DATE] tablets of the [MEDICATION NAME] and that she had to sign that she would pay for the medication. She stated the Pharmacy would not accept the order from the nurse. The DON was asked to provide any invoices for the medication and any communication between the Pharmacy and the facility related to the [MEDICATION NAME] or allergies [REDACTED]. When asked if [MEDICATION NAME] was available in the stat/emergency box, the DON stated it used to be. Observation on [DATE] at 12:40 PM of the stat box in the medication room revealed it contained [MEDICATION NAME] 3.125 mg tablets #6. Review on [DATE] at 9:45 AM of the Pharmacy Invoice for medications supplied to the facility from [DATE] thru [DATE] revealed Resident #7's [MEDICATION NAME] was shipped on [DATE] and delivered [DATE] at 12:18 AM. During a phone interview on [DATE] at 1:07 PM the Pharmacy Manager asked what the issue was and said he would call the corporate office to get permission to release the information. He called back and stated he was unable to speak with the surveyor about the issue with Resident #7 due to privacy regulations. He stated if he received a signed written request for information along with a business card he could obtain the information and then speak with the surveyor. The facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] Fibrillation) Record review on [DATE] at 1:00 PM of the Physician order [REDACTED].<_ 120 and diastolic blood pressure <_ 80". Review of the September and [DATE] Medication Administration Record (MAR) revealed only two documentation of blood pressure checks prior to medication administration. During an interview on [DATE] at 4:05 PM, with Registered Nurse (RN) #1 stated they use the daily "Vital Sign Sheet" obtained by the Certified Nursing Assistants (CNA) on the ,[DATE] shift for vital signs. During observation of the "Vital Sign Sheet" for [DATE], ,[DATE] shift, the residents blood pressure was documented ,[DATE]. RN #1 confirmed the blood pressure out of parameters, no documentation on the MAR for the blood pressure check and that the medication was administered given. Upon further review of the "Vital Signs and Weight Record" in the residents chart revealed that most of the blood pressure checks for the ,[DATE], ,[DATE] shift was out of parameters for the medication to be given, however the medication was administered on those days. Upon review of the facilities policy "Documentation Standards", on [DATE] at 1:50 PM, revealed "Vital Signs (Temp, Pulse, Resp, B/P) will be documented daily within the body of the Medicare charting and the vital signs flow sheet. Licensed staff will refer to the medical record to insure that the physician orders [REDACTED]. On [DATE] between 2 PM and 4 PM, the Director of Nurses (D)N) confirmed the above Narcotic Logs, MARs and physician's orders [REDACTED]. Even though the Narcotic Log and the actual drug counts were correct, there was a noted excess of controlled substances for the above residents. The DON confirmed that there was an excess of controlled substances for the residents. She agreed that the facility nurses were not giving the prescribed controlled substances to the residents as ordered. The DON also confirmed that she was aware of possible medication errors but stated that she did not have any direct evidence. The DON also could not provide any evidence of investigation, re-education or termination for any nurse involved in potential drug errors. The DON stated that there was not an Action Plan initiated related to medication errors or controlled substances. She also stated that she was unaware of any concerns with controlled substances and had not been notified by the Pharmacy Consultant of any concerns. Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #16 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520 Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on [DATE] at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On [DATE] all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning [DATE] related to the grievance policy. On [DATE] "...All medication records were audited on [DATE] versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on [DATE]. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders Observation on [DATE] by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On [DATE] prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-333 was lowered in scope and severity from "L" to "F".

On the days of the Recertification, Complaint and Extended Survey based on observations, record review, interview and review of the Pharmacy Reports, Immediate Jeopardy was identified on 11/08/2011 related to the facility's failure to assure controlled substances were reconciled monthly. The Pharmacy Consultant failed to assure 7 of 8 residents (#17, #19, #20, #21, #22, #23 and #24) receiving scheduled controlled medications received them as ordered. The findings included: Review of the October 2011, Drug Count Verification Sheet revealed blanks where both nurses did not sign at change of shift narcotic count. During an interview on 10/31/2011 at approximately 2 PM, RN #3 stated that at shift change both nurses counted the narcotics and then signed the sheet. RN #3 confirmed the blanks and stated that she had not signed for her shift as of 2 PM. During an interview on 10/31/2011 at 5:30 PM, Consultant Pharmacist #1 stated that she was not assigned to the facility but was aware of what the procedure entailed. She stated that during the monthly medication review controlled substances should be reconciled by checking the narcotic sheets to the actual count. Comparing routine medications and as needed medications, risk assessments, blanks on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated that if there was an excess of medication she would look to see if the resident was refusing the medication. She stated that she would also train staff on administration and documentation. During an interview on 10/31/2011 at 5:45 PM, the Director of Nurses stated that she was not aware of any concerns related to controlled substances. She stated that on 10/24/11, the Quarterly Quality Assurance Review was conducted by Pharmacy. She stated that no concerns were found during the review related to controlled substance administration. She also stated that the pharmacist did not inform her of any concerns during the monthly review related to controlled substance administration. Review of the Quarterly Quality Assurance Review dated 10/24/11 revealed the Pharmacist identified the shift to shift narcotic counts were not signed by both nurses for each shift. No other concerns were noted related to controlled substances. During an interview on 11/7/2011 at 5:30 PM, Consultant Pharmacist #2 stated that she was assigned to the facility. She stated that during her monthly review that she "in general" looked at the controlled substances. She stated that she checked the narcotic counts and MARs for accuracy. She stated that no concerns related to narcotic administration "jumped out at her." During another interview on 11/8/2011 at 2:10 PM, Consultant Pharmacist #2 stated that during her monthly reviews she had noted for one resident the MAR indicated [REDACTED]. However, during the next month's follow up, the resident had been discharged . She stated that she did not find any more concerns related to that issue. Consultant Pharmacist #2 stated that other concerns she had identified were related to facility staff using different cards and narcotic logs. She stated that it was "mostly documentation." She stated that she did not notice any trends related to controlled substance administration. Consultant Pharmacist #2 stated that she did a 20% detailed medication review every month and had not noticed any concerns or trends related to controlled substance administration. Review of the Facility's policy on Pharmacy Services revealed: "Upon delivery by pharmacy: A facility nurse or other licensed facility staff member should sign the delivery manifest, note the time of arrival, and take responsibility for the receipt, proper storage and distribution of the delivered medications... facility staff should immediately log controlled substances into the facility's controlled drug inventory system and should store such controlled substances in compliance with applicable law... The facility should maintain separate individual controlled substance records on all Schedule II drugs in the form of a declining inventory, Resident name, prescriber name, prescription number, drug name, strength, dosage form, dosage, date and time of administration and signature of person administering the drug...The facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances at least once daily or at the change of shift and document the results on a Controlled Drug Count Verification... A facility representative should regularly check the inventory records to reconcile inventory. The facility should reconcile current and discontinued inventory of controlled substances to the log used in the facility's controlled drug inventory system. The facility should reconcile the current inventory to the controlled drug declining inventory record and to the resident's medication administration record. The facility should regularly reconcile unused controlled substances held in storage awaiting destruction with the declining inventory record." Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #1 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-514 Resient Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520 Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 "...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-428 was lowered in scope and severity from "L" to "F".

On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified at the facility related to the failure to ensure medication administration policies and procedures were followed for seven of eight residents with pain and/or antianxiety medications (controlled substances) and one of one resident that received a Benzodiazepines without an order. The findings included: Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #16 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520, Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and/or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 "...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records/reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-490 was lowered in scope and severity from "L" to "F".

On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified at the facility related to the failure to maintain clinical records in accordance with accepted professional standards and practices for seven of eight residents (#17, #19, #20, #21, #22, #23 and #24) with pain and/or antianxiety medications (controlled substances) and one of one resident (#16) that received a Benzodiazepines without an order. Two residents (#2 and #7) with physician's orders [REDACTED]. The findings included: Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-520, Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and/or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 "...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records/reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-514 was lowered in scope and severity from "L" to "F".

On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified related to the facility's failure to identify, develop and implement a plan of action related to the administration of pain and / or antianxiety medications (controlled substances). Seven of eight residents did not receive controlled substances per the physician's orders [REDACTED]. The findings included: On 10/31/11 between 2 PM and 4 PM, the Director of Nurses confirmed that there was an excess of controlled substances for the residents. She agreed that the facility nurses were not giving the prescribed controlled substances to the residents as ordered. The DON also confirmed that she was aware of possible medication errors but stated that she did not have any direct evidence. The DON also could not provide any evidence of investigation, re-education or termination for any nurse involved in potential drug errors. The DON stated that there was not an Action Plan initiated related to medication errors or controlled substances. She also stated that she was unaware of any concerns with controlled substances and had not been notified by the Pharmacy Consultant of any concerns. Review of the Quarterly Quality Assurance Review dated 10/24/2011 revealed the Pharmacist identified the shift to shift narcotic counts were not signed by both nurses for each shift. No other concerns were noted related to controlled substances. During an interview on 11/8/2011 at 2:10 PM, the Consultant Pharmacist #2 stated that during her monthly reviews she did not notice any trends related to controlled substance administration. The Consultant Pharmacist #2 stated that she did a 20% detailed medication review every month and had not noticed any concerns or trends related to controlled substance administration. Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #1 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 "...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-520 was lowered in scope and severity from "L" to "F".

On the days of the Recertification, Complaint and Extended Survey, based on observations, record review, interview and review of the facility's policy on Abuse and Neglect, Substandard Quality of Care and Immediate Jeopardy was identified on 11/08/2011 related to the facility's failure to ensure one of one allegation of neglect was thoroughly investigated. The facility was unable to provide evidence of a thorough investigation of the family's concern that Resident #16 received an unprescribed Benzodiazepine medication. Resident #16's family found the resident unresponsive at the facility on 9/17/2011 and asked that she be admitted to the hospital. The family asked the emergency room (ER) physician to perform a Toxicology Screen on 9/17/2011 during the ER visit. The Urine Toxicology Screen showed a Benzodiazepine medication that was not prescribed for Resident #16. On 9/19/2011 the family voiced their concerns to the facility related to the drug screen. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Resident #16 was discharged on [DATE] to an acute care hospital. Resident #16's closed medical record was reviewed due to a complaint that a Benzodiazepine medication was found during a Toxicology Screen at a hospital on [DATE]. In an interview on 10/31/2011 at 11:45 AM, the Director of Nurses (DON) stated that Resident #16's family member informed the facility of the positive urine sample and that the resident was not prescribed any Benzodiazepines. The DON stated that the Licensed Practical Nurse (LPN) #3) on duty the night of the incident, denied during interview, administering "anything that was not prescribed to the resident." The DON further stated that LPN #3 had other medication errors and was re-educated. During the "re-education", LPN #3 apparently made another error and was then placed on PRN (as needed) staffing. The DON stated that LPN #3 had not worked since. The DON stated the facility did not obtain proof of the positive toxicology screen, reported by the resident's family. Review of an undated, written statement provided by the DON, she documented, "On 9/19/11, (Resident #16's family member) came in and told me about his experience with LPN #3, second shift nurse. He explained that... after she was admitted , her bed sheets were dirty. Stating they were bloodstained and when LPN #3 was informed she cut off paper/plastic bracelets from the hospital and stated that the bracelets cut her arm. She in fact had no cuts on her... On Saturday, (Resident #16) was visiting with 2 family members and she became unresponsive. They placed her into a wheelchair and moved to bed. (LPN #3) informed the family that she could have had a TIA ([MEDICAL CONDITION]) or stroke and they asked about her vital signs. Her vital signs came back normal and after a little while (Resident #16's son) asked for his mother to be sent to the ER (emergency room ). He further stated that (LPN #3) was verbally rude to him when he asked what medications she had given his mother and when EMS (emergency medical service) arrived (LPN #3) said she needed to talk to them and he needed to leave. At the ER he had his mother tested for medications and the results came back with Benzodiazepines in her system. (Resident #16's son) agreed to give a summary of the events and a copy of the drug results. He said that at some point (LPN #3) said to him that it was his word against hers and she would be fine and he just needed to leave. All the above information was also shared with (the Administrator) by (Resident #16's son.)" No other investigative material was provided at the time of the survey. During a follow up interview on 10/31/2011, the DON, confirmed her written statement and stated that she did not have any other documentation related to the investigation. She stated that the resident's son did not provide the toxicology screen therefore she did not have proof the error occurred. The DON stated that she did not attempt to obtain the toxicology screen from the hospital. The DON stated that she knew LPN #3 had made other errors in the past. She also confirmed that she did not have any documentation related to LPN #3's re-education or evidence that errors were made on the med pass observation. The DON confirmed that LPN #3 worked with residents until 10/8/2011. She stated that LPN #3 was working under the supervision of another nurse. However, there was no evidence LPN #3 worked with another nurse. The DON also confirmed that Resident #16's roommate was prescribed [MEDICATION NAME] (a Benzodiazepines). The DON confirmed again that a formal investigation had not been initiated related to the Responsible Party's complaint. During an interview on 11/7/2011 at 4:15 PM, a family member stated that on 9/17/11 Resident #16 was unresponsive. The family member stated that on arrival at the facility around 5 PM, the resident was in her room. LPN #3 informed the family that the resident could have had a TIA. She told the family she had not administered anything other than Tylenol. The family stated that LPN #3 became defensive and uncooperative. The family then requested that Resident #16 be transported to the hospital where a drug screen was ordered and the resident was positive for Benzodiazepines. The family stated that on Monday, 9/19/11, the DON was told of the concerns related to the drug screen and LPN #3; the DON requested the Administrator join the conference. Review of the Clean Catch Urine Toxicology Screen dated 9/17/2011 at 9:49 PM, revealed Resident #16 was "POS" (positive) for Benzodiazepines. Review of the physician's orders [REDACTED]. Review of the facility's policy on Abuse and Neglect revealed: "Investigation: 1) A complete and thorough investigation will be conducted to identify the cause of all injuries. 2) The investigation will be conducted with the resident's safety as the foremost concern in order to protect the resident from future harm. 3) If abuse or neglect is suspected, the individual suspected of abusing or neglecting the resident will be placed on suspension pending the outcome of the investigation. If Administration is unable to determine that there is a clear suspect, all staff assigned to the resident prior to the incident/injury will be interviewed in an effort to identify who may be responsible. 4) If after interviewing all staff, Administration is still unable to conclude that a staff member is responsible, Administration will increase observation and surveillance of the hall or unit. Administration will implement any procedures deemed appropriate and necessary at the time, i.e. change in staff assignments, nursing administrative rounds, etc. 5) Administration will continue to make daily checks on any and all residents who have "cause unknown" injuries or who have may been abused to ensure that injuries are not still occurring." Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility staffs' failure to properly administer medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one resident received Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to the investigation of an allegation of neglect and the administration of controlled substances. Cross Refers to F-520 Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 "...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Substandard Quality of Care and the Immediate Jeopardy citation at F-226 was lowered in scope and severity from "J" to "D".