Every finding on record at Windsor Nursing and Rehabilitation Center of San D

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 3 residents whose care plans were reviewed. The facility failed to ensure Resident #1's comprehensive care plan was implemented by not providing the required two-person assistance during bathing. Resident #1 received bathing assistance from only one staff member on 07/16/26.This failure could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs. The findings include:Record review of Resident #1's face sheet dated 07/28/26 reflected a [AGE] year-old-female with an original admission date of 07/11/26. Diagnoses included Guillain-Barre syndrome (rare autoimmune disorder where the immune system attacks the peripheral nerves, leading to muscle weakness and paralysis) and high blood pressure. Record review of Resident #1's admission MDS reflected a BIMS score of 15 (cognition intact). Resident #1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity). Or the assistance of 2 or more helpers is required for the resident to complete the activity for bathing or showering. Record review of Resident #1's care plan initiated on 07/12/26 reflected:Resident #1 has ADL self-care performance deficit r/t disease process of myopathies (group of diseases that primarily affect the skeletal muscles).Interventions included:Resident # 1 requires extensive assistance by 2 staff members with bathing and showering. In an interview on 07/28/26 at 11:11 a.m., Resident #1 stated on 07/16/26 CNA A transported her to the shower room and proceeded to bathe her without assistance. Resident #1 stated, she knew her plan of care required two staff members to assist with bathing and stated only one staff member provided the bathing assistance on that day. In a phone interview on 07/28/26 at 1:43 p.m., CNA A stated she and another CNA transferred Resident #1 to a shower bed and transported her to the shower room. CNA A stated she then stated to the other CNA that she could go finish what she was doing and proceeded to bathe Resident #1 without assistance. CNA A stated Resident #1's care plan required two staff members to provide bathing assistance but stated she believed she could safely complete the bath independently because Resident #1 was able to assist with turning. In an interview on 07/28/26 at 2:30 p.m., the DON stated Resident #1's care plan required two staff members to provide bathing assistance. The DON stated on 07/16/26, only one CNA, CNA A, competed Resident #1's bath and the plan of care was not followed. The DON stated staff should have adhered to the care plan requirement of two-person assistance during bathing to ensure care was provided as planned.Record review of the facility's Comprehensive Care Plans policy dated 10/24/22 reflected: Policy:It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 1 of 1 resident (Resident #46) reviewed for residents' discharge. Resident #46 was discharged home on [DATE] without a notice to the LTC state ombudsman. This failure could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman.Record review of Resident #46's face sheet dated 04/29/2026 reflected a [AGE] year-old female admitted on [DATE]. Resident #46 admitted with diagnoses of Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it hard to breathe), Depression, Hyperlipidemia (having too many fats, such as cholesterol in the blood) , Hypertension (high blood pressure), Peripheral Vascular Disease (blockage in the blood vessel outside the heart), insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). Record review of Resident #46's MDS discharge date d 04/10/2026 reflected Resident #46 was Independent in Cognitive Skills for daily Decision making. Section Q indicated Discharge Plan was activated and already occurred for Resident #46 to return to the community. Record review of Resident #46's care plan reflected Resident #46 wishes to return/be discharged home. Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan as needed. Record review of Resident #46's electronic medical record reflected a progress note dated 04/06/2026 stated Resident #46 had been discharged on 04/10/2026 home with family. Record review of Resident #46's electronic medical record from 04/10/2026 to 04/29/2026 reflected no evidence of notice given to the LTC Ombudsman pertaining to Resident #46's discharge home. In an interview on 04/28/2026 at 2:10 p.m. the SW stated that he has been covering for this facility's social worker who was out on leave and had been in this role since 02/11/2026. The SW stated that he had not notified the LTC Ombudsman of discharges because he had not received a spreadsheet log. He stated that he was not familiar with the residents at this facility. The SW stated that he was aware of the requirement to notify the LTC Ombudsman of discharges. He stated that it was his responsibility to have created a spreadsheet and send discharge notifications via email. The SW stated that it was important to notify the LTC Ombudsman to show the services provided at discharge, including if going home with hospice and durable medical equipment. In an Email communication on 04/29/26 at 8:18 a.m., the Ombudsman revealed that she had not received any resident discharge notices from this facility. In an interview on 04/29/2026 at 9:50 a.m. the Administrator stated she was not aware the local ombudsman had not been notified of resident discharges from the facility. She stated she was aware that the facility was required to be sending the Local ombudsman resident discharge notifications. The Administrator stated that it was important for the LTC Ombudsman to be notified to let her know it was a safe discharge and to ensure follow-up with PCP appointments. Record review of the facilities policy titled Transfer and Discharge (including AMA), dated 03/05/2025 revealed: Policy, Explanation and Compliance Guidelines: . 3. The facility's transfer/discharge notice will be provided to the resident and residents representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: d. An explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. h. The name, address (mailing and email), and phone number of the representative of the office of the State Long Term Care Ombudsman.

Based on record review and interviews, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #34 and Resident #6) of 6 residents reviewed for comprehensive care plans in that: 1. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #34's diagnosis of Viral Hepatitis C (a blood-borne virus that causes severe liver inflammation and long-term damage). 2.The facility failed to revise Resident #6's comprehensive care plan to include the resident's use of an antibiotic medication (Clindamycin). These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their current health needs. 1.Record review of Resident #34's face sheet dated 04/28/2026 reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #34 had a diagnosis of Viral Hepatitis C (a blood-borne virus that causes severe liver inflammation and long-term damage). Record review of Resident #34's Quarterly MDS assessment, dated 02/18/2026, reflected that he scored a 15 on his BIMS which reflected intact cognition. Section I Active Diagnosis reflected Viral Hepatitis. Record review of Resident #34 most recent Care Plan reflected Resident #34 did not have Viral Hepatitis C developed on his care plan or interventions. In an interview on 04/28/2026 at 3:54 p.m., LVN A stated the diagnosis of Viral Hepatitis C should have been care planned. She stated that it was important for it to be care planned to ensure appropriate precautions were followed and to understand how others were caring for him, such as wearing proper PPE. LVN A stated that it should have been care planned within 24-48 hours of admission but was not certain. She stated that the DON or the weekend RN were responsible for care planning. In an interview on 04/28/2026 at 4:14 p.m., the MDS coordinator stated she and the charge nurses were responsible for developing care plan for Resident #34. The MDS coordinator stated that the diagnosis of Viral Hepatitis C should have been care planned but does not know why it was not completed because he came from another facility. She stated it was important for it to be care planned because it was an infection, and people needed to know how to take care of themselves and the residents. The MDS coordinator stated the negative outcome would be a risk of not properly addressing Resident #34's needs and a risk for staff to ensure he was receiving what he needed accordingly. In an interview on 04/29/2026 at 9:39 a.m. with the DON, stated the MDS coordinator, she, the ADON, and the charge nurse were responsible for completing the care plan for Resident #34. She stated the diagnosis of Viral Hepatitis C should have been care planned and was not completed. The DON stated it was important for it to be completed to let staff know about the care that needs to be provided to Resident #34. She stated the negative outcome would be the spread of infection. 2. Record review of Resident #6's face sheet dated 04/27/2026 reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] and with an original admitted date 11/25/2025. Resident #6 had diagnosis of toenail avulsion. Record review of Resident #6's Quarterly MDS assessment, dated 04/14/2026, reflected a BIMS score of 02 which indicated severely impaired cognition. Record review of Resident #6's most recent Care Plan reflected Resident #6 did not have the antibiotic developed on his care plan or interventions. Record review of Resident #6's Physician Order Summary Report reflected Clindamycin Oral Capsule 300mg one capsule by mouth three times daily for 7 days ordered 04/23/2026. In an interview on 04/28/2026 at 3:54 p.m., LVN A stated when there was a change in condition and antibiotics were ordered, it should have been care planned. She stated that she was not sure how soon it should have been care planned. LVN A stated the infection control nurse was responsible for care planning antibiotics. She stated it was important for it to be care planned to ensure that residents received their antibiotics and completed the full course to help treat the infection. In an interview on 04/28/2026 at 4:14 p.m., the MDS coordinator stated that the nurse who received the order was the one responsible for completing the care plan but if not there then we take care of it. She stated that antibiotics should be care planned within 24 hours. The MDS coordinator stated that if order comes in after 5 or 6 p.m., then during their morning meeting the following day, it will get added to the care plan and their change of condition discussed. She stated she did not know why Resident #6's antibiotic was missed. The MDS coordinator stated if the order comes in on Friday, then it would be reviewed Monday morning. She stated that it might be where it was overlooked. The MDS coordinator stated that the negative outcome would be that the nurses do not know to observe or monitor for an adverse reaction to it. In an interview on 04/29/2026 at 9:39 a.m. with the DON, stated all antibiotics should be care planned. She stated they were all responsible for completing Resident #6's antibiotic care plan. The DON stated antibiotics should be care planned as soon as they receive the order, but it was best practice to care plan them within 3 to 4 days. She stated that they all provide oversight to ensure updates were implemented, and revisions were completed for all changes of conditions during their daily morning meetings. She stated it was important to have antibiotics care planned so that everyone would be aware if there was any change, adverse reaction, or affect. Record review of the facility's Comprehensive Care Plans policy, date revised 10/24/2022 revealed:Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. Record review of the facility's Care Plan Revisions Upon Status Change policy, date revised 10/24/2022 revealed:Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines:1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member.

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one of five Residents (Resident #21) that were reviewed for infection control and transmission-based precautions policies and practices. The facility failed to ensure LVN A sanitized the blood pressure cuff prior to taking Resident #21's blood pressure. This failure could place residents at risk of infection through cross contamination of pathogens and infectious diseases. Findings include: Record review of Resident #21's face sheet dated 04/29/26 reflected an [AGE] year-old female with an original admission date of 04/15/26. Diagnoses included sepsis (life threatening condition caused by the body's extreme and dysregulated response to an infection, leading to organ dysfunction and potentially death), high blood pressure, and type two diabetes (insufficient production of insulin in the body). Record review of Resident #21's admission MDS dated [DATE] revealed a BIMS of 13 (cognition intact) and an active diagnosis of sepsis. During an observation conducted on 04/28/26 at 9:20 am, LVN A was observed applying a blood pressure cuff to Resident #21 after it had been used on another resident without being sanitized between uses. In an interview on 04/28/26 at 9:26 am, LVN A stated that she forgot to disinfect the blood pressure cuff prior to using it on Resident #21. LVN A stated that she was expected to sanitize the equipment between each use. LVN A further stated that the cuff had been used on multiple dialysis residents prior to use on Resident #21. LVN A stated that failure to disinfect the cuff between uses poses risks for cross-contamination and infection. In an interview on 04/29/26 at 9:44am, the DON stated that staff are required to sanitize blood pressure cuffs after each use to prevent the spread of infection. The DON reported that an infection control in-service was initiated on 04/28/26 for LVN A and all staff. The DON sated in-services for infection control in-service was conducted as needed and monthly. The DON stated she and the Infection Preventionist were responsible for overseeing proper infection control practices. The Infection Preventionist was unavailable for interview due to an emergency-related absence from work. Record review of the facility's Infection Prevention and Control Program dated 05/13/23 reflected: Policy This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. 10. Equipment Protocol a. All resuable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #17) of 6 residents reviewed for accuracy and completeness of clinical records. The facility failed to accurately document the correct duration of time for Resident #17's order for enteral nutrition. The order stated the hours were 6:00 AM to 10:00 PM, when the correct duration was 10:00 PM to 6:00 AM. This failure could result in residents' records not accurately reflecting the administration of enteral nutrition and could result in further error including weight gain/loss. The findings included: Record review of Resident #17's face sheet dated 02/10/25 revealed a [AGE] year-old female with an original admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included Alzheimer's Disease and gastrostomy status (surgical procedure that creates an opening in the abdomen and inserts a tube directly into the stomach). Record review of Resident #17's Quarterly MDS Assessment section C, cognitive patterns, dated 12/23/24 revealed a BIMS score of 10 (moderate impairment). Record review of Resident #17's order summary revealed an active order dated 01/17/25 for every night shift [enteral nutrition] at (65ccs per hour) via G-tube stationary pump. RUN Time: (6am to 10pm) Provides: 624 kcal, 29 g pro and 419 mL water, (1020CC total with flush). Record review of Resident #17's comprehensive care plan dated 02/10/25 revealed the problem [Resident #17] requires tube feeding r/t Swallowing problem, Weight loss initiated on 09/24/24. Interventions listed for the problem included: - As per MD orders for feeding tube initiated on 03/31/23. - Enteral Feed AS per MD orders initiated on 03/31/23. In an interview with Resident #17 on 02/10/25 at 11:12 AM, Resident #17 stated she received nutrition from the feeding tube at night while she slept. Resident #17 stated she was not sure about the specific hours that it was on. In an interview with LVN A on 02/11/25 at 2:23 PM, LVN A stated Resident #17 had a G-tube. LVN A stated Resident #17 received nutrition during the night but was not sure about the specific hours. LVN A stated if she was not sure what time the resident received nutrition, she would check the MAR and orders. LVN A stated Resident #17 ate food during the day. LVN A stated if there was a discrepancy in the order she would talk to the DON and call the dietician to confirm what the correct timing was for the order. LVN A stated the order for enteral nutrition showed the duration 6:00 AM to 10:00 PM but she thought it was supposed to be 10:00 PM to 6:00 AM. LVN A stated the audit review on the order showed the dietician, the DON and the MD all saw the order and approved it. LVN A stated an incorrect order like this could result in the resident gaining a lot of weight and the facility would not know why it was happening. In an interview with the ADON on 02/11/25 at 2:42 PM, the ADON stated she ran a report every day showing all new orders from the previous day and reviewed them. The ADON stated she reviewed them for indication, parameters of whether to give the medication or not, and duration. The ADON stated Resident #17 had a G-tube. The ADON stated Resident #17 received nutrition at night through the tube. The ADON stated Resident #17 received breakfast, lunch, and dinner every day as well. The ADON stated if she did not know what hours the G-tube was supposed to run, she would look it up in the MAR or plan of care to see what the correct hours were. The ADON stated the order currently stated the run time was from 6:00 AM to 10:00 PM. The ADON stated the correct time was 10:00 PM to 6:00 AM. The ADON stated this was an order she would have reviewed. The ADON stated if she saw an incorrect order, she would call the person who put in the order to confirm what the order should be. The ADON stated with the order written the way it was the resident could inadvertently receive extra nutrition. In an interview with the DON on 02/11/25 at 2:55 PM, the DON stated the charge nurses reviewed new medication orders. The DON stated she reviewed all new dietician orders. The DON stated when she reviewed orders she looked to see if there were any changes or new recommendations in the orders. The DON stated Resident #17 ate breakfast, lunch, dinner and snacks and received enteral nutrition only at night. The DON stated if she was not sure of the hours of the enteral nutrition, she looked it up in the orders. The DON stated the order in the computer stated the enteral nutrition was from 6:00 AM to 10:00 PM. The DON stated the correct time was 10:00 PM to 6:00 AM. The DON stated when an order for enteral nutrition was not put in correctly the resident was at risk of being overfed or underfed. Record review revealed the facility policy titled Medication Reconciliation implemented 04/10/23 stated the following: 5. Daily Processes: b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. c. Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. e. Verify medications received match the medication orders. 6. Monthly Processes: c. Verify orders printed on new monthly physician order forms and medication administration records match current medication orders.

Based on observation, interview and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission-based precautions to be followed to prevent the spread of infections or diseases for 2 of 4 units reviewed for laundry services. -Laundry Aide A left the laundry bin with clean linens uncovered on units 100 and 200. These failures could affect residents and staff and place them at risk for healthcare associated cross contamination, infections, and COVID-19 (coronavirus). The findings included: Observation on 11/14/23 at 01:50 PM Laundry Aide A delivered clean linens to the 100 care unit. The bin was left uncovered when Laundry Aide A went into a resident's room to deliver clean linen. An unknown resident was observed to grab a pair of socks from the uncovered laundry bin. The surveyor notified Laundry Aide A and the socks were retrieved. Interview on 11/16/23 at 02:39 PM the Administrator stated the Housekeeping Supervisor is out for personal reasons and this surveyor would have no way of contacting her at the moment. Administrator stated she does not know the laundry process. Observation on 11/16/23 at 04:21 PM revealed Laundry Aide A delivered clean linen on the 200 care unit, the laundry bin was left uncovered. A the same time, the ADON observed clean linen being delivered to the 200 care unit hall residents in an uncovered laundry bin by Laundry Aide A. ADON/Infection Control Prevention stated she was going to look at the policy and get back with this surveyor to see what the policy stated about how clean linen should be delivered in care units. During an interview on 11/16/23 at 04:28 PM the ADON/Infection Control Prevention stated the Infection Control Policy was reviewed and laundry bins should have been covered as to prevent cross contamination. The ADON stated in-service will immediately be conducted and the facility would ensure laundry bins are covered at all times while clean linen is being distributed in care units. During an interview on 11/17/23 at 04:25 PM with Laundry Aide A stated she brought the laundry bin full of clean linen covered from outside but once inside, Laundry Aide A stored the laundry bin cover in a utility room when she passed out the clean linen to residents. Laundry Aide A stated she kept the laundry bin uncovered as it was easier to pass out the clean linen. Laundry Aide A stated the laundry bin should be covered at all times while in care unit areas, so residents are not tempted to grab clothing out of the bin and to prevent cross contamination. Laundry Aide A stated she did not know when the last time she in-services on infection control and the procedures of passing out clean linen in care unit areas. Record review of Infection Prevention and Control Program dated 5/13/2023 stated: 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closet

Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 7 residents (Resident # 9) reviewed for pharmacy services, in that; Resident # 9 was administered Memantine (used to treat memory loss/Dementia) at a dose not prescribed. This failure could place residents at risk for not receiving the therapeutic effects of the medications prescribed. The findings included: A record review of Resident # 9's admission record revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included Alzheimer's disease. A record review of Resident # 9's quarterly MDS assessment dated [DATE] revealed Resident # 9 was assessed with a BIMS score of 05 out of 15 which indicated severe cognitive impairment. During an observation of medication administration on 11/16/2023 at 7:15 AM, Medication Aide B Administered Resident # 9 Memantine 10 mgs. A record review of Resident # 9's physician orders summary dated 11/16/2023 revealed Resident # 9 was to receive memantine. 1 tablet, 5 mg, given by mouth two times a day. During an interview with Medication Aide B on 11/16/2023 at 10:30 AM she said the order was for 5 mg, but her pharmacy card had a 10 mg dose. She said she gave the wrong dose of medication. She said she did not check the dose and would notify the physician. During an interview with the DON on 11/16/2023 at 10:40 AM she said the medication cart had a card for 10 mg and a card for 5 mg. She said the medication order had been revised and the old card was not removed from the cart and instead was rubber banded to the new dose. She said she would notify the physician. During an interview with the ADON and the DON on 11/17/2023 at 10:15 AM they said Resident #9 had a GDR for memantine ordered on 10/25/23 for a dose reduction from 10 mg to 5 mg. It was a gradual dose recommendation made by pharmacy. On 11/16/2023 the medication error was discovered. The ADON said the old medication was supposed to be taken out as soon as possible, and it was possible for the medication to be taken out before 11/16/2023. The new medication arrived on 10/25/2023. The ADON said the old medication should have been removed when they received the order, before they got the new medication, and that did not happen. The old medications were left in the medication cart. The ADON said the order was taken by her. The ADON said usually it would be the charge nurses that take the old medications out, but she could have. The ADON said that most of the time the medication aid will verify the medications to ensure it is the right one during routine med passes. There were two medication passes a day for more than three weeks that were wrong. The ADON said the facility failed to remove the discontinued medication and failed to verify the dose of the medication. The ADON said many things could happen to a resident with the wrong medications. The ADON said the breakdown was no one took the old medication out for three weeks. The ADON said the order was probably not communicated. The ADON said the medication aides are supposed to put discontinued medications in a locked cabinet they have access to, and that was not done. The ADON said discontinued medications show up as discontinued on the MAR. The ADON said nurses also communicate medication changes during shift change, and nurses have a 24-hour report as well. A record review of the 24-hour report from 10/25/2023 correctly indicated a change in medication dose for Resident #9's memantine from 10 mg to 5 mg that was written by the ADON. During an interview with the ADON on 11/17/2023 at 10:30 AM she said that discontinued medications are supposed to be taken from the medication cart and left in the med room under two locks and collected at least once a month for destruction. During an interview with the Corporate Nurse on 11/17/2023 at 10:15 AM she said the Pharmacist did a cart check on 11/14/2023. She said the Pharmacist looked to see if there were any expired medications, and they pull them out as well. She said the pharmacy missed it as well, but she does not look at every cart. She said the Pharmacist picks a cart at random and submits what cart she looked at on her report. A record review of the Monthly Consultant Pharmacist Report compiled on 11/14/2023 indicated an expired medication was found in a medication cart. The pharmacist indicated both medication carts were inspected. Record review of facility medication administration policy and procedures dated 10/24/22 indicates mediations are administered by licensed nurses, or other staff who are legally authorized to so in this state, as ordered by a physician and in accordance with professional standards of practice. Staff are required to review MAR to identify medication to be administered. Staff are required to compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route and time.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation: 1. The facility failed to ensure utensils were clean. 2. The facility failed to keep accurate temperature and chemical logs for the dishwasher. 3. The facility failed to dispose of expired foods. These failures could place residents at risk of foodborne illnesses. Findings include: Observation of the kitchen and interview with the DM on [DATE] beginning at 11:30 a.m. revealed a DA pouring coffee into cups on 2 trays. One tray was done, the other cups on the other tray had a removable white residue in them. The DM removed the residue with his thumb. He stated they probably needed to adjust the bleach during the wash cycle. The DM stated the residents could get sick if they served beverages in dirty cups. The DM stated he assumed the white residue was bleach. The DM stated he would not want to drink from one of those cups. The refrigerators had a large, expired container of tomato sauce (identified by the DM) with a prep date of [DATE] and a use-by date of [DATE]. There was a large, expired container of ketchup (identified by the DM) with a prep date of [DATE] and a use-by date of [DATE]. There was a large, expired container of coleslaw (identified by the DM) with a prep date of [DATE] and a use-by date of [DATE]. A record review of the dishwasher temperature logs dated from [DATE] to the present day revealed the same numbers in all columns, on all days and shifts. Observation of the DM on [DATE] at 11:47 a.m. when he took a chemical strip sample of the dishwasher and the result was 50 ppm. Interview with the DA on [DATE] at 11:35 a.m. stated she did not think the empty cups were clean and she was responsible for checking the cups before she poured beverages into them. An interview with the DM on [DATE] at 11:40 a.m. revealed his head cook was responsible for checking the dates on foods in the refrigerators every morning when she checked the refrigerator temperatures. The DM stated another cook took care of the refrigerators when his head cook was not there. The DM stated food had to be discarded or used before the use-by date because it was no longer safe to be consumed after the use-by date and could make the residents sick because bacteria could be growing by then. An interview with the HC on [DATE] at 11:45 a.m. revealed she had been off work for a couple of days. When asked if she had been here yesterday, she stated yes and shrugged her shoulders as to why she did not dispose of the expired foods in the refrigerator. Interview with the DM on [DATE] at 11:47 a.m. stated the logs did not look right, and that the numbers written for the temperatures and chemicals should have some variation; they should go up or down. The DM stated the dietary aids were responsible for entering accurate numbers in the logs. The DM stated the cooks were responsible for the aids, and he was responsible for the cooks and everyone else. The DM stated he had not looked at the logs since he started here ,d+[DATE] months ago because he assumed the staff were taking care of it. The DM stated the point of having temperature and chemical logs was to make sure everything was clean, the temperature was right (to get dishes clean), and the chlorine was right to disinfect and sanitize the dishes. The DM stated he would not be having this problem (residue in the dishes) if the logs were right. The DM stated it was important to have accurate logs, so they could follow trends and take care of problems before the problem. The DM stated he should have been looking at the logs. A request for in-services and training for temperatures and chemical logging for the dishwasher were requested. A record review of the dietary staff time sheets revealed the COOK worked [DATE]-[DATE] and recorded the refrigerator logs but did not dispose of the expired foods in the refrigerator. The HC worked on [DATE] and [DATE] and recorded refrigerator temperatures but did not dispose of the expired foods in the refrigerator. The COOK was unavailable for interview throughout this investigation. Record review of the dishwasher temperature logs dated from [DATE] to the present day revealed the same numbers in all columns, on all days and shifts. The morning wash temperatures and the final rinse temperatures were all documented to be 120F. All sanitizer documentation was 100 ppm. The exception was [DATE], three-compartment sink, where the water temperature was consistently 200F and the sanitizer was consistently 120 ppm. The three-compartment sink was checked twice daily instead of three times daily. There was missing documentation for the three-compartment sink for [DATE]-4, ,d+[DATE], ,d+[DATE], and 29 for the third service. There were no other logs provided for the three-compartment sink. There were no logs at all provided for the months of January, February, March, April, May, July, and [DATE]. Record review of the facility policy titled, Food Receiving and Storage rev. ,d+[DATE] documented 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Record review of the facility policy titled, Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment dated [DATE] documented: 7. a. The temperature of the wash water must be at least 120 degrees Fahrenheit. 7. f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used. A sample Dish Machine Temperature and Sanitizing Log follows this Policy. Record review of the Dish Machine Washing and Sanitizing sample documented: *Wash-120 degrees Fahrenheit *Final Rinse 50 ppm (parts per million) chlorine on dish surface in final rinse . References: FDA Food Code .refrigerated, ready-to-eat, time/temperature controlled for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit for a maximum of 7 days. The day of preparation shall be counted as day 1. TAC 228.111 (p) Warewashing equipment (three-compartment-sink) determining chemical sanitizer concentration: concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Figure: 25 TAC 228.111(n)(1) Sanitizer Concentration range: ,d+[DATE] ppm, when the minimum temperature is 120 degrees Fahrenheit

Based on observation, interview and record review, the facility failed to ensure that resident received adequate assistance with the use of an assistance device for one resident (R#1) of one resident reviewed for accidents and supervision. CNA A and CNA B failed to properly transfer R#1 using a gait belt from bed to wheelchair. The failure placed residents, who required assistance with gait belt transfers at risk for accidents, falls and injuries. Findings included: Review of R#1's quarterly MDS assessment dated [DATE] reflected (R#1) was an [AGE] year-old female who admitted to the facility on [DATE] with a readmitted [DATE]. R#1's active diagnoses included Alzheimer's disease (type of brain disorder that causes problem with memory, thinking), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), heart failure (a progressive heart disease that affects pumping action of the heart muscles), muscle wasting and atrophy (wasting away of muscles), difficulty in walking, muscle weakness, unsteadiness on feet, pain in right knee, hypertension (high blood pressure), cardiomegaly (enlarged heart), and acute kidney failure. Rt#1 had a BIMS score of 09, which indicated moderate cognitive impairment. Resident #1 required substantial/maximal assistance with sit to stand ability. Helper does more than half the effort. Review of Resident #1's care plan, revision on 3/1/2023 reflected R#1 was at high risk for falls related to Alzheimer's and dementia. The goal was to minimize risks and injuries. R#1 has ADL self-care performance deficit related to dementia. Interventions for transfers states R#1 requires total assistance with transfers. Observation on 5/18/2023 at 3:23pm of bed to wheelchair (w/c) transfer of R#1, revealed, CNA A lifted bed to appropriate height. CNA A and CNA B placed gait belt around R#1's waist while R#1 was in bed. First attempt to place gait belt by CNA A and CNA B revealed, gait belt placed twisted around R#1's waist and was unable to be secured. Second attempt, gait belt straightened out by both CNA A and CNA B, but gait belt was backwards, and CNA A was unable to secure gait belt properly. A third attempt was made by both CNA A and CNA B. Gait belt was correctly placed around R#1. CNA B struggled to secure/tighten gait belt and could not fasten gait belt securely around R#1's waist. Gait belt was greater than two fingers width of space and was noticeably loose around R#1. Transfer continued and gait belt remained loose fitting and not secure. R#1 was lifted off bed by both CNA A and CNA. During transfer, gait belt slid all the way up to R#1'a under arms pulling up R#1's shirt exposing her bare back. Both CNAs had to place their arm under R#1's underarms to transfer resident to wheelchair. Interview with CNA A on 5/18/2023 at 3:32pm. CNA A stated, R#1 uses gait belt for transfers and gait belt should be used on every transfer for residents who require assistance with transfers. Gait belt should be placed on the resident securely with no more than two fingers with when checking for secure placement. Gait belt was loose on resident and was greater than two fingers width. If gait belt was not secure, resident was at risk for getting a skin tear, injury or fall. CNA A did not remember when last in person gait belt training was conducted. Interview with CNA B on 5/18/2023 at 4:28pm revealed, gait belts are used every time a resident is transferred. CNA B stated last in-service on transfers/gait belts, was this past Monday or Tuesday but could not remember. CNA B stated the gait belt was greater than two fingers width apart when transferring R#1 and this improper use of the gait belt can cause a skin tear or injury to a resident. CNA B was hired on 4/16/23 at the facility and stated she was nervous during the transfer. Interview with DON, ADON on 5/15/23 at 4:00pm. In-service on gait belts was conducted on 4/21/23 and was in-person training. CNA A and CNA B both attended the gait belt training/in-service. DON and ADON stated they started in-servicing on gait belts as soon as possible. Review of the facility's policy titled; Activities of Daily Living (ADLs) dated 10/24/2022. The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care services will be provided for the following activities of daily living: 2. Transfer and ambulation Review of the facility's transfer procedures and steps (not dated) states: -Review the patient's medical record for cognitive status and wight-bearing or medical precautions that may influence transfer safety -Assess the patient's needs and abilities when making decisions -Gather and prepare the necessary equipment and supplies -Perform hand hygiene -Use proper body mechanics during transfer -Place wheelchair next to the bed, with the wheelchair parallel to or angled slightly to the bed on same side as the patient's univolved or stronger lower extremity -Lock brakes on the wheelchair and the bed -Remove the wheelchair footrests -Ensure the bed is in the lowest position parallel to the floor -Help the patient put on nonskid shoes or slippers -Secure the gait belt around the patient's waist, if necessary.

Based on observation, interview, and record review, the facility failed to ensure that enough water was available in case of a loss of water supply and did not have written procedures defining sources of water, and was unaware of the method for estimating the volume of water required for 1 of 1 facility. There were only 16, 5-gallon jugs of water on hand for a census of 54 residents and employees. This failure could place residents at serious risk for complications from dehydration and sanitation. Findings were: During an observation of the emergency water supply accompanied by the MS on 8/16/22 at 10:58 a.m. revealed 16, 5-gallon jugs of water (80 gallons) for emergency use for a current census of 54. The MS said he was not sure of the exact amount that was to be on hand, and he would have to look it up. He said this was the only place they stored emergency water. Record review of the facility's emergency preparedness, operations 6: OP6 0508.00, Loss of Water Supply revised October 2021, reflected under Procedure; preparation; 1. Each center maintains a supply of drinking water based on specific requirements (see OPS 1511.00, state emergency water requirements.) .at minimum, the center has on hand two gallons of water per resident (2 gallons per resident x 54 residents=108 gallons needed per day) and per employee ( 2 gallons per employee x 57 employees = 114 gallons needed per day) per day for at least three days (108 gallons for residents + 114 gallons for employees =222 gallons x 3 days =666 gallons needed for residents and employees for 3 days) or more for patients who were on medications that required water or were at risk for dehydration. Record review of OP6 1511.00 Policy revised 6/2015, stated: keep at least a three-day (3) supply of water per person; each person will need a gallon each day. (54 residents + 57 employees = 111 x 3 days=333 gallons) Record review of the facility emergency water policy per bottled water company dated 1/1/2020 stated: recommended supply on hand for hurricane season (beginning June 1st): 2 gallons per resident per day, dietary: 40 gallons per day, sanitary: 40 gallons per day. (2 gallons per resident x 54 residents=108 gallons for residents + 40 gallons for dietary =148 gallons + 40 gallons for sanitary =188 total gallons per day, just for residents). Record review of the facility disaster planning policy from another vendor dated February 2022 reflected: this program is separated to make the task of planning your facility's response a little easier and to help [the vendor] serve our customers in the event of a natural disaster or a man-made disaster in order to accomplish this we need certain customer information to be available at our facility included are several forms that describe the 2022 disaster planning policy. It is essential that you review all of the information and complete the last 3 pages and scan or email on or before March 31, 2022 (so they will have the facility's disaster order on file). A record review of a letter from a hospice provider dated 8/17/2022 regarding backup supplies and water for the facility reflected they would serve as a backup for resources (provide supplies and water) for the facility. This letter was not in place at the time of entry on 8/16/22. This letter was not provided until after 4 p.m. on 8/18/22. A record review of a letter on the county emergency management letterhead dated 8/17/22 regarding drinking water and non-potable water reflected they had 2 pallets of drinking water reserved for the facility. This letter was not in place at the time of entry on 8/16/22. This letter was not provided until after 4 p.m. on 8/18/22. During an interview with the ADM on 8/18/22 at 4:02 p.m. revealed she was unaware of their facility policy OP6 0508.00 and asked where the definition was for the amount of water they should have on hand in the policy. The information was provided as outlined above and she said she would have to figure out how many residents she had who were on medications that required water and how many employees in order to tally the figure. She said emergency water was important in case something happened. She also said, the forecast isn't predicting any hurricanes at this time.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchens and 1 of 1 nutrition room. There were personal food items in the kitchen refrigerator and dry storage areas, contaminated and/or broken equipment, the dishwasher temperature was below requirements, the kitchen handwashing sink temperature was above requirements, and there was expired and unlabeled food in the nutrition room. These failures could place residents at serious risk for complications from food contamination. Findings were: During the initial tour on [DATE] beginning at 10:25 a.m., observation of the kitchen and an interview with DS revealed a personal container of a white liquid substance labeled with the initials of the DC. There was a large drinking vessel with a name on it in indelible marker, on a high shelf, in the very back of the dry food storage area. The DS said the container in the refrigerator was not supposed to be there, nor was the container in the dry storage area. She said personal items could be stored in her office or elsewhere, but not in the food storage or food prep areas because of infection control issues that could arise with outside food and/or drink. There was a heavily dented colander hanging in the prep area that the DS wasn't sure if it was being used but could not explain why else it would be there. Three spatulas had severely melted plastic handles, creating deep crevasses and very sharp edges; one of the spatulas had a severely bent and crevassed tip. There was a 10-inch chef knife with chunks missing from the blade and about an inch missing from the tip; it was broken off. The DS removed them from the drawer the utensils were in, in the prep area and said, These should not even be here. She said the utensils were not safe to handle and that they could harbor bacteria. The low-temperature dishwasher water temperature reflected 100 degrees F when observed on [DATE] at 10:25 a.m. and 10:55 a.m. Low temperature dishwashers have a minimum water temperature of 120 degrees F for chemical sanitation, per manufacturer's instructions. The DM said it would get to temperature. After 4 attempts and fifteen minutes, the washer remained at 100 degrees F. The DS said she did not know how long the washer was like that and said they were supposed to be getting a new one but did not know when. The DM confirmed the DS's statement. The DA said the correct running temperature of the dishwasher was supposed to be 120 degrees F. Shesaid she did not know what she was supposed to do if it was not running at temperature. She could not say why the water temperature was important for sanitizing dishes. The DS told her she should tell someone. During an interview with the DC on [DATE] at 10:30 a.m. revealed the personal item in the container wuth the white substance in the kitchen refrigerator belonged to her and she removed it promptly. She said it was not supposed to be in there and offered no explanation as to why it was and was unaware of the potential of cross contamination from outside personal sources being stored with meal prep items. Observation and interview on [DATE] at 11:00 a.m. of the nutrition room, accompanied by Licensed Vocational Nurse (LVN) A revealed the following: a container of an unidentifiable liquid substance with Resident #34's initials and dated [DATE], but the container was not labeled, an unlabeled chocolate bar and an unlabeled 8oz bottle of flavored water, a total of 16, 33.8oz bottles of expired tube feeding formulas: 1 with an expiration date of [DATE], 6 with expiration dates of [DATE], and 8 with expiration dates of [DATE], 10 packets of nutritional powder with expiration dates of [DATE], and 1 33.8oz bottle of tube feeding formula on the shelf, unrefrigerated, unlabeled, opened, and coagulated. LVN A said she thought the kitchen was responsible for the contents in the refrigerator but was not sure. She said she did not know who was responsible for items on the shelves of the nutrition room but thought it might be the nurses. During an observation and interview on [DATE] at 1:57 p.m. of the dishwasher temperature accompanied by the DS, DM, and MS revealed the water temperature was 100 degrees F. Observation further revealed the temperature of the water at the handwashing sink in the kitchen was 138 degrees F. The MS said he would look into it. The DM could not explain why the dishwasher temperature log differed from what had been revealed in the last two days. A record review of the dishwasher temperature log for [DATE] revealed 120 degrees F for every check. During an observation of the food prep area on [DATE] at 2:00 p.m. accompanied by the DS, revealed the same damaged utensils as described above had been replaced into the same drawer they had been removed from previously. The DS immediately removed them again without explanation. During an interview with the MS on [DATE] at 2:32 p.m. regarding the handwashing sink at 138 degrees F revealed: he only went by what the dietary papers say. The MS was informed a water temperature of 138 degrees F could possibly scald the skin in under 5 seconds. He shook his head slowly from side to side and could not produce any policies regarding safe water temperatures.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (#35) of five residents reviewed for infection control practices during personal care: Certified Nurse Aide (CNA) A did not perform hand hygiene between glove changes while providing Resident #35 with incontinent care. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. The findings included: Observation of R #35 on 08/18/22 at 10:12 AM revealed she was escorted from the dining area to her room by CNA A and CNA B. CNA A pulled clean gloves from the box of gloves located on the wall rack, left of the bedroom door. There was a hand sanitizer dispenser affixed to the wall just below the rack of gloves. CNA A then used her gloved hands to remove the gait belt from her wait and put it around Resident #35's waist. CNA A assisted Resident #35 to bed. CNA A removed her gloves, threw them in the trash and grabbed clean gloves and put them on, without performing any hand hygiene. CNA A removed Resident #35's clothing and brief then cleaned Resident #35's vaginal area and her indwelling urinary catheter tubing with cleansing wipes. CNA A removed her gloves and put on clean gloves, without performing hand hygiene and continued to put on a clean brief and clothing on Resident #35. In an interview with CNA A on 08/18/22 at 10:30 AM she stated she changed her gloves twice while providing Resident #35 incontinent care because The gloves were contaminated. When asked, what was the next step to do after contaminated gloves were removed or changed, CNA A paused then said Wash my hands. When asked if she recalled performing hand hygiene between glove changes, CNA A said No. When asked why, CNA A said I got nervous, I guess. CNA A said it was important to perform hand hygiene to prevent infection. CNA A said her last hand hygiene training was approximately one month ago. In an interview with CNA B on 08/18/22 at 10:36 AM revealed she said CNA B did not wash her hands before putting on clean gloves. CNA B said she did not want to interrupt the process by telling CNA A to wash her hands because You were there. CNA B said she was trained to wash her hands between gloves changes to prevent cross-contamination and infection. CNA B said her last hand hygiene training was approximately one month ago. Interview with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) on 08/18/22 at 12:01 PM revealed the ADON said she just observed and evaluated CNA A's hand hygiene and personal care competency March 2022, Which she met competency. The DON said She was nervous because you were watching her. The DON said CNA A should have performed hand hygiene between glove changes. Record review of CNA A's Skills Checklist: Hand Hygiene dated 03/03/22 revealed she met criteria for hand hygiene procedure. CNA A had a Certificate of Completion for incontinent care dated 10/04/21. Record review of the facility's Hand Hygiene policy and procedure dated January 2022 documented .A. Indications for Hand Washing using soap and water include: 1. When hands are visibly dirty or are visibly soiled with blood or other body fluids. 2. Before eating and after using the restroom B. Indications for Hand Hygiene using alcohol-based hand sanitizer include: 1. Before having direct contact with residents . 3. After contact with a resident's intact skin . 4. When hands are not visibly soiled after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings . 7. Before donning gloves. 8. After removing gloves.

Based on interview and record review the facility failed to ensure that an alleged violation involving neglect, was reported immediately, but not later than 2 hours after the allegation was made, if the event that caused the allegation resulted in serious bodily injury, or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one (R#1) of seven residents reviwed for reporting of allegations, in that: The facility did not immediately report an incident of possible neglect involving Resident #1 to the State Agency on 02/19/21. This failure could affect residents and place them at risk of not having allegations reported as required to agencies timely. Findings included: Review of Resident #1's Face Sheet, dated 02/23/21, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Review of Resident #1's Progress Notes revealed a note dated 02/19/21 by the DON (Director of Nurses) reporting the Charge Nurse was informed by Resident Care Specialist (RSC) that Resident #1 was found on the floor near her bed with the remote-control wire wrapped around her neck. Notes revealed Resident #1 was asked by the RSC what happened, and Resident #1 confirmed the attempted suicide, stating she intentionally wrapped the cord around her neck to kill herself. The RSC was not at the facility at the time of the investigation. Attempt to interview the RSC via telephone on 02/23/21 at 1:00 PM, was unsuccessful. Phone call to the RSC was unanswered and unreturned by the time of exit. In an interview on 02/23/21 at 2:30 PM, the DON was asked if the attempted suicide of Resident #1 was reported to the state agency and she said no. The DON said she was informed of the incident and did not feel it needed to be reported to the state because Resident #1 experienced no serious injury. The DON stated incidents were reported to the state only when they resulted in injury to the resident. The DON stated the incident reporting policy followed the chain of command starting with the Charge Nurse, ADON, DON, then Administrator. The reporting to the state was done by the first available of the ADON, DON, and Administrator. In an interview on 02/23/21 at 2:35 PM, the Administrator was asked if the attempted suicide of Resident #1 was reported to the state agency and she said no, she did not feel it needed to be reported to the state because Resident #1 experienced no serious injury. The Administrator stated incidents were reported to the state only when they resulted in injury to the resident. Review of facility policy for Incident/Accident Reporting for Residents dated February 2017 indicated: All incidents, accidents, and unusual occurrences involving a resident are investigated, documented and reported in accordance with Federal and State law. Adverse Event (Significant or Serious Incidents) - An adverse event is an untoward, undesirable, and unusually unanticipated event that causes death or serious injury, or risk thereof. Review of undated facility policy OP2 0304.00 Abuse & Neglect Prohibition Policy Update Summary identified Neglect as follows: Neglect - Expanded to include that neglect applies to the facility, its employees or service providers; 'pain and emotional distress' replaces 'mental illness'. Reporting and Response - New timelines for reporting : 24 hours if there are no allegations of abuse and there is no indication of serious bodily harm.

Based on interview and record review, the facility failed to notify the resident and the resident's representative(s) of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand, for one Resident (R#1) of one resident reviewed for hospitalization s. The facility did not send a transfer or discharge notice in writing to R#1 or R#1's Responsible Party after R#1's transfer to the hospital. This failure could place residents at risk of not having access to available advocacy services, discharge/transfers options and appeal processes. The findings were: Record review of R#1's Admission Record, dated 06/23/19, revealed R#1 was a [AGE] year-old male who was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's annual Minimum Data Set (MDS) assessment, dated 07/02/19, revealed R#1 had severely impaired cognition and required extensive assistance for activities of daily living. Record review of R#1's Progress Note, dated 07/11/19, revealed, patient pick up by air med X 2 attendants to transport to (name of hospital) ER. Left on wheel chair. Patient was made aware of place he was going. Report call in to ER nurse (name of nurse) RN. Also call (name of different hospital) behavioral hospital, spoke to (name of nurse) RN, said was expecting patient. Was assign to room [ROOM NUMBER] BED -2. (name of hospital) ph # (number). (name of hospital) PH # (number). Record review of physician order [REDACTED]. Record review of R#1's clinical record revealed there was no documentation that R#1 or R#1's resident representative (RP) was provided a written transfer notice. In an interview with the DON, the administrator and the regional nurse consultant, on 08/01/19 at 4:15 p.m. they all said their electronic health record system has no notice of transfer or discharge as required by the federal regulation. They said the responsible party as well as the ombudsman were notified by phone. In an interview with the administrator on 08/01/19 at approximately 4:30 p.m. he said he was going to see if he could create a template for the notice of transfer/discharge. The Administrator said Nothing we have can be printed. Paper forms are no longer used. Record review of the facility's policy titled Transfer or Discharge Procedure Revision Date: (MONTH) (YEAR), revealed: Procedure: Transfer or Discharge 1. The facility assists with the preparation and orientation of the resident to ensure safe and orderly transfer or discharge from the facility. 2. Nursing staff completes the Resident Transfer form (Electronic Health Record) if the resident is transferring to an acute health care facility or another nursing facility. The information provided to the receiving provider must include at minimum: a. Contact information of the practitioner responsible for the care of the resident; b. Resident representative's contact information; c. Advance Directive information; d. All special instructions or precautions for ongoing care, as appropriate; e. Comprehensive care plan goals; f. A copy of the Physician Discharge Summary; and g. All other necessary information or documentation to ensure a safe and effective transition of care.

Based on interview and record review, the facility failed to ensure that Resident #1 (R#1) received treatment and care in accordance with professional standards of practice for one (R#1) of four residents reviewed for quality of care, in that: Facility nursing staff did not consult with the physician when R#1 was resistive to the collection of a urine sample from 07/02/19 to 07/07/19 for a urinalysis (UA) to monitor and/or treat a possible urinary tract infection. These failures could affect residents who required lab work as prescribed by a physician and could result in a decline in health. Findings include: Record review of R#1's Admission Record, dated 06/23/19, revealed R#1 was a [AGE] year-old male who was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's annual Minimum Data Set (MDS) assessment, dated 07/02/19, revealed R#1 had severely impaired cognition and required extensive assistance for activities of daily living. Record review of R#1's Physician order [REDACTED]. Record review of R#1's SBAR Communication Form and Progress Note dated 07/02/19 revealed Patient got new order to check ammonia level, CMP and a UA with C&S due to behaviors. Orders carried out. Responsible party made aware. Record review of the facility's 24-Hour Report/Change of Condition Reports reflected for R#1: 07/02/19: resistive to collecting urine; continue to attempt; UA not able to collect. 07/03/19: Attempted to collect UA, resistive continue to attempt. Labs done. Needs U[NAME] 07/04/19: Attempt to collect UA-combative X2; collect UA Friday. 07/05/19: Resident resistive to care-Unable to collect UA; collect UA Sunday; X1 to collect unsuccessful. 07/06/19 agitated, foul language-monitor behaviors; collect UA Sunday. 07/07/19: UA collected. Record review of R#1's Nursing Progress Notes dated 07/07/19 revealed UA collected on resident, clean catch. Record review of R#1's clinical record revealed there were no Nursing Progress Notes from 07/02/19 through 07/06/19 for R#1. In an interview with the DON on 08/01/19 at 2:10 p.m. regarding whether they contacted R#1's physician about not being able to collect the urine sample because the resident was combative, the DON said, I don't think we would have, because that's his behavior. In an interview with R#1's physician on 08/01/19 at 2:30 p.m. he stated the facility should have contacted him or his office when the facility staff were unable to collect the urine sample after several attempts. R#1's physician said he would have ordered that the resident be sent out to the emergency room or that they give the resident an injection of antibiotics [MEDICATION NAME]. In an interview with the DON and the ADON on 08/01/19 at 2:45 p.m. both said that they found no documentation that anyone had called the doctor to report the facility's inability to collect the urine sample for R#1. On 08/01/19 at approximately 3:00 p.m. when asked for policy regarding procedures to follow when facility staff are unable to carry out physician orders [REDACTED]. Record review of facility policies titled: Standards of Nursing Practice, Revision Date: (MONTH) (YEAR); Routine Resident Care, Revised: (MONTH) 2011; and Changes in Resident Condition, Revised: (MONTH) (YEAR), revealed none of these policies addressed resident combativeness or procedures to follow when nursing staff were unable to carry out physician orders.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control and prevention program designed to provide a safe, sanitary and comfortable environment including handwashing and prevent the development and transmission of communicable disease, for two (#51, #57) of 14 residents reviewed for infection control practices. 1.) Certified Nurse Aides A and B did not perform hand hygiene between gloves changes while providing R #51 with incontinent care, per the facility's policy/procedure. 2.) Certified Nursing Assistant (CNA) D: - Did not doff her gloves and washed/hand sanitized her hands after folding up R #57's dirty brief and throwing it into R #57's trashcan. -Did not wash/hand sanitized her hands and don clean gloves prior to touching R #57's clean brief. -Touched R #57's call light with the same dirty gloves on that were used through the entire course of R #57's incontinent care. This failure could place at least 52 residents occasionally or frequently incontinent of bladder and bowel at risk for infections. The findings included: R #51's Face Sheet dated 09/13/18 documented a [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. Observation of R #51 on 09/11/18 at 10:16 AM revealed she was lying on her right side in bed, with her eyes closed, with her HOB elevated. R #51 did not respond/awaken to verbal stimuli. On 09/11/18 at 3:37 PM CNA A and CNA B entered R #51's room and informed the R #51 of the care to be provided. CNA A verified that R #51 was unable to speak and was totally dependent on staff for all activities of daily living. Both staff washed their hands prior to donning gloves. After CNA B cleaned R #51's buttocks of feces, she doffed her gloves and immediately donned clean gloves (without performing hand hygiene). At 3:48 p.m., CNA A doffed her gloves then immediately donned clean gloves (without performing hand hygiene) then continued to apply a clean brief on R #51 and positioned her to her right side. Simultaneous interview with CNA A and B on 09/11/18 at 03:51 PM revealed they were asked what they had been taught to do after removing gloves, CNA B stated wash my hands. Both staff said they changed their gloves because they were dirty. CNA B said she did not wash or sanitize her hands because she was trying to hurry up because she did not want the surveyor to get tired of watching. CNA B removed a bottle of hand sanitizer from her right pant pocket to show the surveyor she carried it with her. -R #57 R #57's Face Sheet documented an [AGE] year-old female admitted to the facility on [DATE] with Cerebral Infarction ( a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Diabetes Mellitus (high blood glucose), Dysphagia (Difficulty in swallowing), Difficulty in walking, Right shoulder pain, Cognitive Communication Deficit (problems with communicating), [MEDICAL CONDITION] (excessive body fat that increases the risk of health problems), Chronic Ischemic [MEDICAL CONDITION] (narrowed arteries leading to less blood and oxygen reaches the heart muscle), Aphonia (loss of ability to speak through disease of or damage to the larynx or mouth), [MEDICAL CONDITION] (paralysis of one side of the body), [MEDICAL CONDITION] (weakness on half of the body), [MEDICAL CONDITION] (degeneration of peripheral nerves that spreads toward the center of the body). Review of R #502's Care Plan dated 03/08/18 indicated: -R #57 has actual elimination deficit related to bladder incontinence, bowel incontinence, chronic constipation. Provide assistance as required for toileting total care times 2. - R #57 had episodes of bladder incontinence r/t (related to) disease process ataxia ( loss of full control of bodily movements), impaired mobility. Toileting plan: prompt upon rising, before and after meals, and at bedtime, and as needed. - R #57 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t immobility, physical limitations.' - R #57 had ADL (activities of daily living) self-care performance deficit r/t my [MEDICAL CONDITION]. Toilet use: R #57 is totally dependent on 2 staff for toilet use. - R #57 is incontinent of bowel r/[MEDICAL CONDITION]. Check R #57 frequently and assist with toileting as needed. Provide pericare after each incontinent episode. -R #57 has [MEDICAL CONDITION] and [MEDICAL CONDITION]. Observe/document bladder and bowel function. R #57's Quarterly Minimum (MDS) data set [DATE] revealed R #57 required extensive assistance with 2-person physical assistance for bed mobility, transferring, dressing, toileting, personal hygiene, and limited assistance requiring 1 person physical assist in eating. R #57 was always incontinent of the bladder and bowel. Record review of R #57's Braden Scale for Predicting Pressure Score Risk dated 09/09/18 revealed a Braden Risk Scale Score of 15 and is at risk. Observation on 09/10/18 at 1:19 PM of R #57 in room [ROOM NUMBER]-A with CNA (Certified nursing assistant) E and CNA D. CNA D and CNA E each washed their hands for over 20 seconds, and donned clean gloves in R #57's restroom. CNA E lowered R #57's bed to the lowest position, and CNA D placed a gait belt around R #57's waist. Both CNA D and CNA E lifted R #57 from w/c to standing position and transferred R #57 onto her bed from R #57's w/c (wheelchair). CNA D removed R #57's blue pants and raised R #57's bed to waist height. CNA D unfastened R #57's brief, and wiped each side of R#57's peri area with a clean wipe for each side. CNA D and CNA E turned R #57 onto her left side. CNA D wiped R #57's buttocks. Observed R #57's back, buttocks, and legs with no rashes, redness, bruising, or sores. CNA D took out a clean brief without doffing her gloves, washing/hand sanitizing her hands and donning clean gloves prior to touching R #57's clean brief. CNA D threw the dirty wipes into R #57's dirty brief and rolled up dirty brief prior to throwing it in the trashcan. CNA D did not doff her gloves nor hand sanitized her hands prior to placing the clean brief under R #57's buttocks. CNA D handed R #57 the call light with the same dirty gloves still on. CNA D then doffed her gloves and washed her hands afterwards. Interview on 09/10/18 at 1:29 PM CNA D confirmed she did not doff her gloves and wash/hand sanitize her hands and stated, I'm supposed to remove my gloves and hand sanitize/wash my hands before I (CNA D) placed her (R #57) clean brief. I (CNA D) should have taken my gloves off and wash my hands prior to handing R #57 her call bell. CNA D stated, It's important as it prevents contamination and spreading of germs. The facility's Glove Use Policy dated 2012 documented To provide guidelines for the use of gloves for resident and employee protection .E. Perform hand hygiene after removing gloves Review of the facility's Hand Hygiene guidelines dated (MONTH) (YEAR) documented, Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Employees must wash their hands for at least 20 seconds using soap and water and must rub hands together until all of the alcohol-based hand rub has dried when used under the following conditions: -Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens (such as [MEDICAL CONDITION] and bacillus anthracis) is strongly suspected or proven, and after using the restroom. -Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, and after contact with inanimate objects in the patient's environment. The facility's Center for Medicaid and Medicare Services form 672 dated 09/10/18 listed a census of 71 residents; a sample of 17 residents was chosen. Form 672 identified 52 residents observed for incontinent care of the bladder and 37 residents observed for incontinent care of the bowel.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and [DIAGNOSES REDACTED]. The dietary manager failed to have the appropriate license, certification, or qualifications to function as the food service supervisor. This failure could place the 62 residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: On 09/10/18 the current Food Service Supervisor (FSS) said I am enrolled in a Certified Dietary Manager's course and have not yet started the course. On 09/11/18 an interview was conducted with the facility Administrator. Surveyor asked if the current FSS was certified. The Administrator replied no, the FSS was not certified at this time. Surveyor asked the Administrator does the Consultant Dietitian work full time at this facility . The Administrator replied no. Record review of former FSS's personnel file revealed - the former FSS's termination date from this facility was 08/29/18. Review of the facility's Job Description Dietary Manager revised 09/13/18 indicated Entry Qualifications Successful completion of a course approved by the Dietary Managers's Association. Review of Texas Food Establishment Rules §228.33 Certified Food Protection Manager and Food Handler Requirements §228.33(a) states: At least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program. Review of the facility's CMS form 672 (Resident Census and Conditions of Residents) dated 09/10/18 confirmed a census of 62 oral fed (receiving nourishment either through regular diet or mechanically altered) residents.

Based on observation, interview, and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, for two (R #51, R and #57) of 14 residents reviewed for personal care, in that: 1.) Certified Nurse Aides A and B did not perform hand hygiene between gloves changes while providing R #51 with incontinent care, per the facility's policy/procedure. 2.) Certified Nursing Assistant (CNA) D: - Did not doff her gloves and washed/hand sanitized her hands after folding up R #57's dirty brief and throwing it into R #57's trashcan. -Did not wash/hand sanitized her hands and don clean gloves prior to touching R #57's clean brief. -Touched R #57's call light with the same dirty gloves on that were used the entire course of R #57's incontinent care. This failure could place at least 52 residents occasionally or frequently incontinent of bladder and bowel at risk for infections. The findings included: R #51's Face Sheet dated 09/13/18 documented a [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. Observation of R #51 on 09/11/18 at 10:16 AM revealed she was lying on her right side in bed, with her eyes closed, with her HOB elevated. R #51 did not respond/awaken to verbal stimuli. On 09/11/18 at 3:37 PM CNA A and CNA B entered R #51's room and informed the R #51 of the care to be provided. CNA A verified that R #51 was unable to speak and was totally dependent on staff for all activities of daily living. Both staff washed their hands prior to donning gloves. After CNA B cleaned R #51's buttocks of feces, she doffed her gloves and immediately donned clean gloves (without performing hand hygiene). At 3:48 p.m., CNA A doffed her gloves then immediately donned clean gloves (without performing hand hygiene) then continued to apply a clean brief on R #51 and positioned her to her right side. Simultaneous interview with CNA A and B on 09/11/18 at 03:51 PM revealed they were asked what they had been taught to do after removing gloves, CNA B stated wash my hands. Both staff said they changed their gloves because they were dirty. CNA B said she did not wash or sanitize her hands because she was trying to hurry up because she did not want the surveyor to get tired of watching. CNA B removed a bottle of hand sanitizer from her right pant pocket to show the surveyor she carried it with her. Review of CNA B's Skills Checklist dated 04/26/18 documented she demonstrated and was validated as having met the basic personal skills of glove usage, standard precautions, and perineal care Review of CNA A's Skills Checklist dated 04/30/18 documented she demonstrated and was validated as having met the basic personal skills of glove usage, standard precautions, and perineal care. - R#57 R #57's Face Sheet documented an [AGE] year-old female admitted to the facility on [DATE] with Cerebral Infarction ( a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Diabetes Mellitus (high blood glucose), Dysphagia (Difficulty in swallowing), Difficulty in walking, Right shoulder pain, Cognitive Communication Deficit (problems with communicating), [MEDICAL CONDITION] (excessive body fat that increases the risk of health problems), Chronic Ischemic [MEDICAL CONDITION] (narrowed arteries leading to less blood and oxygen reaches the heart muscle), Aphonia (loss of ability to speak through disease of or damage to the larynx or mouth), [MEDICAL CONDITION] (paralysis of one side of the body), [MEDICAL CONDITION] (weakness on half of the body), [MEDICAL CONDITION] (general degeneration of peripheral nerves that spreads toward the center of the body). Review of R #502's Care Plan dated 03/08/18 indicated: -R #57 has actual elimination deficit related to bladder incontinence, bowel incontinence, chronic constipation. Provide assistance as required for toileting total care times 2. - R #57 had episodes of bladder incontinence r/t (related to) disease process ataxia ( loss of full control of bodily movements), impaired mobility. Toileting plan: prompt upon rising, before and after meals, and at bedtime, and as needed. - R #57 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t immobility, physical limitations.' - R #57 had ADL (activities of daily living) self-care performance deficit r/t my [MEDICAL CONDITION]. Toilet use: R #57 is totally dependent on 2 staff for toilet use. - R #57 is incontinent of bowel r/[MEDICAL CONDITION]. Check R #57 frequently and assist with toileting as needed. Provide pericare after each incontinent episode. -R #57 has [MEDICAL CONDITION] and [MEDICAL CONDITION]. Observe/document bladder and bowel function. R #57's Quarterly Minimum (MDS) data set [DATE] revealed R #57 required extensive assistance with 2-person physical assistance for bed mobility, transferring, dressing, toileting, personal hygiene, and limited assistance requiring 1 person physical assist in eating. R #57 was always incontinent of the bladder and bowel. Record review of R #57's Braden Scale for Predicting Pressure Score Risk dated 09/09/18 revealed a Braden Risk Scale Score of 15 and is at risk. Observation on 09/10/18 at 1:19 PM of R #57 in room [ROOM NUMBER]-A with CNA (Certified nursing assistant) E and CNA D. CNA D and CNA E each washed their hands for over 20 seconds, and donned clean gloves in R #57's restroom. CNA E lowered R #57's bed to the lowest position, and CNA D placed a gait belt around R #57's waist. Both CNA D and CNA E lifted R #57 from w/c to standing position and transferred R #57 onto her bed from R #57's w/c (wheelchair). Observed R #57's blue jean pants wet with urine on R #57's behind and R #57's blue jean pants was removed by CNA D. CNA D raised R #57's bed to waist height, unfastened R #57's brief, and wiped each side of R#57's peri area with a clean wipe for each side. CNA D and CNA E turned R #57 onto her left side. CNA D wiped R #57's buttocks. Observed R #57's back, buttocks, and legs with no rashes, redness, bruising, or sores. CNA D took out a clean brief without doffing her gloves, washing/hand sanitizing her hands and donning clean gloves prior to touching R #57's clean brief. CNA D threw the dirty wipes into R #57's dirty brief and rolled up dirty brief prior to throwing it in the trashcan. CNA D did not doff her gloves nor hand sanitized her hands prior to placing the clean brief under R #57's buttocks. CNA D handed R #57 the call light with the same dirty gloves still on. CNA D then doffed her gloves and washed her hands afterwards. Interview on 09/10/18 at 1:29 PM CNA D confirmed she did not doff her gloves and wash/hand sanitize her hands and stated, I'm supposed to remove my gloves and hand sanitize/wash my hands before I (CNA D) placed her (R #57) clean brief. I (CNA D) should have taken my gloves off and wash my hands prior to handing R #57 her call bell. CNA D stated, It's important as it prevents contamination and spreading of germs. The facility's Glove Use Policy dated 2012 documented To provide guidelines for the use of gloves for resident and employee protection .E. Perform hand hygiene after removing gloves Review of the facility's Hand Hygiene guidelines dated (MONTH) (YEAR) documented, Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Employees must wash their hands for at least 20 seconds using soap and water and must rub hands together until all of the alcohol-based hand rub has dried when used under the following conditions: -Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens (such as [MEDICAL CONDITION] and bacillus anthracis) is strongly suspected or proven, and after using the restroom. -Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, and after contact with inanimate objects in the patient's environment. The facility's Center for Medicaid and Medicare Services form 672 dated 09/10/18 listed a census of 71 residents; a sample of 17 residents was chosen. Form 672 identified 52 residents observed for incontinent care of the bladder and 37 residents observed for incontinent care of the bowel.

Based on observation, interview, and record review the facility failed to ensure residents receive necessary treatment and services, consistent with professional standards of practice, to prevent infection, pressure ulcer development, and/or deterioration of an existing pressure ulcer for one (R #25) of eight residents reviewed and identified as at risk for pressure ulcer/injury development. The facility failed to correctly identify and stage R #25's facility acquired left heel pressure ulcer according to the facility's policy and the National Pressure Ulcer Advisory Panel. This deficient practice could place five resident identified as having pressure ulcers and seven residents receiving preventive skin care at risk for infection, pressure ulcer development, and/or pressure ulcer deterioration. The findings included: R #25's Face Sheet dated 09/13/18 documented a [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #25's Significant Change Minimum (MDS) data set [DATE] documented R #25: -had a brief interview of mental status of 14 (cognitively intact); -required extensive assist with one or two person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene; -was at risk of pressure ulcer development; no ulcers present upon admission, prior assessment, re-entry. R #25's Purchase Order dated 06/07/18 documented Pressure Relief Shoe Medium. R #25's Physician order [REDACTED]. R #25's Care Plan dated 07/13/18 documented: ·I have ADL self-care performance deficit related to Impaired balance. ·I will be at optimal level of function. Nursing staff to review within the next 90 days ·BED MOBILITY: The resident is totally dependent on (X) 1 staff for repositioning and turning in bed frequently and as necessary. ·SHOWERING: she requires total help by one staff member ·DRESSING: Allow sufficient time for dressing and undressing. ·DRESSING: The resident is totally dependent on X (1) staff for dressing. ·ORAL CARE ROUTINE assist (resident) with oral care every am and pm and prn ·PERSONAL HYGIENE requires total care x1 staff member ·TOILET USE: The resident is totally dependent on 2 staff for toilet use. use Hoyer lift ·TRANSFER: The resident uses gait belt and x 1 to maximize independence with transferring. ·Encourage the resident to participate to the fullest extent possible with each interaction . ·I have a actual/potential for impaired skin integrity r/t disease process, limited mobility, weight, fragile skin, poor nutrition admitted with callous to left heal and multiple discolorations to bilateral upper extremities I sit for long periods of time due to [MEDICAL TREATMENT] treatments 07/18/18 - I have a diabetic ulcer of the left foot related to Diabetes. Lack of sensation to affected area, poor glycemic control, [MEDICAL CONDITION], vascular insufficiency .ensure appropriate protective devices are applied to affected areas; observe/document wound size, depth, margins; pressure ulcer to left heel: SN to cleanse with normal saline pat dry with gauze, apply no sting barrier, allow to dry, cover with foam and rolled gauze daily till healed . 7/24/18-rash/excoriation buttocks-[MEDICATION NAME] powder ·I will be improve skin integrity through the review date. ·Encourage good nutrition and hydration in order to promote healthier skin. ·Identify potential causative factors and eliminate/resolve when possible. ·Inform/instruct staff of causative factors and measures to prevent skin breakdown. ·Keep skin clean and dry. Use lotion on dry scaly skin. ·Observe/document location, size and treatment of [REDACTED]. to Medical Doctor. ·RCS to apply moisturizing lotion to bilateral lower extremities to prevent dryness. ·The resident needs cushion while in chair. ·The resident needs offloading while in bed and have heel protection when out of bed. ·The resident needs pressure relief mattress to protect the skin while in bed. ·The resident needs their nails kept short to reduce risk of scratching or injury from picking at skin. ·Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface . R #25's Physician order [REDACTED]. R #25's Braden Scale for Predicting Pressure Sore Risk dated 08/14/18 documented a score of 16- at risk. R #25's Skin Head to Toe Skin Check dated 09/04/18 documented Skin intact . Observation and interview of R #25 on 09/11/18 at 11:34 AM revealed Registered Nurse (RN) C/Treatment Nurse was in R #25's room, on the floor, assessing R #25's feet due to R #25 complaining of pain to her left heel. RN C removed R #25's left foot black boot and exposed a black/brown closed discolored area with an intersecting area of purple discoloration that was also closed. The bottom aspect of the surrounding skin appeared yellow in color. R #25's ankles and feet were noticeably swollen. RN C said the wound was a Deep Tissue Injury. RN C was asked if the wound formation was attributed to R #25's special boot; RN C stated I don't know, it could if it is too tight. She does have frequent swelling of her feet that could cause the boot to feel tighter. At 11:42 p.m., the Assistant Nurse of Director (ADON) entered the room to assess R #25's left heel wound. At this time. RN C measured R #25's wound as the ADON held up R #25's left leg. RN C said 1.2 X 2.1 centimeters (cm). The surveyor asked RN C what color the center scab presented to her and she stated It has black, it feels hard and dry, and the purple side feels soft. It could be that it was a blister and it burst and now the skin is black. None of this was there yesterday because I (RN C)have been checking it daily. She (R #25) had a yellow closed callous in that area but I was watching it because she has developed ulcers in the same area before. Again RN C confirmed R #25's left heel did not have the black and purple discoloration or blister on 09/10/18. R #25 stated she felt pain to her left heel therefore she asked the nurse to check it. R #25 confirmed she used her heels to propel her wheelchair for mobility. R #25 verified she had a history of [REDACTED]. The ADON stated R #25 had the special boot for off-loading purposes. The ADON said she was going to order R #25 another boot but In a larger size. R #25's Skin - Weekly Pressure Ulcer Record dated 09/11/18 documented Left Heel: Date of Onset: 09/11/18: Pressure Suspected Deep Tissue Injury (SDTI) 1.2 X 2.1 X 0.00 cm, color charcoal, deep purple to maroon with yellow color to surrounding edges, no drainage. Calloused wound edges, increased pigmentation and hardening of the skin with swelling. R #25's Braden Scale for Predicting Pressure Sore Risk dated 09/11/18 documented a score of 16- at risk. An addition to R #25's Care Plan revealed Date initiated 09/11/18: I have a Suspected Deep Tissue Injury to my left heel that was caused by my rubbing my foot against the floor to self propel .Assess site daily and report any abnormalities; treatment to left heel as ordered; use of offloading shoe when out of bed; weekly skin assessment. R #25's Physician order [REDACTED]. R #25's physician's orders [REDACTED]. Interview with the ADON on 09/13/18 at 11:01 AM revealed she was presented a copy of R #25's Skin-Weekly Pressure Ulcer Record dated 09/11/18. The ADON verified R #25's left heel pressure ulcer was identified as a SDTI. ADON said she agreed with the wound being a SDTI. When RN was asked how she ruled out the wound being an unstageable she stated We assess the wound and we also investigate how the wound developed. We asked (R #25) how she was propelling and she said she was propelling herself in her wheelchair using her heels. The wound also was not there the day before because (RN C) was checking it daily. One part of the wound was darker and the other part was purple. ADON was asked if she agreed that R #25's wound bed had black tissue covering a part of the wound bed and RN said yes. ADON said The black area was not a scab that overlayed the top layer of the skin like a scab you get from a cut, it was deeper than the top layer of the skin, it was attached to the skin. ADON confirmed R #25's black layer of tissue was determined to feel hard. The ADON explained that sometimes when a blood blister flattened, the tissue turned black. The surveyor informed ADON that R #25's prior assessments did not include an identification of a blood-filled blister, the ADON said she had not seen or knew of R #25 having an actual blood-filled blister. The surveyor asked how the assessor or she could assume R #25's black tissue was an effect from a blood-filled blister when a blister was not identified, ADON did not respond. The ADON read out loud the definition of a SDTI from R #25's Skin Weekly Pressure Ulcer Record saying Deep Tissue Injury- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent skin. The surveyor asked the ADON if the description of R #25's wound met the definition of the definition of a SDTI however, the ADON did not respond. ADON showed the surveyor documentation from a binder she had entitled Wound Care Education Institute 2011 and referred the surveyor to page 28 and read out loud Suspected Deep Tissue Injury: 1. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear . 4. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The surveyor asked ADON if R #25 was confirmed to have a blister at any time, the ADON replied No. The ADON asked if she could go back and edit the assessment to provide a more detailed description of the wound. RN stated it was important to ensure the assessment and staging of pressure ulcers was correct to ensure the resident received the most accurate treatment. Further review of the facility's Wound Care Education Institute 2011 Binder revealed page 27, Unstageable: 1. Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. 2. Unable to visualize true depth of tissue destruction. 3. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore, stage, cannot be determined. 4. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Record review of R #25's Nurse's/Progress Notes, Head to Toe Assessments, and Weekly Skin Pressure Ulcer Assessments dated 09/10/18-09/13/18 at 2:46 p.m. revealed there no other documentation of R #25's left heel pressure ulcer. The facility's (MONTH) (YEAR) Skin Management System documented Policy: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes Staging Classification: The following Staging Classification is consistent with the National Pressure Ulcer Advisory Panel (NPUAP) . Unstageable - Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the depth is obscured by slough (dead tissue, usually cream or yellow in color) or eschar (dead tissue; dry black hard necrotic tissue). If sough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer may be revealed. Stable eschar (ie. dry, adherent, intact, without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. When eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided. Identify/document as eschar covered area, as unable to determine depth and stage, etc. Eschar in the wound may be covered by yellow, tan, brown, black in color. Unstageable wounds may be covered by yellow, tan, gray, green, or brown slough. When the slough and/or eschar covering an Unstageable pressure ulcer has been debrided or removed, the ulcer should be reassessed for appropriate staging . Suspected Deep Tissue Injury - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, pruple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister is present. Pain and temperature change often precede skin color changes. This wound results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The area may be preceded by tissue that is firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss even with optimal treatment. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (Unstageable, Stage 3 or Stage 4) . According to the National Pressure Ulcer Advisory Panel website (http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/) searched on 09/12/18 revealed: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. -Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Additional pressure injury definitions. Medical Device Related Pressure Injury: This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. The facility's Centers for Medicare and Medicaid Services Form 672 identified five residents with pressure ulcers and seven residents receiving preventative skin care.

Based on observation, interview and record review, the facility failed to complete an accurate assessment of one Resident, (R#10), of 15 Residents reviewed for accuracy of assessments. The facility did not accurately assess R#10's behaviors, cognitive impairment and amount of assistance needed with activities of daily living on the most recent Minimum Data Set (MDS). This failure could cause 70 residents to have care plans that did not accurately address their needs. The findings were: Review of R#10's Face Sheet dated 10/18/17 revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. R#10's [DIAGNOSES REDACTED]. R#10 was [AGE] years old. Observation at 11:00 on 10/17/17 revealed some clothing was on the floor just inside R#10's room. R#10 was standing inside her room, looking out into the hall. R#10 did not respond when spoken to. Review of R#10's annual MDS (Minimum Data Set) (Resident Assessment Instrument-RAI) dated 11/17/16 revealed she usually understood others and was sometimes understood by others. The BIMS (Brief Interview for Mental Status) was not completed because R#10 had moderately impaired cognition. R#10 had no behavior concerns. R#10 required limited assistance with the help of one person with dressing, toileting and hygiene, and was occasionally incontinent of bowels and bladder. R#10 was totally dependent with the help of one staff person for assistance with bathing (4/2). Review of Psychologist' Complete Evaluation of R#10 dated 02/27/17 revealed she was referred for a psychological evaluation and treatment due to cognitive, emotional, behavioral and social problems. R#10 had a [MEDICAL CONDITION], with multiple depressive episodes, and was treated with an antidepressant medication. R#10 has had episodes of [MEDICAL CONDITION]. Her current medical [DIAGNOSES REDACTED]. R#10's demeanor was flat and revealed a depressed mood. Disorganized and bizarre behavior had been observed. Psychotic or borderline psychotic symptoms were present, with disorganized thoughts which affected her words (word salad). R#10 displayed uncooperative behavior during the examination. Review of R#10's most recent quarterly MDS dated [DATE] revealed she usually understood others and was sometimes understood. R#10 displayed inattention and disorganized thinking but was cognitively independent. R#10 could dress, ambulate and transfer without assistance, but was still rated as being totally dependent on one staff person for assistance with bathing (4/2). R#10 was occasionally incontinent of bowel but was continent of bladder. Review of R#10's Psychiatric assessment dated [DATE] revealed she was incoherent and MR (mentally retarded). R#10 had lived with her mother and was potty trained but was unable to learn at school so she was not sent to school. R#10 had a history of [REDACTED]. Review of R#10's Care Plan revealed: 05/19/17: Hoards salt, pepper, sugar packets 08/16/17: Had a potential/actual safety risk related to not wanting the call light in her room. 09/30/17: Putting paper towels down the toilet, which tended to clog the toilet. 09/19/17: R#10 was able to self shower three times a week and as needed with limited assistance X 1 staff member 08/16/17: Had behavior problems related to mental illness. 10/15/17: Was resistive to care related to not liking staff to take her out of her room. R#10 chose to wear the same clothes and hang her clothes on the curtain around her bed in her room. 10/15/17: Could be verbally aggressive, when family or staff tried to tell her what to do if she did not want to do it. 02/13/17: Had impaired cognitive function or impaired thought processes related to ID and would sometimes slam her mattress and yell in her room using foul language. 08/16/17: Would isolate herself and not come out of her room. 07/21/17: Had psychosocial well-being problems related to dependent behavior. In an interview at 3:00 p.m. on 10/18/17, when shown R#10's MDS dated [DATE]; the MDS dated [DATE], and R#10's Care Plan, the MDS Coordinator said R#10 was able to shower herself most of the time and required limited assistance. The MDS Coordinator said Resident Care Specialists (RCSs) used the computer system to document assistance that they provide to residents with ADLs. The MDS Coordinator retrieved the documentation that RCSs had put into the computer for October, 2017, for assistance with R#10's ADLs. Review of the ADL log of the PCC (Point Click Care) system for October, 2017 revealed R#10 frequently did not bathe. The following documentation was noted on the October, 2017 ADL performance log for bathing, all documented on the 6:00 a.m. to 2:00 p.m. shift: 10/03/17: 3/2 (extensive assistance with the help of one person) 10/10/17: 1/1 (supervision with set up help only) 10/12/17: 2/2 (limited assistance with the help of one person) 10/14/17: 4/2 (totally dependent with the help of one person) 10/15/17: 1/1 (supervision with set up help only) In the interview at 3:00 p.m. on 10/18/17, the MDS Coordinator said R#10 refused showers quite a bit and said that the variation in documentation of how much assistance R#10 required with showers could be because of her behaviors or could be because of who was doing the documenting in PCC. The MDS said the MDS assessments should show that R#10 had behavior problems and the MDSs that showed she had no behavior problems were inaccurate. The MDS Coordinator said R#10 was not independent in her ability to make decisions and said this was an incorrect entry on the MDS dated [DATE]. In an interview at 3:50 p.m. on 10/18/17 with the MDS Coordinator, Administrator and District Director of Care Management (DDCM), surveyor asked if the 4/2 (total dependence with the help of one person) was a correct assessment for the type of assistance R#10 needed with bathing. The MDS Coordinator said she would review the PCC records for bathing for R#10 for the weeks prior to the MDS to see why the MDS was coded as 4/2 for bathing. These records were not provided to surveyor prior to exit. In an interview at 11:05 a.m. on 10/19/17 with the MDS Coordinator and the DDCM, when asked if the MDS Coordinator should enter into the MDS record the average ability of the resident to perform ADLs, and the average amount of assistance that the resident needed with ADLs, the DDCM said the MDS Coordinator should enter information into the MDS that reflects the resident's usual ability to perform the ADL task, and the usual amount of assistance needed with that task. Review of the RAI Process Policy and Procedure, revised February 2017, revealed the purpose of the RAI was to comply with federal requirements for care planning. The RAI was used at the facility to provide the care giving staff with ongoing assessment information necessary to develop a resident care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status. The MDS provided a core set of screening, clinical, and functional status elements that formed the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicare or Medicaid. The facility was expected to use resident observation, communication, and interview as the primary source of information when completing the MDS. This observation and communication must be in real time. In addition to direct resident observation and communication, the facility should use a variety of other sources, to include communication with licensed and non-licensed staff members on all shifts. This may include discussions with the resident's physician, family members, or outside consultants, as well as review of the resident's medical record. Review of Form 672 dated 10/18/17 revealed there were 70 residents in the facility at the time of entrance on 10/16/17.

Based on observation, interview and record review the facility failed to provide proper hydration for one Resident (R #2) of six Residents reviewed for hydration and infections. The facility was aware R #2 was at risk for dehydration but did not implement their written policy to identify the risk and prevent associated complications. R #2 was sent to the hospital with dehydration, [MEDICAL CONDITION], septic shock and [MEDICAL CONDITION]. R #2 remained in the hospital during this investigation. These deficient practices placed 60 residents with hydration issues at risk of not receiving proper hydration assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #2's Face Sheet dated 05/13/14 revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 sometimes understood others; sometimes made self understood; did not reject care; was not dehydrated; required one person physical assistance with eating; was totally dependent on staff for dressing, toilet use and personal hygiene; and was incontinent of bowel and bladder. R #2's Care Plan "Weight Loss/Nutrition" dated 08/18/14 revealed R #2 was a "potential" weight loss/nutrition risk related to mental illness and skin conditions. Approaches included to provide meal assistance as needed. R #2's Physician order [REDACTED].#2 did not have an order for [REDACTED]. R #2's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. R #2's Telephone Order dated 09/12/14 revealed an order to send R #2 to the emergency room . R #2's Nurses Notes revealed the following: -09/11/14: There was no evidence R #2 was assessed, -09/12/14 at 1:00 a.m.: "...(No signs or symptoms) of distress. Comfort and safe (measures) maintained. Call light within reach." R #2's "Resident Transfer Form" dated 09/12/14 at 8:50 a.m. revealed: "... CNA reported to nurse resident 'not wanting to eat.' Upon assessment vital signs as noted below (Blood pressure 88/40, pulse 60, respirations (illegible), temperature 101, blood sugar 202) ... Resident was up feeding self yesterday ..." R #2's emergency room Record dated 09/12/14 at 10:02 a.m. from Hospital "AA" revealed R #2: -Was unresponsive and "critical", -Was intubated (a tube inserted through the mouth or nose to provide oxygen for breathing), -Had a fever of 100.5 and blood pressure of 58/30. R #2's History and Physical dated 09/12/14 from Hospital "AA" revealed R #2 was admitted to ICU with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] "likely secondary" to [MEDICAL CONDITION], -Acute [MEDICAL CONDITION], -Rhabdomyolysis secondary to dehydration "causing the [MEDICAL CONDITION]." The History and Physical revealed R #2's "Prognosis is very poor." R #2's laboratory results dated [DATE] from Hospital "AA" revealed: -Sodium 161, High, -Blood/urea/nitrogen 102, High, -Creatinine 7.2, High, -Estimated GFR (kidney function) 8, Low, -White blood cells 39.4, High. The laboratory results dated [DATE] indicated R #2 may have had dehydration, kidney failure and an infection. According to www.nlm.nih.gov/medlineplus/ency/article/ 8.htm on 09/19/14 entitled Septic Shock, "...Septic shock is a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure ... This may lead to ... poor organ function ... Septic shock is a medical emergency ... Septic shock has a high death rate ..." According to www.nlm.nih.gov/medlineplus/ency/article/ 3.htm on 09/19/14 entitled Rhabdomyolysis, "...Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage ... Problems that may lead to this disease include: ... severe dehydration ..." Observation of R #2 at Hospital "AA" on 09/16/14 at 10:30 a.m. revealed R #2 lying in bed with his eyes open and he was breathing on his own. R #2 did not respond to investigator's questions. According to www.ncbi.nlm.nih.gov/pubmed/ 951 on 09/22/14 entitled "Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision", an adult's average daily fluid consumption should be approximately 1500 milliliters (mL) per day. R #2's "Resident Input by Day Chart" dated 08/17/14 through 09/11/14 revealed R #2's total daily fluid intakes were: -08/17/14: 480 mL, -08/18/14: 480 mL, -08/19/14: 840 mL, -08/20/14: 240 mL, -08/21/14: 240 mL, -08/22/14: 1080 mL, -08/23/14: 240 mL, -08/24/14: 840 mL, -08/25/14: 680 mL, -08/26/14: 480 mL, -08/27/14: 240 mL, -08/28/14: 0 mL, -08/29/14: 720 mL, -08/30/14: 480 mL, -08/31/14: 680 mL, -09/01/14: 240 mL, -09/02/14: 0 mL, -09/03/14: 360 ml, -09/04/14: 360 mL, -09/05/14: 0 mL, -09/06/14: 580 mL, -09/07/14: 220 mL, -09/08/14: 0 mL, -09/09/14: 0 mL, -09/10/14: 360 mL, -09/11/14: 0 mL. R #2's Physician order [REDACTED].#2 did not have an order for [REDACTED]. On 09/16/14 at 3:20 p.m., Licensed Vocational Nurse (LVN) "A" stated it was the facility's policy to document a resident's daily fluid intake when a resident was at risk for dehydration. LVN "A" stated the Certified Nurse Aides (CNAs) documented the fluid intakes. LVN "A" stated she did not know who monitored residents' documented fluid intakes. LVN "A" stated a resident's condition and vital signs would be documented in the nurses notes, and if there was no documentation, it "wasn't done." On 09/16/14 at 4:20 p.m., LVN "B" stated it was the facility's policy to document a resident's daily fluid intake when a resident was at risk for dehydration. LVN "B" stated the CNAs documented the fluid intakes. LVN "B" stated she was "not sure" who monitored resident's documented fluid intakes. On 09/16/14 at 4:55 p.m., CNA "C" stated it was the facility's policy to document a resident's daily fluid intake. CNA "C" stated the CNAs documented the fluid intakes. CNA "C" stated she was "not sure" who monitored the fluid intakes. CNA "C" stated monitoring would prevent urinary tract infections and dehydration. On 09/16/14 at 5:10 p.m., CNA "D" stated it was the facility's policy to document a resident's daily fluid intake. CNA "D" stated the CNAs documented the fluid intakes. CNA "D" stated she was "not sure" who monitored the fluid intakes. CNA "D" stated the purpose of documenting fluid intakes was to "make sure (a resident was) not dehydrated." On 09/16/14 at 5:20 p.m., LVN "A" stated the purpose of documenting a resident's daily fluid intake was to "make sure if the resident is retaining fluid, dehydrated, skin breakdown, can shut down kidneys." LVN "A" stated R #2 was monitored for dehydration every day and the monitoring was charted in the nurses notes. R #2's Nurses Notes and "SBARs" (an assessment form) dated 09/09/14 through 09/12/14 revealed no evidence R #2 was consistently assessed for dehydration. On 09/16/14 at 5:40 p.m., the Director of Nurses (DON) stated resident's documented daily fluid intakes were monitored by the interdisciplinary team and discussed by the interdisciplinary team during morning meetings. The DON stated she was not aware of any resident who did not have adequate fluid intakes. On 09/16/14 at 5:55 p.m., the Administrator stated it was the facility's policy to document a resident's daily fluid intake. The Administrator stated he did not "know who monitors fluid intakes." The facility's "Weight/Hydration Management" Policy dated 02/2010 indicated: "...The Federal Regulations (F-Tag 327) also indicate that residents are provided with sufficient fluid intake to maintain proper hydration and health..." The policy did not indicate how the facility ensured residents were provided sufficient fluids. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 09/16/14 revealed 60 residents with hydration issues. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing proper hydration. As of exit on 09/16/14 at 6:40 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to implement their written policy and procedure that prohibits neglect for one Resident (R #2) of six Residents reviewed for hydration and infections. The facility was aware R #2 was at risk for dehydration but did not implement their written policy to identify the risk and prevent associated complications. R #2 was sent to the hospital with dehydration, [MEDICAL CONDITION], septic shock and [MEDICAL CONDITION]. R #2 remained in the hospital during this investigation. These deficient practices placed 60 residents with hydration issues at risk of not receiving proper hydration assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: The facility's "Abuse & Neglect Prohibition" Policy dated 06/2013 indicated: "... Each resident has the right to be free from mistreatment, neglect ... Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ..." The facility's "Weight/Hydration Management" Policy dated 02/2010 indicated: "...The Federal Regulations (F-Tag 327) also indicate that residents are provided with sufficient fluid intake to maintain proper hydration and health..." The policy did not indicate how the facility ensured residents were provided sufficient fluids. R #2's Face Sheet dated 05/13/14 revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 sometimes understood others; sometimes made self understood; did not reject care; was not dehydrated; required one person physical assistance with eating; was totally dependent on staff for dressing, toilet use and personal hygiene; and was incontinent of bowel and bladder. R #2's Care Plan "Weight Loss/Nutrition" dated 08/18/14 revealed R #2 was a "potential" weight loss/nutrition risk related to mental illness and skin conditions. Approaches included to provide meal assistance as needed. R #2's Physician order [REDACTED].#2 did not have an order for [REDACTED]. R #2's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. R #2's Telephone Order dated 09/12/14 revealed an order to send R #2 to the emergency room . R #2's Nurses Notes revealed the following: -09/11/14: There was no evidence R #2 was assessed, -09/12/14 at 1:00 a.m.: "...(No signs or symptoms) of distress. Comfort and safe (measures) maintained. Call light within reach." R #2's "Resident Transfer Form" dated 09/12/14 at 8:50 a.m. revealed: "... CNA reported to nurse resident 'not wanting to eat.' Upon assessment vital signs as noted below (Blood pressure 88/40, pulse 60, respirations (illegible), temperature 101, blood sugar 202) ... Resident was up feeding self yesterday ..." R #2's emergency room Record dated 09/12/14 at 10:02 a.m. from Hospital "AA" revealed R #2: -Was unresponsive and "critical", -Was intubated (a tube inserted through the mouth or nose to provide oxygen for breathing), -Had a fever of 100.5 and blood pressure of 58/30. R #2's History and Physical dated 09/12/14 from Hospital "AA" revealed R #2 was admitted to ICU with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] "likely secondary" to [MEDICAL CONDITION], -Acute [MEDICAL CONDITION], -Rhabdomyolysis secondary to dehydration "causing the [MEDICAL CONDITION]." The History and Physical revealed R #2's "Prognosis is very poor." R #2's laboratory results dated [DATE] from Hospital "AA" revealed: -Sodium 161, High, -Blood/urea/nitrogen 102, High, -Creatinine 7.2, High, -Estimated GFR (kidney function) 8, Low, -White blood cells 39.4, High. The laboratory results dated [DATE] indicated R #2 may have had dehydration, kidney failure and an infection. According to www.nlm.nih.gov/medlineplus/ency/article/ 8.htm on 09/19/14 entitled Septic Shock, "...Septic shock is a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure ... This may lead to ... poor organ function ... Septic shock is a medical emergency ... Septic shock has a high death rate ..." According to www.nlm.nih.gov/medlineplus/ency/article/ 3.htm on 09/19/14 entitled Rhabdomyolysis, "...Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage ... Problems that may lead to this disease include: ... severe dehydration ..." Observation of R #2 at Hospital "AA" on 09/16/14 at 10:30 a.m. revealed R #2 lying in bed with his eyes open and he was breathing on his own. R #2 did not respond to investigator's questions. According to www.ncbi.nlm.nih.gov/pubmed/ 951 on 09/22/14 entitled "Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision", an adult's average daily fluid consumption should be approximately 1500 milliliters (mL) per day. R #2's "Resident Input by Day Chart" dated 08/17/14 through 09/11/14 revealed R #2's total daily fluid intakes were: -08/17/14: 480 mL, -08/18/14: 480 mL, -08/19/14: 840 mL, -08/20/14: 240 mL, -08/21/14: 240 mL, -08/22/14: 1080 mL, -08/23/14: 240 mL, -08/24/14: 840 mL, -08/25/14: 680 mL, -08/26/14: 480 mL, -08/27/14: 240 mL, -08/28/14: 0 mL, -08/29/14: 720 mL, -08/30/14: 480 mL, -08/31/14: 680 mL, -09/01/14: 240 mL, -09/02/14: 0 mL, -09/03/14: 360 ml, -09/04/14: 360 mL, -09/05/14: 0 mL, -09/06/14: 580 mL, -09/07/14: 220 mL, -09/08/14: 0 mL, -09/09/14: 0 mL, -09/10/14: 360 mL, -09/11/14: 0 mL. R #2's Physician order [REDACTED].#2 did not have an order for [REDACTED]. On 09/16/14 at 3:20 p.m., Licensed Vocational Nurse (LVN) "A" stated it was the facility's policy to document a resident's daily fluid intake when a resident was at risk for dehydration. LVN "A" stated the Certified Nurse Aides (CNAs) documented the fluid intakes. LVN "A" stated she did not know who monitored residents' documented fluid intakes. LVN "A" stated a resident's condition and vital signs would be documented in the nurses notes, and if there was no documentation, it "wasn't done." On 09/16/14 at 4:20 p.m., LVN "B" stated it was the facility's policy to document a resident's daily fluid intake when a resident was at risk for dehydration. LVN "B" stated the CNAs documented the fluid intakes. LVN "B" stated she was "not sure" who monitored resident's documented fluid intakes. On 09/16/14 at 4:55 p.m., CNA "C" stated it was the facility's policy to document a resident's daily fluid intake. CNA "C" stated the CNAs documented the fluid intakes. CNA "C" stated she was "not sure" who monitored the fluid intakes. CNA "C" stated monitoring would prevent urinary tract infections and dehydration. On 09/16/14 at 5:10 p.m., CNA "D" stated it was the facility's policy to document a resident's daily fluid intake. CNA "D" stated the CNAs documented the fluid intakes. CNA "D" stated she was "not sure" who monitored the fluid intakes. CNA "D" stated the purpose of documenting fluid intakes was to "make sure (a resident was) not dehydrated." On 09/16/14 at 5:20 p.m., LVN "A" stated the purpose of documenting a resident's daily fluid intake was to "make sure if the resident is retaining fluid, dehydrated, skin breakdown, can shut down kidneys." LVN "A" stated R #2 was monitored for dehydration every day and the monitoring was charted in the nurses notes. R #2's Nurses Notes and "SBARs" (an assessment form) dated 09/09/14 through 09/12/14 revealed no evidence R #2 was consistently assessed for dehydration. On 09/16/14 at 5:40 p.m., the Director of Nurses (DON) stated resident's documented daily fluid intakes were monitored by the interdisciplinary team and discussed by the interdisciplinary team during morning meetings. The DON stated she was not aware of any resident who did not have adequate fluid intakes. On 09/16/14 at 5:55 p.m., the Administrator stated it was the facility's policy to document a resident's daily fluid intake. The Administrator stated he did not "know who monitors fluid intakes." The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 09/16/14 revealed 60 residents with hydration issues. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing proper hydration. As of exit on 09/16/14 at 6:40 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to implement their policy and procedure that prohibits neglect for one Resident (R #2) of six Residents reviewed for hydration and infections. The facility was aware R #2 was at risk for dehydration but did not implement their written policy to identify the risk and prevent associated complications. R #2 was sent to the hospital with dehydration, [MEDICAL CONDITION], septic shock and [MEDICAL CONDITION]. R #2 remained in the hospital during this investigation. These deficient practices placed 60 residents with hydration issues at risk of not receiving proper hydration assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #2's Face Sheet dated 05/13/14 revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R #2 sometimes understood others; sometimes made self understood; did not reject care; was not dehydrated; required one person physical assistance with eating; was totally dependent on staff for dressing, toilet use and personal hygiene; and was incontinent of bowel and bladder. R #2's Care Plan "Weight Loss/Nutrition" dated 08/18/14 revealed R #2 was a "potential" weight loss/nutrition risk related to mental illness and skin conditions. Approaches included to provide meal assistance as needed. R #2's Physician order [REDACTED].#2 did not have an order for [REDACTED]. R #2's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. R #2's Telephone Order dated 09/12/14 revealed an order to send R #2 to the emergency room . R #2's Nurses Notes revealed the following: -09/11/14: There was no evidence R #2 was assessed, -09/12/14 at 1:00 a.m.: "...(No signs or symptoms) of distress. Comfort and safe (measures) maintained. Call light within reach." R #2's "Resident Transfer Form" dated 09/12/14 at 8:50 a.m. revealed: "... CNA reported to nurse resident 'not wanting to eat.' Upon assessment vital signs as noted below (Blood pressure 88/40, pulse 60, respirations (illegible), temperature 101, blood sugar 202) ... Resident was up feeding self yesterday ..." R #2's emergency room Record dated 09/12/14 at 10:02 a.m. from Hospital "AA" revealed R #2: -Was unresponsive and "critical", -Was intubated (a tube inserted through the mouth or nose to provide oxygen for breathing), -Had a fever of 100.5 and blood pressure of 58/30. R #2's History and Physical dated 09/12/14 from Hospital "AA" revealed R #2 was admitted to ICU with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] "likely secondary" to [MEDICAL CONDITION], -Acute [MEDICAL CONDITION], -Rhabdomyolysis secondary to dehydration "causing the [MEDICAL CONDITION]." The History and Physical revealed R #2's "Prognosis is very poor." R #2's laboratory results dated [DATE] from Hospital "AA" revealed: -Sodium 161, High, -Blood/urea/nitrogen 102, High, -Creatinine 7.2, High, -Estimated GFR (kidney function) 8, Low, -White blood cells 39.4, High. The laboratory results dated [DATE] indicated R #2 may have had dehydration, kidney failure and an infection. According to www.nlm.nih.gov/medlineplus/ency/article/ 8.htm on 09/19/14 entitled Septic Shock, "...Septic shock is a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure ... This may lead to ... poor organ function ... Septic shock is a medical emergency ... Septic shock has a high death rate ..." According to www.nlm.nih.gov/medlineplus/ency/article/ 3.htm on 09/19/14 entitled Rhabdomyolysis, "...Rhabdomyolysis is the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood. These substances are harmful to the kidney and often cause kidney damage ... Problems that may lead to this disease include: ... severe dehydration ..." Observation of R #2 at Hospital "AA" on 09/16/14 at 10:30 a.m. revealed R #2 lying in bed with his eyes open and he was breathing on his own. R #2 did not respond to investigator's questions. According to www.ncbi.nlm.nih.gov/pubmed/ 951 on 09/22/14 entitled "Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision", an adult's average daily fluid consumption should be approximately 1500 milliliters (mL) per day. R #2's "Resident Input by Day Chart" dated 08/17/14 through 09/11/14 revealed R #2's total daily fluid intakes were: -08/17/14: 480 mL, -08/18/14: 480 mL, -08/19/14: 840 mL, -08/20/14: 240 mL, -08/21/14: 240 mL, -08/22/14: 1080 mL, -08/23/14: 240 mL, -08/24/14: 840 mL, -08/25/14: 680 mL, -08/26/14: 480 mL, -08/27/14: 240 mL, -08/28/14: 0 mL, -08/29/14: 720 mL, -08/30/14: 480 mL, -08/31/14: 680 mL, -09/01/14: 240 mL, -09/02/14: 0 mL, -09/03/14: 360 ml, -09/04/14: 360 mL, -09/05/14: 0 mL, -09/06/14: 580 mL, -09/07/14: 220 mL, -09/08/14: 0 mL, -09/09/14: 0 mL, -09/10/14: 360 mL, -09/11/14: 0 mL. R #2's Physician order [REDACTED].#2 did not have an order for [REDACTED]. On 09/16/14 at 3:20 p.m., Licensed Vocational Nurse (LVN) "A" stated it was the facility's policy to document a resident's daily fluid intake when a resident was at risk for dehydration. LVN "A" stated the Certified Nurse Aides (CNAs) documented the fluid intakes. LVN "A" stated she did not know who monitored residents' documented fluid intakes. LVN "A" stated a resident's condition and vital signs would be documented in the nurses notes, and if there was no documentation, it "wasn't done." On 09/16/14 at 4:20 p.m., LVN "B" stated it was the facility's policy to document a resident's daily fluid intake when a resident was at risk for dehydration. LVN "B" stated the CNAs documented the fluid intakes. LVN "B" stated she was "not sure" who monitored resident's documented fluid intakes. On 09/16/14 at 4:55 p.m., CNA "C" stated it was the facility's policy to document a resident's daily fluid intake. CNA "C" stated the CNAs documented the fluid intakes. CNA "C" stated she was "not sure" who monitored the fluid intakes. CNA "C" stated monitoring would prevent urinary tract infections and dehydration. On 09/16/14 at 5:10 p.m., CNA "D" stated it was the facility's policy to document a resident's daily fluid intake. CNA "D" stated the CNAs documented the fluid intakes. CNA "D" stated she was "not sure" who monitored the fluid intakes. CNA "D" stated the purpose of documenting fluid intakes was to "make sure (a resident was) not dehydrated." On 09/16/14 at 5:20 p.m., LVN "A" stated the purpose of documenting a resident's daily fluid intake was to "make sure if the resident is retaining fluid, dehydrated, skin breakdown, can shut down kidneys." LVN "A" stated R #2 was monitored for dehydration every day and the monitoring was charted in the nurses notes. R #2's Nurses Notes and "SBARs" (an assessment form) dated 09/09/14 through 09/12/14 revealed no evidence R #2 was consistently assessed for dehydration. On 09/16/14 at 5:40 p.m., the Director of Nurses (DON) stated resident's documented daily fluid intakes were monitored by the interdisciplinary team and discussed by the interdisciplinary team during morning meetings. The DON stated she was not aware of any resident who did not have adequate fluid intakes. On 09/16/14 at 5:55 p.m., the Administrator stated it was the facility's policy to document a resident's daily fluid intake. The Administrator stated he did not "know who monitors fluid intakes." The facility's "Abuse & Neglect Prohibition" Policy dated 06/2013 indicated: "... Each resident has the right to be free from mistreatment, neglect ... Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness ..." The facility's "Weight/Hydration Management" Policy dated 02/2010 indicated: "...The Federal Regulations (F-Tag 327) also indicate that residents are provided with sufficient fluid intake to maintain proper hydration and health..." The policy did not indicate how the facility ensured residents were provided sufficient fluids. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 09/16/14 revealed 60 residents with hydration issues. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing proper hydration. As of exit on 09/16/14 at 6:40 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to conduct a comprehensive assessment that was accurate for one Resident (R #6) of two residents reviewed who were new admissions. R #6's Minimum Data Set did not accurately reflect her pressure ulcer status. R #6 was admitted to the facility on [DATE] for treatment of [REDACTED]. A skin assessment was not conducted at admission on R #6's entire body. The facility had not addressed the area of eschar on R #6's right inner medial ankle. Fourteen days after being admitted R #6 was assessed and found with two unstageable pressure ulcers under the dressing/gauze; one pressure ulcer on her right inner medial ankle and one pressure ulcer on her right outer foot. This failure placed any of the 24 new admissions at risk for inaccurate care and services. The findings were: R #6's Face Sheet dated 05/29/13 indicated R #6 was admitted to the facility on [DATE]. R #6 was [AGE] years old. R #6's Five Day Admission Minimum Data Set ((MDS) dated [DATE] revealed R #6 had clear speech, had clear comprehension and was able to make herself understood. R #6's cognition was intact and R #6 was non-ambulatory. The MDS revealed R #6 was at risk of developing pressure ulcers. The MDS indicated R #6 did not have a Stage one or higher pressure ulcer or any un-stageable pressure ulcers. The area of eschar on R #6's right inner medial ankle was not indicated on the MDS. R #6's Hospital Progress Notes dated 05/21/13 revealed R #6 had a Right Ankle Fracture with an External Fixation Application (the use of plates and screws or a rod to stabilize the bone; holes are drilled into uninjured areas of bones around the fracture and special bolts or wires are screwed into the holes. Outside the body, a rod or a curved piece of metal with special ball-and-socket joints joins the bolts to make a rigid support). The Progress Notes indicated R #6 had a black eschar (According to Mosby's Medical Dictionary, 9th Edition, p. 644 Eschar is defined as "a scab or dry crust that results from trauma) on her medial (middle) aspect of her right ankle. R #6's Hospital Discharge Orders dated 05/23/13 revealed her Discharge [DIAGNOSES REDACTED]. Discharge instructions for wound care were "Elevate right lower extremity to decrease swelling. May apply ice as needed. Continue pin care, 1/2 Normal Saline and 1/2 hydrogen peroxide. Keep operation sites clean and dry. May change dressings daily. Do not apply creams or lotions. Do not debride area of eschar to medial ankle, allow it to continue to demarcate (separate), it will come off on its own." Review of the R #6's entire medical binder revealed there were no other admission orders [REDACTED]. R #6's Consolidated Physician's Orders dated June 2013 revealed R #6 [DIAGNOSES REDACTED]. The Consolidated Physician's Orders indicated R #6 was to have a head to toe skin check assessment weekly with a start date of 05/23/13. The Consolidated Physician's Orders did not address the area of eschar on R #6's right medial ankle or how often dressing changes were to be completed. R #6's Nursing Admission assessment dated [DATE] indicated R #6's admitting [DIAGNOSES REDACTED]. R #6 required bed rest. The Nursing Admission Braden Scale for Predicting Pressure Sore Risk, attached to the Nursing Admission Assessment, indicated R #6 scored an 11 and was a "High Risk for Pressure Sores." The Braden Scale indicated a total score of 12 or less represented a "High Risk for Pressure Sores." The Nursing Admission Assessment indicated if a risk score was 18 or less and/or skin integrity problems were identified, initiate an Interdisciplinary Team (IDT) referral and care plan. The Nursing Assessment indicated additional risk factors for R #6 were incontinence and impaired/decreased mobility and decreased functional ability. The Nursing Admission Assessment had forms with an outline of the human body and locations of skin conditions/wounds were to be marked on the outline. The External Fixation to R #6's right foot was indicated on the picture. There was no indication on the forms of the area of eschar on R #6's right inner medial ankle. The assessment indicated if a pressure ulcer was present, initiate daily and weekly pressure ulcer documentation forms. The Nursing Admission Assessment was signed by Licensed Vocational Nurse (LVN) "G." The admitting nurse, LVN "G", stated in a telephone interview on 06/06/13 at 2:50 p.m. she had admitted R #6 into the facility. LVN "G" stated she completed a head to toe assessment of R #6 and R #6 had an incision. LVN "G" stated she did not remember seeing a pressure ulcer but she did not look at R #6's fractured foot. LVN "G" said she did not take off the dressing/gauze on R #6's fractured foot because the dressing had just been put on R #6's foot at the hospital. LVN "G" stated the treatment nurse was to change R #6's dressing on a daily basis and clean the pin sites with saline. R #6's Initial Plan of Care dated 05/23/13 indicated R #6 had a surgical site and the goal of the Care Plan was for R #6's skin to remain intact without signs of breakdown by the next review. R #6's surgical wound would show signs of healing with area decreasing in overall size and depth by next review. The Care Plan indicated R #6 required assistance with Activities of Daily Living (ADLs, bathing, grooming, toileting). There was not an indication R #6 had an area of eschar on her right inner medial ankle or that any interventions were initiated to ensure R #6 did not develop pressure ulcers. R #6's Care Plan for Non-Pressure Ulcer Skin Impairment dated 05/23/13 indicated the IDT had initiated a Care Plan for R #6's pin sites to the Right External Fixation. The goal of the Plan was for the surgical site to heal without complications by 90 days. The approaches to be utilized by nursing staff were to observe skin weekly and document findings, wound care as ordered, and document observation of any non-pressure related skin impairments. The Care Plan for Non-Pressure Ulcer Skin Impairments did not address the area of eschar on R #6's right inner medial ankle. R #6's Non-Pressure Skin Condition Record dated 05/23/13 indicated R #6 had "external brace to fx (fracture) R (right) (lower) ext (extremity) with pin site to right outer and inner ankle. As well as 2 pin sites on right ("shen") area." There was not an indication on the Non-Pressure Skin Condition Record that R #6 had an area of eschar on her right inner medial ankle. Review of R #6's entire medical chart with Director of Nursing (DON) "A" and Licensed Vocational Nurse (LVN) "B" present revealed there was not a Head to Toe Skin Check for R #6 dated for May 2013. Review of R #6's medical binder revealed there was not a daily or weekly pressure ulcer documentation form. R #6's Treatment Administration Record (TAR) for Weekly Skin Check/assessment dated [DATE] through 05/31/13 revealed no documentation of a weekly Skin Check from 05/23/13 through 05/31/13. R #6's Head to Toe Skin Checks form dated 06/2013 did not have any documentation that indicated a Head to Toe Skin Check had been conducted in June 2013. R #6's TAR for Weekly Skin Check/assessment dated [DATE] through 06/06/13 had no documentation R #6 had a weekly Skin Check from 06/01/13 through 06/06/13. Weekly Pressure Ulcer Record dated 06/06/13, not signed indicated R #6 had an "unstageable" (According to Centers for Medicare Medicaid Services, an unstageable ulcer is defined as an ulcer related to the coverage of a wound bed by eschar, full thickness tissue loss and/or the base of the ulcer is covered by eschar) pressure ulcer 7.3 centimeters (cm) by 3 cm to her right outer lateral plantar (bottom surface) foot, date of onset 06/06/13. The Weekly Pressure Ulcer Record indicated under "Description of Stages: Unstageable was to be coded as a Stage IV on the Minimum Data Set (MDS)." Weekly Pressure Ulcer Record dated 06/06/13 and completed by the Regional Consultant Registered Nurse indicated R #6 had an "unstageable pressure ulcer" 2.0 cm by 2.8 cm to her right inner ankle area, date of onset 06/06/13. The Weekly Pressure Ulcer Record indicated under "Description of Stages: Unstageable was to be coded as a Stage IV on the MDS." R #6 stated in an interview on 06/05/13 at 2:50 p.m. since she had been admitted to the facility two weeks ago it was "the worst treatment ever." R #6 said she had complained to the Social Worker (SW) "C" on 06/03/13 that she (R #6) had not had wound treatment or a check of all of her foot that was covered with gauze since she had arrived at the facility. R #6 stated all the nurses had done was unwrap the gauze/dressing where the external fixation was attached to her leg and wipe off the pin sites. R #6 stated the nurses had not even cleaned the tape residue or iodine off her leg from the surgery at the hospital. R #6 stated the nurses had not removed the immobilizer boot (orthopedic boot used to immobilize ankle fractures/foot fractures) and checked her right foot. Observation of R #6's foot and leg on 06/05/13 at 2:50 p.m. revealed R #6's right foot was elevated on a foam cushion. Her right lower leg, from the knee down to her toes was wrapped in gauze and the external fixation protruded from different areas in her right leg. Her leg was in an immobilizer boot with Velcro straps across the top. R #6 stated in an interview on 06/06/13 at 12:45 p.m. a nurse had cleaned her foot and leg this morning (06/06/13). R #6 stated "it took them two weeks to start treatment on my foot." R #6 said the nurse had taken off the immobilizer boot and gauze/dressing and looked at her entire right foot. R #6 said she had two pressure ulcers. LVN "B" stated in an interview on 06/06/13 at 1:20 p.m. she was not able to locate a Skin Assessment for R #6 for 05/29/13 or 05/30/13. The surveyor reviewed R #6's medical binder with LVN "B" present. LVN "B" stated that on 05/29/13 R #6 had returned to the facility from [MEDICAL TREATMENT] treatment and R #6 was in pain. LVN "B" stated she remembered telling the LVN/Treatment Nurse (LVN/TN) "D" she (LVN/TN "D") needed to do a Skin Assessment. LVN "B" stated she did not remember if LVN/TN "D" completed the Skin Assessment. LVN "B" stated as of the morning of 06/06/13 R #6 was assessed and had two new "pressure sores" on her right foot. LVN "B" reviewed the discharge records from the hospital with the surveyor present and stated she did not know why the physician wrote "may change dressings daily." LVN "B" stated the physician could have written to change dressings daily if he wanted the dressing on R #6's foot changed every day. LVN "B" stated she had left the physician a telephone message 06/06/13 to verify the order for dressing changes from 05/23/13. LVN "B" stated the admitting nurse should have clarified the Physician's Order when R #6 was admitted . The Administrator stated in an interview, with the DON "H" present, on 06/06/13 at 2:10 p.m., R #6's right foot had not been assessed for a pressure ulcer due to R #6 had a dressing and an immobilizer. DON "H" nodded her head up and down when asked by the surveyor if it was good nursing practice to remove a dressing and immobilizer when performing skin assessments. Resident Care Manager/LVN (RCM/LVN) "F" stated in an interview on 06/06/13 at 3:20 p.m. the development of a Care Plan for Pressure Ulcers was the responsibility of the DON and himself. RCM/LVN "F" stated there had not been an initial Care Plan completed for R #6 regarding her area of eschar on her right inner medial foot when she was admitted . RCM/LVN "F" said if the admitting LVN had documented R #6's initial area of eschar the area of eschar would have been discussed at the next morning meeting and a Care Plan developed that addressed the removal of R #6's dressing and immobilizer. RCM/LVN "F" said "this was not done." LVN/TN "D" stated in a telephone interview on 06/06/13 at 4:50 p.m. she had not completed the Weekly Skin Assessment on R #6 when R #6 was admitted . LVN/TN "D" said the admitting nurse had completed the first Skin Assessment at the time of admission. LVN/TN "D" said she completed the next Weekly Skin Assessment but she did not know if she wrote it down on the Weekly Skin Assessment form. LVN/TN "D" said she took off the straps of R #6's immobilizer and cleaned the pin sites only. LVN/TN "D" said she paid attention to R #6's right heel and there were no pressure ulcers on the heel. LVN/TN "D" said she remembered a Residential Care Specialist (RCS) pointing out a black mark on top of R #6's foot that looked like a marker from the hospital. LVN/TN "D" said "some days you go in and are expected to do treatments and have to do other jobs. The treatments get done later in the day." LVN/TN "D" said she did not know who completed skin treatments on the days she was scheduled off. Admission list dated 06/06/13 indicated there were 24 admissions into the facility from 04/01/13 through 06/06/06. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to assessments. As of exit on 06/06/13 at 3:30 p.m., the facility provided no further information.

Based on observation interview and record review the facility failed to provide services in accordance with the Physicians Plan of Care (Physician' Orders) for one Resident (R #6) of two residents reviewed who were new admissions to the facility and had or were at risk for the development of pressure ulcers. R #6 was admitted to the facility with an immobilizer on her right foot and had Physician's Orders for a weekly skin check. There was no documentation indicating R #6 received a complete weekly skin check until 14 days after admission; R #6 was found with two pressure ulcers under the immobilizer. This failure could place any new admission at risk for the development of new pressure ulcers, the worsening of existing pressure ulcers, inaccurate care and/or improper care and services. The findings were: R #6's Face Sheet dated 05/29/13 indicated R #6 was admitted to the facility on [DATE]. R #6 was [AGE] years old. R #6's Hospital Progress Notes dated 05/21/13 revealed R #6 had a Right Ankle Fracture with an External Fixation Application (the use of plates and screws or a rod to stabilize the bone; holes are drilled into uninjured areas of bones around the fracture and special bolts or wires are screwed into the holes. Outside the body, a rod or a curved piece of metal with special ball-and-socket joints joins the bolts to make a rigid support). The Progress Notes indicated R #6 had a black eschar (According to Mosby's Medical Dictionary, 9th Edition, p. 644 Eschar is defined as "a scab or dry crust that results from trauma)on her medial (middle) aspect of her right ankle. R #6's Hospital Discharge Orders dated 05/23/13 revealed her Discharge [DIAGNOSES REDACTED]. Discharge instructions for wound care were "Elevate right lower extremity to decrease swelling. May apply ice as needed. Continue pin care, 1/2 Normal Saline and 1/2 hydrogen peroxide. Keep operation sites clean and dry. May change dressings daily. Do not apply creams or lotions. Do not debride area of eschar to medial ankle, allow it to continue to demarcate (separate), it will come off on its own." Review of the R #6's entire medical binder revealed there were no other admission orders [REDACTED]. R #6's Consolidated Physician's Orders dated June 2013 revealed R #6 [DIAGNOSES REDACTED]. The Consolidated Physician's Orders indicated R #6 was to have a head to toe skin check assessment weekly with a start date of 05/23/13. The Consolidated Physician's Orders did not address the area of eschar on R #6's right medial ankle or how often dressing changes were to be completed. R #6's Nursing Admission assessment dated [DATE] indicated R #6's admitting [DIAGNOSES REDACTED]. R #6 required bed rest. The Nursing Admission Braden Scale for Predicting Pressure Sore Risk, attached to the Nursing Admission Assessment, indicated R #6 scored an 11 and was a "High Risk for Pressure Sores." The Braden Scale indicated a total score of 12 or less represented a "High Risk for Pressure Sores." The Nursing Admission Assessment indicated if a risk score was 18 or less and/or skin integrity problems were identified, initiate an Interdisciplinary Team (IDT) referral and care plan. The Nursing Assessment indicated additional risk factors for R #6 were incontinence and impaired/decreased mobility and decreased functional ability. The Nursing Admission Assessment had forms with an outline of the human body and locations of skin conditions/wounds were to be marked on the outline. The External Fixation to R #6's right foot was indicated on the picture. There was no indication on the forms of the area of eschar on R #6's right inner medial ankle. The assessment indicated if a pressure ulcer was present, initiate daily and weekly pressure ulcer documentation forms. The Nursing Admission Assessment was signed by Licensed Vocational Nurse (LVN) "G." The admitting nurse, LVN "G", stated in a telephone interview on 06/06/13 at 2:50 p.m. she had admitted R #6 into the facility. LVN "G" stated she completed a head to toe assessment of R #6 and R #6 had an incision. LVN "G" stated she did not remember seeing a pressure ulcer but she did not look at R #6's fractured foot. LVN "G" said she did not take off the dressing/gauze on R #6's fractured foot because the dressing had just been put on R #6's foot at the hospital. LVN "G" stated the treatment nurse was to change R #6's dressing on a daily basis and clean the pin sites with saline. R #6's Initial Plan of Care dated 05/23/13 indicated R #6 had a surgical site and the goal of the Care Plan was for R #6's skin to remain intact without signs of breakdown by the next review. R #6's surgical wound would show signs of healing with area decreasing in overall size and depth by next review. The Care Plan indicated R #6 required assistance with Activities of Daily Living (ADLs, bathing, grooming, toileting). There was not an indication R #6 had an area of eschar on her right inner medial ankle or that any interventions were initiated to ensure R #6 did not develop pressure ulcers. R #6's Care Plan for Non-Pressure Ulcer Skin Impairment dated 05/23/13 indicated the IDT had initiated a Care Plan for R #6's pin sites to the Right External Fixation. The goal of the Plan was for the surgical site to heal without complications by 90 days. The approaches to be utilized by nursing staff were to observe skin weekly and document findings, wound care as ordered, and document observation of any non-pressure related skin impairments. The Care Plan for Non-Pressure Ulcer Skin Impairments did not address the area of eschar on R #6's right inner medial ankle or checking for pressure ulcers under the immobilizer. R #6's Non-Pressure Skin Condition Record dated 05/23/13 indicated R #6 had "external brace to fx (fracture) R (right) (lower) ext (extremity) with pin site to right outer and inner ankle. As well as 2 pin sites on right ("shen") area." There was not an indication on the Non-Pressure Skin Condition Record that R #6 had an area of eschar on her right inner medial ankle. Review of R #6's entire medical chart with Director of Nursing (DON) "A" and Licensed Vocational Nurse (LVN) "B" present revealed there was not a Head to Toe Skin Check for R #6 dated for May 2013. Review of R #6's medical binder revealed there was not a daily or weekly pressure ulcer documentation form. R #6's Treatment Administration Record (TAR) for Weekly Skin Check/assessment dated [DATE] through 05/31/13 revealed no documentation of a weekly Skin Check from 05/23/13 through 05/31/13. R #6's Head to Toe Skin Checks form dated 06/2013 did not have any documentation that indicated a Head to Toe Skin Check had been conducted in June 2013. R #6's TAR for Weekly Skin Check/assessment dated [DATE] through 06/06/13 had no documentation R #6 had a weekly Skin Check from 06/01/13 through 06/06/13. R #6's Five Day Admission Minimum Data Set ((MDS) dated [DATE] revealed R #6 had clear speech, had clear comprehension and was able to make herself understood. R #6's cognition was intact and R #6 was non-ambulatory. The MDS revealed R #6 was at risk of developing pressure ulcers. The MDS indicated R #6 did not have a Stage one or higher pressure ulcer or any unstageable pressure ulcers. The area of eschar on R #6's right inner medial ankle was not indicated on the MDS. Weekly Pressure Ulcer Record dated 06/06/13, not signed indicated R #6 had an "unstageable" (According to Centers for Medicare Medicaid Services, an unstageable ulcer is defined as an ulcer related to the coverage of a wound bed by eschar, full thickness tissue loss and/or the base of the ulcer is covered by eschar) pressure ulcer 7.3 centimeters (cm) by 3 cm to her right outer lateral plantar (bottom surface) foot, date of onset 06/06/13. The Weekly Pressure Ulcer Record indicated under "Description of Stages: Unstageable was to be coded as a Stage IV on the Minimum Data Set (MDS)." Weekly Pressure Ulcer Record dated 06/06/13 and completed by the Regional Consultant Registered Nurse indicated R #6 had an "unstageable pressure ulcer" 2.0 cm by 2.8 cm to her right inner ankle area, date of onset 06/06/13. The Weekly Pressure Ulcer Record indicated under "Description of Stages: Unstageable was to be coded as a Stage IV on the MDS." R #6 stated in an interview on 06/05/13 at 2:50 p.m. since she had been admitted to the facility two weeks ago it was "the worst treatment ever." R #6 said she had complained to the Social Worker (SW) "C" on 06/03/13 that she (R #6) had not had wound treatment or a check of all of her foot that was covered with gauze since she had arrived at the facility. R #6 stated all the nurses had done was unwrap the gauze/dressing where the external fixation was attached to her leg and wipe off the pin sites. R #6 stated the nurses had not even cleaned the tape residue or iodine off her leg from the surgery at the hospital. R #6 stated the nurses had not removed the immobilizer boot and checked her right foot. Observation of R #6's foot and leg on 06/05/13 at 2:50 p.m. revealed R #6's right foot was elevated on a foam cushion. Her right lower leg, from the knee down to her toes was wrapped in gauze and the external fixation protruded from different areas in her right leg. Her leg was in an immobilizer boot with Velcro straps across the top. R #6 stated in an interview on 06/06/13 at 12:45 p.m. a nurse had cleaned her foot and leg this morning (06/06/13). R #6 stated "it took them two weeks to start treatment on my foot." R #6 said the nurse had taken off the immobilizer boot and gauze/dressing and looked at her entire right foot. R #6 said she had two pressure ulcers. LVN "B" stated in an interview on 06/06/13 at 1:20 p.m. she was not able to locate a Skin Assessment for R #6 for 05/29/13 or 05/30/13. The surveyor reviewed R #6's medical binder with LVN "B" present. LVN "B" stated that on 05/29/13 R #6 had returned to the facility from [MEDICAL TREATMENT] treatment and R #6 was in pain. LVN "B" stated she remembered telling the LVN/Treatment Nurse (LVN/TN) "D" she (LVN/TN "D") needed to do a Skin Assessment. LVN "B" stated she did not remember if LVN/TN "D" completed the Skin Assessment. LVN "B" stated as of the morning of 06/06/13 R #6 was assessed and had two new "pressure sores" on her right foot. LVN "B" reviewed the discharge records from the hospital with the surveyor present and stated she did not know why the physician wrote "may change dressings daily." LVN "B" stated the physician could have written to change dressings daily if he wanted the dressing on R #6's foot changed every day. LVN "B" stated she had left the physician a telephone message 06/06/13 to verify the order for dressing changes from 05/23/13. LVN "B" stated the admitting nurse should have clarified the Physician's Order when R #6 was admitted . The Administrator stated in an interview, with the DON "H" present, on 06/06/13 at 2:10 p.m., R #6's right foot had not been assessed for a pressure ulcer due to R #6 had a dressing and an immobilizer. DON "H" nodded her head up and down when asked by the surveyor if it was good nursing practice to remove a dressing and immobilizer when performing skin assessments. Resident Care Manager/LVN (RCM/LVN) "F" stated in an interview on 06/06/13 at 3:20 p.m. the development of a Care Plan for Pressure Sores was the responsibility of the DON and himself. RCM/LVN "F" stated there had not been an initial Care Plan completed for R #6 regarding her area of eschar on her right inner medial foot when she was admitted . RCM/LVN "F" said if the admitting LVN had documented R #6's initial area of eschar the area of eschar would have been discussed at the next morning meeting and a Care Plan developed that addressed the removal of R #6's dressing. RCM/LVN "F" said "this was not done." LVN/TN "D" stated in a telephone interview on 06/06/13 at 4:50 p.m. she had not completed the Weekly Skin Assessment on R #6 when R #6 was admitted . LVN/TN "D" said the admitting nurse had completed the first Skin Assessment at the time of admission. LVN/TN "D" said she completed the next Weekly Skin Assessment but she did not know if she wrote it down on the Weekly Skin Assessment form. LVN/TN "D" said she took off the straps of R #6's immobilizer and cleaned the pin sites only. LVN/TN "D" said she paid attention to R #6's right heel and there were no pressure ulcers on the heel. LVN/TN "D" said she remembered a Residential Care Specialist (RCS) pointing out a black mark on top of R #6's foot that looked like a marker from the hospital. LVN/TN "D" said "some days you go in and are expected to do treatments and have to do other jobs. The treatments get done later in the day." LVN/TN "D" said she did not know who completed skin treatments on the days she was scheduled off. Admission list dated 06/06/13 indicated there were 24 admissions into the facility from 04/01/13 through 06/06/06. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to services provided provided by qualified persons in accordance with a resident's written plan of care. As of exit on 06/06/13 at 3:30 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to ensure one Resident (R #6) of two residents who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated the pressure ulcers were unavoidable. R #6 was admitted to the facility on [DATE] for recovery after surgery for [REDACTED]. An area of eschar on her right inner medial ankle was noted on her hospital discharge orders. Facility was aware R #6 was a high risk for developing pressure ulcers. The nursing staff did not: -perform a complete initial/admission assessment, -assess the area of the right inner foot with eschar already identified by the physician, -perform weekly skin assessments or examine R #6's right foot/ankle under the immobilizer for possible skin breakdown until 06/06/13, 14 days after admission. -On 06/06/13 the facility identified that R #6 had two un-stageable pressure ulcers under the immobilizer: one pressure ulcer on her right inner ankle and one pressure ulcer on her right outer foot. This failure could place the 24 newly admitted residents at risk of developing pressure ulcers. The findings were: R #6's Face Sheet dated 05/29/13 indicated R #6 was admitted to the facility on [DATE]. R #6 was [AGE] years old. R #6's Hospital Progress Notes dated 05/21/13 revealed R #6 had a Right Ankle Fracture with an External Fixation Application (the use of plates and screws or a rod to stabilize the bone; holes are drilled into uninjured areas of bones around the fracture and special bolts or wires are screwed into the holes. Outside the body, a rod or a curved piece of metal with special ball-and-socket joints joins the bolts to make a rigid support). The Progress Notes indicated R #6 had a black eschar (According to Mosby's Medical Dictionary, 9th Edition, p. 644 Eschar is defined as "a scab or dry crust that results from trauma) on her medial (middle) aspect of her right ankle. Weekly Pressure Ulcer Record dated 06/06/13, not signed indicated R #6 had an "unstageable" (According to Centers for Medicare Medicaid Services, an unstageable ulcer is defined as an ulcer related to the coverage of a wound bed by eschar, full thickness tissue loss and/or the base of the ulcer is covered by eschar) pressure ulcer 7.3 centimeters (cm) by 3 cm to her right outer lateral plantar (bottom surface) foot, date of onset 06/06/13. The Weekly Pressure Ulcer Record indicated under "Description of Stages: Unstageable was to be coded as a Stage IV on the Minimum Data Set (MDS)." Weekly Pressure Ulcer Record dated 06/06/13 and completed by the Regional Consultant Registered Nurse indicated R #6 had an "unstageable pressure ulcer" 2.0 cm by 2.8 cm to her right inner ankle area, date of onset 06/06/13. The Weekly Pressure Ulcer Record indicated under "Description of Stages: Unstageable was to be coded as a Stage IV on the MDS." National Pressure Ulcer Advisory Panel defines an Unstageable Pressure Ulcer as "full thickness skin or tissue loss with an unknown depth. The full thickness tissue loss in which actual depth of the ulcer is completely obscured by eschar. Until the eschar is removed to expose the base of the wound, the true depth cannot be determined, but it will be either a Category Stage III or IV. A Category III pressure ulcer, subcutaneous fat may be visible. A Category IV pressure ulcer is tissue loss with exposed bone, tendon or muscle." R #6's Hospital Discharge Orders dated 05/23/13 revealed her Discharge [DIAGNOSES REDACTED]. Discharge instructions for wound care were "Elevate right lower extremity to decrease swelling. May apply ice as needed. Continue pin care, 1/2 Normal Saline and 1/2 hydrogen peroxide. Keep operation sites clean and dry. May change dressings daily. Do not apply creams or lotions. Do not debride area of eschar to medial ankle, allow it to continue to demarcate (separate), it will come off on its own." Review of the R #6's entire medical binder revealed there were no other admission orders [REDACTED]. R #6's Consolidated Physician's Orders dated June 2013 revealed R #6 [DIAGNOSES REDACTED]. The Consolidated Physician's Orders indicated R #6 was to have a head to toe skin check assessment weekly with a start date of 05/23/13. The Consolidated Physician's Orders did not address the area of eschar on R #6's right inner medial ankle or how often dressing changes were to be completed. R #6's Nursing Admission assessment dated [DATE] indicated R #6's admitting [DIAGNOSES REDACTED]. R #6 required bed rest. The Nursing Admission Braden Scale for Predicting Pressure Sore Risk, attached to the Nursing Admission Assessment, indicated R #6 scored an 11 and was a "High Risk for Pressure Sores." The Braden Scale indicated a total score of 12 or less represented a "High Risk for Pressure Sores." The Nursing Admission Assessment indicated if a risk score was 18 or less and/or skin integrity problems were identified, initiate an Interdisciplinary Team (IDT) referral and care plan. The Nursing Assessment indicated additional risk factors for R #6 were incontinence and impaired/decreased mobility and decreased functional ability. The Nursing Admission Assessment had forms with an outline of the human body and locations of skin conditions/wounds were to be marked on the outline. The External Fixation to R #6's right foot was indicated on the picture. There was no indication on the forms of the area of eschar on R #6's right inner medial ankle. The assessment indicated if a pressure ulcer was present, initiate daily and weekly pressure ulcer documentation forms. The Nursing Admission Assessment was signed by Licensed Vocational Nurse (LVN) "G." The admitting nurse, LVN "G", stated in a telephone interview on 06/06/13 at 2:50 p.m. she had admitted R #6 into the facility. LVN "G" stated she completed a head to toe assessment of R #6 and R #6 had an incision. LVN "G" stated she did not remember seeing a pressure ulcer but she did not look at R #6's fractured foot. LVN "G" said she did not take off the dressing/gauze on R #6's fractured foot because the dressing had just been put on R #6's foot at the hospital. LVN "G" stated the treatment nurse was to change R #6's dressing on a daily basis and clean the pin sites with saline. R #6's Initial Plan of Care dated 05/23/13 indicated R #6 had a surgical site and the goal of the Care Plan was for R #6's skin to remain intact without signs of breakdown by the next review. R #6's surgical wound would show signs of healing with area decreasing in overall size and depth by next review. The Care Plan indicated R #6 required assistance with Activities of Daily Living (ADLs, bathing, grooming, toileting). There was not an indication R #6 had an area of eschar on her right inner medial ankle or that any interventions were initiated to ensure R #6 did not develop pressure ulcers. R #6's Care Plan for Non-Pressure Ulcer Skin Impairment dated 05/23/13 indicated the IDT had initiated a Care Plan for R #6's pin sites to the Right External Fixation. The goal of the Plan was for the surgical site to heal without complications by 90 days. The approaches to be utilized by nursing staff were to observe skin weekly and document findings, wound care as ordered, and document observation of any non-pressure related skin impairments. The Care Plan for Non-Pressure Ulcer Skin Impairments did not address the area of eschar on R #6's right inner medial ankle. R #6's Non-Pressure Skin Condition Record dated 05/23/13 indicated R #6 had "external brace to fx (fracture) R (right) (lower) ext (extremity) with pin site to right outer and inner ankle. As well as 2 pin sites on right ("shen") area." There was not an indication on the Non-Pressure Skin Condition Record that R #6 had an area of eschar on her right inner medial ankle. Review of R #6's entire medical chart with Director of Nursing (DON) "A" and Licensed Vocational Nurse (LVN) "B" present revealed there was not a Head to Toe Skin Check for R #6 dated for May 2013. Review of R #6's medical binder revealed there was not a daily or weekly pressure ulcer documentation form. R #6's Treatment Administration Record (TAR) for Weekly Skin Check/assessment dated [DATE] through 05/31/13 revealed no documentation of a weekly Skin Check from 05/23/13 through 05/31/13. R #6's Head to Toe Skin Checks form dated 06/2013 did not have any documentation that indicated a Head to Toe Skin Check had been conducted in June 2013. R #6's TAR for Weekly Skin Check/assessment dated [DATE] through 06/06/13 had no documentation R #6 had a weekly Skin Check from 06/01/13 through 06/06/13. R #6's Five Day Admission MDS dated [DATE] revealed R #6 had clear speech, had clear comprehension and was able to make herself understood. R #6's cognition was intact and R #6 was non-ambulatory. The MDS revealed R #6 was at risk of developing pressure ulcers. The MDS indicated R #6 did not have a Stage one or higher pressure ulcer or any unstageable pressure ulcers. The area of eschar on R #6's right inner medial ankle was not indicated on the MDS.. Weekly Pressure Ulcer Record dated 06/06/13, not signed indicated R #6 had an "un-stageable" pressure ulcer 7.3 centimeters (cm) by 3 cm to her right outer lateral plantar foot, date of onset 06/06/13. Weekly Pressure Ulcer Record dated 06/06/13 and completed by the Regional Consultant Registered Nurse indicated R #6 had an "un-stageable pressure ulcer" 2.0 cm by 2.8 cm to her right inner ankle area, date of onset 06/06/13. R #6 stated in an interview on 06/05/13 at 2:50 p.m. since she had been admitted to the facility two weeks ago it was "the worst treatment ever." R #6 said she had complained to the Social Worker (SW) "C" on 06/03/13 that she (R #6) had not had wound treatment or a check of all of her foot that was covered with gauze since she had arrived at the facility. R #6 stated all the nurses had done was unwrap the gauze/dressing where the external fixation was attached to her leg and wipe off the pin sites. R #6 stated the nurses had not even cleaned the tape residue or iodine off her leg from the surgery at the hospital. R #6 stated the nurses had not removed the immobilizer boot (orthopedic boot used to immobilize ankle fractures/foot fractures) and checked her right foot. Observation of R #6's foot and leg on 06/05/13 at 2:50 p.m. revealed R #6's right foot was elevated on a foam cushion. Her right lower leg, from the knee down to her toes was wrapped in gauze and the external fixation protruded from different areas in her right leg. Her leg was in an immobilizer boot with Velcro straps across the top. R #6 stated in an interview on 06/06/13 at 12:45 p.m. a nurse had cleaned her foot and leg this morning (06/06/13). R #6 stated "it took them two weeks to start treatment on my foot." R #6 said the nurse had taken off the immobilizer boot and gauze/dressing and looked at her entire right foot. R #6 said she had two pressure ulcers. LVN "B" stated in an interview on 06/06/13 at 1:20 p.m. she was not able to locate a Skin Assessment for R #6 for 05/29/13 or 05/30/13. The surveyor reviewed R #6's medical binder with LVN "B" present. LVN "B" stated that on 05/29/13 R #6 had returned to the facility from [MEDICAL TREATMENT] treatment and R #6 was in pain. LVN "B" stated she remembered telling the LVN/Treatment Nurse (LVN/TN) "D" she (LVN/TN "D") needed to do a Skin Assessment. LVN "B" stated she did not remember if LVN/TN "D" completed the Skin Assessment. LVN "B" stated as of the morning of 06/06/13 R #6 was assessed and had two new "pressure sores" on her right foot. LVN "B" reviewed the discharge records from the hospital with the surveyor present and stated she did not know why the physician wrote "may change dressings daily." LVN "B" stated the physician could have written to change dressings daily if he wanted the dressing on R #6's foot changed every day. LVN "B" stated she had left the physician a telephone message 06/06/13 to verify the order for dressing changes from 05/23/13. LVN "B" stated the admitting nurse should have clarified the Physician's Order when R #6 was admitted . The Administrator stated in an interview, with the DON "H" present, on 06/06/13 at 2:10 p.m., R #6's right foot had not been assessed for a pressure ulcer due to R #6 had a dressing and an immobilizer. DON "H" nodded her head up and down when asked by the surveyor if it was good nursing practice to remove a dressing and immobilizer when performing skin assessments. Resident Care Manager/LVN (RCM/LVN) "F" stated in an interview on 06/06/13 at 3:20 p.m. the development of a Care Plan for Pressure Sores was the responsibility of the DON and himself. RCM/LVN "F" stated there had not been an initial Care Plan completed for R #6 regarding her area of eschar on her right medial foot when she was admitted . RCM/LVN "F" said if the admitting LVN had documented R #6's initial area of eschar the area of eschar would have been discussed at the next morning meeting and a Care Plan developed that addressed the removal of R #6's dressing. RCM/LVN "F" said "this was not done." LVN/TN "D" stated in a telephone interview on 06/06/13 at 4:50 p.m. she had not completed the Weekly Skin Assessment on R #6 when R #6 was admitted . LVN/TN "D" said the admitting nurse had completed the first Skin Assessment at the time of admission. LVN/TN "D" said she completed the next Weekly Skin Assessment but she did not know if she wrote it down on the Weekly Skin Assessment form. LVN/TN "D" said she took off the straps of R #6's immobilizer and cleaned the pin sites only. LVN/TN "D" said she paid attention to R #6's right heel and there were no pressure ulcers on the heel. LVN/TN "D" said she remembered a Residential Care Specialist (RCS) pointing out a black mark on top of R #6's foot that looked like a marker from the hospital. LVN/TN "D" said "some days you go in and are expected to do treatments and have to do other jobs. The treatments get done later in the day." LVN/TN "D" said she did not know who completed skin treatments on the days she was scheduled off. Admission list dated 06/06/13 indicated there were 24 admissions into the facility from 04/01/13 through 06/06/06. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to pressure sores. As of exit on 06/06/13 at 3:30 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one Resident (R #6) of two Residents reviewed as new admissions into the facility and who were at risk of pressure ulcers. R #6 was admitted to the facility on [DATE] for recovery after surgery for [REDACTED]. An area of eschar on her right ankle was noted on her hospital discharge orders. The nursing staff did not: -perform a complete initial/admission nursing assessment, -assess the area with eschar, perform weekly skin assessments or examine R #6's right foot/ankle under the immoblilizer for possible skin breakdown until 06/06/13, 14 days after admission. -On 06/06/13 R #6 had two unstageable pressure ulcers under the immoblilizer: one pressure ulcer on her right inner medial ankle and one pressure ulcer on her right outer foot. These failures could place all 24 newly admitted residents at risk for inadequate and/or improper care. Findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 states: "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;...(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document:...(iii) physician, dentist or podiatrist orders;...(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment;...(P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care..." R #6's Face Sheet dated 05/29/13 indicated R #6 was admitted to the facility on [DATE]. R #6 was [AGE] years old. R #6's Hospital Progress Notes dated 05/21/13 revealed R #6 had a Right Ankle Fracture with an External Fixation Application (the use of plates and screws or a rod to stabilize the bone; holes are drilled into uninjured areas of bones around the fracture and special bolts or wires are screwed into the holes. Outside the body, a rod or a curved piece of metal with special ball-and-socket joints joins the bolts to make a rigid support). The Progress Notes indicated R #6 had a black eschar (According to Mosby's Medical Dictionary, 9th Edition, p. 644 Eschar is defined as "a scab or dry crust that results from trauma.) on her medial (middle) aspect of her right ankle. R #6's Hospital Discharge Orders dated 05/23/13 revealed her Discharge [DIAGNOSES REDACTED]. Discharge instructions for wound care were "Elevate right lower extremity to decrease swelling. May apply ice as needed. Continue pin care, 1/2 Noraml Saline and 1/2 hydrogen peroxide. Keep operation sites clean and dry. May change dressings daily. Do not apply creams or lotions. Do not debride area of eschar to medial ankle, allow it to continue to demarcate (separate), it will come off on its own." Review of the R #6's entire medical binder revealed there were no other admission orders [REDACTED]. R #6's Consolidated Physician's Orders dated June 2013 revealed R #6 [DIAGNOSES REDACTED]. The Consolidated Physician's Orders indicated R #6 was to have a head to toe skin check assessment weekly with a start date of 05/23/13. The Consolidated Physician's Orders did not address the area of eschar on R #6's right inner medial ankle or how often dressing changes were to be completed. R #6's Nursing Admission assessment dated [DATE] indicated R #6's admitting [DIAGNOSES REDACTED]. R #6 required bed rest. The Nursing Admission Braden Scale for Predicting Pressure Sore Risk, attached to the Nursing Admission Assessment, indicated R #6 scored an 11 and was a "High Risk for Pressure Sores." The Braden Scale indicated a total score of 12 or less represented a High Risk for Pressure Sores. The Nursing Admission Assessment indicated if a risk score was 18 or less and/or skin integrity problems were identified, initiate an Interdisciplinary Team (IDT) referral and care plan. The Nursing Assessment indicated additional risk factors for R #6 were incontinence and impaired/decreased mobility and decreased functional ability. The Nursing Admission Assessment had forms with an outline of the human body and locations of skin conditions/wounds were to be marked on the outline. The External Fixation to R #6's right foot was indicated on the picture. There was no indication on the forms of the area of eschar on R #6's right inner medial ankle. The assessment indicated if a pressure ulcer was present, initiate daily and weekly pressure ulcer documentation forms. The Nursing Admission Assessment was signed by Licensed Vocational Nurse (LVN) "G." The admitting nurse, LVN "G", stated in a telephone interview on 06/06/13 at 2:50 p.m. she had admitted R #6 into the facility. LVN "G" stated she completed a head to toe assessment of R #6 and R #6 had an incision. LVN "G" stated she did not remember seeing a pressure ulcer but she did not look at R #6's fractured foot. LVN "G" said she did not take off the dressing/gauze on R #6's fractured foot because the dressing had just been put on R #6's foot at the hospital. LVN "G" stated the treatment nurse was to change R #6's dressing on a daily basis and clean the pin sites with saline. R #6's Initial Plan of Care dated 05/23/13 indicated R #6 had a surgical site and the goal of the Care Plan was for R #6's skin to remain intact without signs of breakdown by the next review. R #6's surgical wound would show signs of healing with area decreasing in overall size and depth by next review. The Care Plan indicated R #6 required assistance with Activities of Daily Living (ADLs, bathing, grooming, toileting). There was not an indication R #6 had an area of eschar on her right inner medial ankle or that any interventions were initiated to ensure R #6 did not develop pressure ulcers. R #6's Care Plan for Non-Pressure Ulcer Skin Impairment dated 05/23/13 indicated the IDT had initiated a Care Plan for R #6's pin sites to the Right External Fixation. The goal of the Plan was for the surgical site to heal without complications by 90 days. The approaches to be utilized by nursing staff were to observe skin weekly and document findings, wound care as ordered, and document observation of any non-pressure related skin impairments. The Care Plan for Non-Pressure Ulcer Skin Impairments did not address the area of eschar on R #6's right inner medial ankle. R #6's Non-Pressure Skin Condition Record dated 05/23/13 indicated R #6 had "external brace to fx (fracture) R (right) (lower) ext (extremity) with pin site to right outer and inner ankle. As well as 2 pin sites on right ("shen") area." There was not an indication on the Non-Pressure Skin Condition Record that R #6 had an area of eschar on her right inner medial ankle. Review of R #6's entire medical chart with Director of Nursing (DON) "A" and Licensed Vocational Nurse (LVN) "B" present revealed there was not a Head to Toe Skin Check for R #6 dated for May 2013. Review of R #6's medical binder revealed there was not a daily or weekly pressure ulcer documentation form. R #6's Treatment Administration Record (TAR) for Weekly Skin Check/assessment dated [DATE] through 05/31/13 revealed no documentation of a weekly Skin Check from 05/23/13 through 05/31/13. R #6's Head to Toe Skin Checks form dated 06/2013 did not have any documentation that indicated a Head to Toe Skin Check had been conducted in June 2013. R #6's TAR for Weekly Skin Check/assessment dated [DATE] through 06/06/13 had no documentation R #6 had a weekly Skin Check from 06/01/13 through 06/06/13. R #6's Five Day Admission Minimum Data Set ((MDS) dated [DATE] revealed R #6 had clear speech, had clear comprehension and was able to make herself understood. R #6's cognition was intact and R #6 was non-ambulatory. The MDS revealed R #6 was at risk of developing pressure ulcers. The MDS indicated R #6 did not have a Stage one or higher pressure ulcer or any un-stageable pressure ulcers. The area of eschar on R #6's right inner medial ankle was not indicated on the MDS.. Weekly Pressure Ulcer Record dated 06/06/13, not signed indicated R #6 had an "un-stageable" (necrotic tissue grayish/yellow slough present or soft/hard eschar present) pressure ulcer 7.3 centimeters (cm) by 3 cm to her right outer lateral plantar (bottom surface) foot, date of onset 06/06/13. Weekly Pressure Ulcer Record dated 06/06/13 and completed by the Regional Consultant Registered Nurse indicated R #6 had an "un-stageable pressure ulcer" 2.0 centimeters (cm) by 2.8 cm to her right inner ankle area, date of onset 06/06/13. R #6 stated in an interview on 06/05/13 at 2:50 p.m. since she had been admitted to the facility two weeks ago it was "the worst treatment ever." R #6 said she had complained to the Social Worker (SW) "C" on 06/03/13 that she (R #6) had not had wound treatment or a check of all of her foot that was covered with gauze since she had arrived at the facility. R #6 stated all the nurses had done was unwrap the gauze/dressing where the external fixation was attached to her leg and wipe off the pin sites. R #6 stated the nurses had not even cleaned the tape residue or iodine off her leg from the surgery at the hospital. R #6 stated the nurses had not removed the immoblilizer boot (orthopedic boot used to immobilize ankle fractures/foot fractures) and checked her right foot. Observation of R #6's foot and leg on 06/05/13 at 2:50 p.m. revealed R #6's right foot was elevated on a foam cushion. Her right lower leg, from the knee down to her toes was wrapped in gauze and the external fixation protruded from different areas in her right leg. Her leg was in an immoblilizer boot with Velcro straps across the top. R #6 stated in an interview on 06/06/13 at 12:45 p.m. a nurse had cleaned her foot and leg this morning (06/06/13). R #6 stated "it took them two weeks to start treatment on my foot." R #6 said the nurse had taken off the immoblilizer boot and gauze/dressing and looked at her entire right foot. R #6 said she had two pressure ulcers. LVN "B" stated in an interview on 06/06/13 at 1:20 p.m. she was not able to locate a Skin Assessment for R #6 for 05/29/13 or 05/30/13. The surveyor reviewed R #6's medical binder with LVN "B" present. LVN "B" stated that on 05/29/13 R #6 had returned to the facility from [MEDICAL TREATMENT] treatment and R #6 was in pain. LVN "B" stated she remembered telling the LVN/Treatment Nurse (LVN/TN) "D" she (LVN/TN "D") needed to do a Skin Assessment. LVN "B" stated she did not remember if LVN/TN "D" completed the Skin Assessment. LVN "B" stated as of the morning of 06/06/13 R #6 was assessed and had two new "pressure sores" on her right foot. LVN "B" reviewed the discharge records from the hospital with the surveyor present and stated she did not know why the physician wrote "may change dressings daily." LVN "B" stated the physician could have written to change dressings daily if he wanted the dressing on R #6's foot changed every day. LVN "B" stated she had left the physician a telephone message 06/06/13 to verify the order for dressing changes from 05/23/13. LVN "B" stated the admitting nurse should have clarified the Physician's Order when R #6 was admitted . The Administrator stated in an interview, with the DON "H" present, on 06/06/13 at 2:10 p.m., R #6's right foot had not been assessed for a pressure ulcer due to R #6 had a dressing and an immoblilizer. DON "H" nodded her head up and down when asked by the surveyor if it was good nursing practice to remove a dressing and immoblilizer when performing skin assessments. Resident Care Manager/LVN (RCM/LVN) "F" stated in an interview on 06/06/13 at 3:20 p.m. the development of a Care Plan for Pressure Sores was the responsibility of the DON and himself. RCM/LVN "F" stated there had not been an initial Care Plan completed for R #6 regarding her area of eschar on her right medial foot when she was admitted . RCM/LVN"F" said if the admitting LVN had documented R #6's initial area of eschar the area of eschar would have been discussed at the next morning meeting and a Care Plan developed that addressed the removal of R #6's dressing. RCM/LVN "F" said "this was not done." LVN/TN "D" stated in a telephone interview on 06/06/13 at 4:50 p.m. she had not completed the Weekly Skin Assessment on R #6 when R #6 was admitted . LVN/TN "D" said the admitting nurse had completed the first Skin Assessment at the time of admission. LVN/TN "D" said she completed the next Weekly Skin Assessment but she did not know if she wrote it down on the Weekly Skin Assessment form. LVN/TN "D" said she took off the straps of R #6's immoblilizer and cleaned the pin sites only. LVN/TN "D" said she paid attention to R #6's right heel and there were no pressure ulcers on the heel. LVN/TN "D" said she remembered a Residential Care Specialist (RCS) pointing out a black mark on top of R #6's foot that looked like a marker from the hospital. LVN/TN "D" said "some days you go in and are expected to do treatments and have to do other jobs. The treatments get done later in the day." LVN/TN "D" said she did not know who completed skin treatments on the days she was scheduled off. Admission list dated 06/06/13 indicated there were 24 admissions into the facility from 04/01/13 through 06/06/06. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to services provided meet professional standards . As of exit on 06/06/13 at 3:30 p.m., the facility provided no further information.

Based on observation, record review, and interview the facility failed to implement facility policy and procedures to prohibit neglect for one Resident (R#7) of 10 Residents whose care was reviewed. ? The facility nurse failed to document assessments for R#7 who complained of abdominal pain, did not consult R#7's physician, and did not immediately transfer R#7 to the hospital when at approximately 10:30 a.m. R#7 said she did not feel well, had abdominal pain and requested to be seen by a Physician in the hospital. ? R#7 was alert and oriented with a history of gastrointestinal (GI) problems who had not eaten breakfast or lunch and complained of abdominal pain to facility staff during the 6:00 a.m. - 2:00 p.m. shift and the 2 p.m.-10 p.m. shift on [DATE]. ? R#7 was transferred to the hospital at approximately 4:25 p.m. after R#7 began to throw up coffee ground vomitus (dark brown vomitus with the color and consistency of coffee grounds, composed of [MEDICAL CONDITION] acids and old blood and indicative of slow upper [MEDICAL CONDITION]) with a [DIAGNOSES REDACTED]. ? R#7 expired at the hospital on [DATE]. This facility failure was determined to be past non-compliance (PNC) due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the complaint investigation. The facility's failure to implement their policy and procedures that prohibit neglect could have affected all 34 residents in hallway "200 and 400" where Licensed Vocational Nurse (LVN) "X" was scheduled to work and could result in their medical condition deteriorating and lead to death. Findings included: After administrative review the investigation was reopened on [DATE]. The original exit date was [DATE]. Review of Changes in Resident Condition Policy dated [DATE] and revised [DATE] revealed the resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. The Change of Condition Forms also documented that the forms were used to assess and document changes in condition in an efficient and effective manner; provide assessment information to the physician, and provide clear comprehensive documentation. R#7's Face Sheet dated [DATE] indicated R#7 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#7 was allergic to [MEDICATION NAME], and [MEDICATION NAME]. Physician's Order dated [DATE] revealed R#7 had a [DIAGNOSES REDACTED]. Record review of R#7's (MDS) minimum (MDS) data set [DATE] revealed R#7 had the ability to express ideas and wants, understood verbal content, had clear speech with distinct intelligible words, and had the ability to understand others with clear comprehension. Cognitive Pattern section indicated R#7 did not have any inattentive behaviors, disorganized thinking, altered level of consciousness, or any evidence of acute change in mental status from R#7's baseline. R#7 was able to report correct day, month and year. Record review of the Provider Investigation Report (PIR) Department of Aging and Disability Services (DADS) Form 3613-A dated [DATE] indicated an Incident Investigation was conducted by the facility for an allegation of Neglect. The PIR documented Licensed Vocational Nurse (LVN) "X" to be the alleged perpetrator and R#7 as the alleged victim. The PIR documented Resident Care Specialist (RCS) "F" notified LVN "X" on [DATE] during the 6:00 a.m. - 2:00 p.m. shift that R#7 complained of abdominal pain and requested to go to the hospital. RCS "F" reported to LVN "X" that R#7 did not eat breakfast or lunch and R#7 had had a bowel movement on [DATE], that same morning. The PIR documented LVN "X" notified LVN "H" that R#7 had abdominal pain and requested to go to the hospital. The PIR documented LVN "H" told LVN "X" that R#7 needed to be assessed. The PIR documented LVN "H" later saw LVN "X" in the hallway with a stethoscope around her neck and LVN "X" reported to LVN "H" that R#7 had slow bowel sounds, vital signs were within normal limits (WNL) and R#7 appeared to be constipated. The PIR documented LVN "X" gave R#7 [MEDICATION NAME] (stool softener). The PIR documented LVN "X" did not document R#7's gastrointestinal assessment. The PIR documented that R#7 continued to complain of stomach pain on the 2:00 p.m. - 10:00 p.m. shift and vomited coffee ground vomitus. The PIR documented LVN "C" (2:00 p.m. - 10 p.m. shift) sent R#7 to the hospital. The facility's PIR dated [DATE] indicated LVN "X" did not remember RCS "F" telling LVN "X" that R#7 did not eat breakfast that morning ([DATE]) but LVN "X" (personally) remembered R#7 did not eat lunch that day. The PIR indicated LVN "X" did not remember RCS "F" telling LVN "X" R#7 had a bowel movement on [DATE] during 6:00 a.m. - 2:00 p.m. shift. The PIR revealed LVN "X" said she never called R#7's Physician about R#7's abdominal pain and did not document any of her (LVN "X") assessments in R#7's chart. The PIR documented LVN "X" said she gave R#7 MOM (milk of magnesium) "from the blue bottle" but did not remember whether R#7 had an order for [REDACTED]. Review of R#7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"AA." R#7's MAR indicated [REDACTED]. The facility Administrator suspended LVN "X" pending the investigation. In-services on Abuse and Neglect, Medication Management and InterACT II were conducted for facility staff on [DATE]. The facility Administrator's Investigative Findings for LVN "X" were "Inconclusive" for the allegation of Neglect. The PIR Provider Action Taken Post-Investigation was the termination of LVN "X" for the lack of documentation of her assessment of R#7 on [DATE]. Review of the facility's PIR dated [DATE] documented LVN "C" was notified by LVN "X" during shift change that R#7 was "constipated" and LVN "X" had given R#7 a "BOMB" which was a mixture of Milk of Magnesium, [MEDICATION NAME], and prune juice. The facility's Interview Record documented LVN "X" told LVN "C" to give R#7 another "BOMB" if R#7 complained again. Record review of R#7's Physician's Orders dated [DATE] revealed R#7 was ordered to receive [MEDICATION NAME] 10 grams by mouth (gm) /15 mililiters (ml) solution every day at 8:00 a.m. for constipation. Review of the Physician's Orders did not contain any order for Milk of Magnesium, prune juice, "BOMB", or to administer a "BOMB" if R#7 complained of abdominal pain. In an interview with LVN "C" on [DATE] at 4:55 p.m. revealed LVN "C" was the 2:00 p.m. - 10:00 p.m. charge nurse for hallways "200" and "400" on [DATE]. LVN "C" said LVN "X" was the charge nurse for hallways "200" and "400" who worked the 6:00 a.m. - 2:00 p.m. shift on [DATE]. LVN "C" said LVN "X" reported to her during shift change at 2:00 p.m. on [DATE] that R#7 had been complaining of stomach pain during the day. LVN "C" said LVN "X" gave R#7 a "BOMB." LVN "C" said LVN "X" described the "BOMB" to be a mixture of laxatives including prune juice, [MEDICATION NAME] (stool softener) and milk of magnesirum. LVN "C" said she had "never heard of a BOMB before," and said the "BOMB" was not ordered on R#7's MAR. LVN "C" said after report with LVN "X", she started to check residents at 2:30 p.m. LVN "C" said RCS "F" approached her in the hallway and asked her to check R#7 because R#7 "didn't look like herself." LVN "C" said RCS "F" also notified LVN "E" about R#7's condition. LVN "C" said she found R#7 to have pale skin, intense abdominal pain, crying, and was throwing up coffee ground emesis (vomit). LVN "C" said R#7 notified her she wanted to go to the hospital. LVN "C" said R#7 also told RCS "F" she wanted to go to the hospital. LVN "C" said she notified her supervisor immediately and asked LVN "E" for assistance. LVN "C" said R#7's physician was called and R#7 was sent to the hospital. Interview with LVN "E" on [DATE] at 2:07 p.m. revealed she (LVN "E") was notified by RCS "F" on [DATE] during the 2:00 p.m. - 10 p.m. shift that R#7 felt ill and to "please check on her." LVN "E" went to R#7's room and observed LVN "C" entering R#7's room. LVN "E" said she heard R#7 say she did not feel well and observed an emesis basin half full with black emesis next to R#7. LVN "E" said the amount of black vomit in the basin was substantial and probably accumulated from an extended period of several hours. LVN "E" said she obtained R#7's blood pressure, respirations, and pulse rate (vital signs) and called her supervisor. LVN "E" then notified R#7's Physician. R#7's Physician gave order to send R#7 to hospital. LVN "E" said LVN "X" was the charge nurse responsible for R#7 that day on the 6:00 a.m. - 2:00 p.m. shift and LVN "X" did not call R#7's Physician about R#7's abdominal pain and R#7's requests to go to the hospital throughout the 6:00 a.m. - 2:00 p.m. shift. LVN "E" revealed she and LVN "C" assessed R#7 to be in distress, have an immediate need to go to the hospital and responded accordingly. LVN "E" said R#7 was alert, crying in obvious pain, and requested several times to go to the hospital. In an interview on [DATE] at 1:38 p.m., RCS "F" said he worked the 6:00 a.m. to 2:00 p.m. shift on [DATE] and had taken care of R#7. RCS "F" said R#7 had refused to eat breakfast and RCS "F" notified the charge nurse, LVN "X". RCS "F" said at approximately 10:30 a.m., R#7 said she felt sick and wanted to go to the hospital. RCS "F" said he reported R#7's statement of feeling sick and request to go to the hospital to LVN "X". RCS "F" said LVN "X" responded by saying "Are you serious? She wants to go to the hospital?" RCS "F" said LVN "X" went to R#7's room. RCS "F" said LVN "X" later told him R#7 was constipated and she (LVN "X") would not send her (R#7) to the hospital "for that." RCS "F" said LVN "X" told RCS "F" she (LVN "X") was going to give R#7 "something for constipation." RCS "F" said LVN "X" asked RCS "F" for information regarding R#7's bowel movements. RCS "F" said he informed LVN "X" that R#7 had passed two formed, regular bowel movements (stools of this nature are not consistent with constipation). RCS "F" said the bowel movements passed by R#7 were not dry or hard. RCS "F" said he notified LVN "X" that R#7 refused to eat breakfast and lunch. RCS "F" said R#7's refusal to eat both breakfast and lunch was unusual behavior for R#7 because R#7 always ate her meals and would frequently ask for second helpings. RCS "F" said shortly after lunchtime on [DATE], R#7 began to vomit clear phlegm. RCS "F" said he notified LVN "X." RCS "F" said he later walked in R#7's room and observed R#7 vomiting coffee ground vomitus and immediately notified new-coming ,[DATE] shift charge nurse LVN "C" and LVN "E" of R#7's symptoms of vomiting. RCS "F" said LVNs "C" and "E" assessed R#7 and sent her to the hospital during the ,[DATE] shift. In a telephone interview with R#7's family member (FM) "G" on [DATE] at 10:41 a.m., FM "G" said R#7 told him she had complained to facility staff that her stomach "really" hurt and told staff several times that day that she "wanted to go to the hospital" on [DATE] during the 6:00 a.m. - 2:00 p.m. shift. FM "G" said R#7 complained to him that staff "wouldn't get to her and she would yell to get their attention." FM "G" said R#7 told him she "pushed the call light but nobody would answer." FM "G" said R#7 told him she thought she was going to die. FM "G" said after R#7 was transferred to Hospital #1 from the nursing facility, R#7 went into [MEDICAL CONDITION]. FM "G" indicated R#7 was then put on a mechanical life support instrument and "halo flighted" to Hospital #2. FM "G" said R#7 did not regain consciousness and was discharged to hospice care where she expired on [DATE]. Review of the facility's PIR dated [DATE] revealed LVN "X" did not notify R#7's physician on [DATE] after R#7 complained of abdominal pain and requested to go to the hospital. Review of Nurses Notes for R#7 dated [DATE] and R#7's chart revealed LVN "X" did not document R#7's requests to go to the hospital, any abdominal or pain assessments, or any change of condition on [DATE]. Review of the facility's PIR dated [DATE] documented RCS "F" asked LVN "E" to "please check" R#7 on [DATE] during the 2:00 p.m. - 10:00 p.m. shift. The Interview Record documented LVN "E" witnessed R#7's "coffee ground vomit" when she entered R#7's room and notified the facility's Registered Nurse (RN) Coordinator to transfer R#7 to the hospital. PIR dated [DATE] revealed LVN "E" was told by RCS "F" on [DATE] during the 6:00 a.m. - 2:00 p.m. shift that LVN "X" ignored R#7's requests to be transferred to the hospital for stomach pain. Record review of R#7's 24 Hour Report/Change of Condition Report on night shift (10:00 p.m. - 6:00 a.m.) dated [DATE] documented R#7 complained of heartburn. The day shift report (6:00 a.m. - 2:00 p.m.) documented R#7 had constipation and to give Tylenol for pain. The evening shift (2:00 p.m. - 10:00 p.m.) documented R#7 was sent to the emergency room for "abdominal pain and coffee ground emesis." Hospital #1 emergency room (ER) records dated [DATE] at 6:20 p.m. revealed R#7 was clinically assessed with [REDACTED]. R#7 was transferred to the Intensive Care Unit (ICU) on [DATE]. Review of Hospital #1 records dated [DATE] revealed R#7 went into cardiopulmonary arrest (heart stopped) and required CPR (Cardiopulmonary Resuscitation). R#7 subsequently required a life-sustaining ventilator. R#7 was later transferred by helicopter to Hospital #2. In an interview on [DATE] at 11:58 a.m., LVN "E" said RCS "F" notified LVN "E" and LVN "C" that R#7 "was not looking good" on [DATE] at approximately 2:30 to 2:45 p.m. LVN "E" said she entered R#7's room and observed R#7 vomiting black vomitus into a basin. LVN "E" said R#7 told her sobbingly, "Miss, I don't feel good." LVN "E" said R#7 requested to see a doctor and wanted to go to the hospital. LVN "E" said R#7 did not normally like doctors and made "every excuse in the book" to miss doctor's appointments. LVN "C" notified R#7's Physician, Physician gave R#7's transfer order to the hospital and R#7 was sent to the hospital. LVN "E" said RCS "F" told her R#7 had passed a soft medium bowel movement earlier that day. LVN "E" said while she and RCS "F" assisted R#7 change clothes, R#7 passed another soft light brown stool. RCS "F" told LVN "E", that he notified LVN "X" "all day long" that R#7 was not feeling well and wanted to go to the hospital. LVN "C" said RCS "F" said he notified LVN "X" that R#7 had not eaten breakfast or lunch and had had a bowel movement that morning ([DATE]). LVN "E" said R#7 was transferred by ambulance to the hospital around 4:30 p.m. LVN "E" said on [DATE] R#7 frequently gagged, moved her head back and forth anxiously and crying, and continued to say "Miss" as R#7 was being transferred to the ambulance outside the facility. In a second interview on [DATE] at 4:44 p.m., LVN "E" said according to her Resident Rights training, a resident had the right to go to the hospital if resident felt that they needed to. LVN "E" said LVN "X" did not respond to R#7's request to go to the hospital and said LVN "X" neglected R#7's pain and requests to go to the hospital. LVN "E" said she did not become aware of R#7's health status until LVN "X" was relieved by LVN "C" and gone for the day. LVN "E" revealed she had concerns with the care R#7's care on [DATE] during the 6:00 a.m. - 2:00 p.m. shift. Review of R#7's Resident Transfer Form dated [DATE], R#7 was transported to the hospital at 4:25 p.m. via ambulance. In an interview on [DATE] at 2:14 p.m., RCS "O" said she helped RCS "F" with R#7 on [DATE]. RCS "O" said R#7 clutched her mid- to low abdomen and said "tengo dolor" (I have pain) and "llevame al hospital" (take me to the hospital). RCS "O" said she told RCS "F" to report R#7's pain to a nurse. RCS "O" said RCS "F" informed RCS "O" that he told the charge nurse. RCS "O" said RCS "F" then spoke to LVN "E". RCS "O" said she (RCS "O") did not see LVN "X" interact or assess R#7. RCS "O" said she helped RCS "F" change R#7 and observed R#7 pass a bowel movement that was not hard or dry. In a second interview on [DATE] at 5:10 p.m., RCS "O" said she considered the care R#7 received on [DATE] to be "neglect." In an interview on [DATE] at 9:55 a.m., the Director of Nurses (DON) said there were many definitions for neglect, including "patient not being attended to or listened to." When the DON was asked about training received on abuse and neglect prevention, the DON said she had received training while in nursing school. The DON said she had not attended any seminars specifically addressing abuse and neglect. When the DON was asked how she identified "Neglect" the DON said if an allegation was brought to her, she would investigate. The DON said, "If I were to see it, I would do an investigation. I have never seen it." When the DON was asked about conditions in which neglect might occur, the DON said "I have never seen it." When the DON was asked about specific conditions in which neglect might be alleged, the DON said "Something might always be alleged." The DON said she had "never seen neglect in its true phase." When the DON was asked how she monitored staff to assure neglect was not occurring in the facility, the DON said she "made rounds frequently" and maintained an "open door policy" to staff and residents. The DON said investigations for possible abuse and neglect were conducted by the facility's Administrator as the Abuse Prevention Program Coordinator. The DON said she assisted with abuse/neglect investigations by gathering information and "sitting in" on interviews. The DON said she "sat in and listened" to two interviews related to the allegation of neglect for the delay in R#7's transfer to the hospital. When asked about an employee counseling form she signed for LVN "X" in which "neglected resident care" was documented, the DON indicated the Administrator documented the finding and she (DON) signed LVN "X" 's counseling form. The DON said the phrase "neglected resident care" referred to a section from the employee handbook on categories of employee misconduct and LVN "X" was terminated from employment at the facility for not documenting. When asked if not documenting was neglect, the DON said "that is why we called you guys" (referencing PIR dated [DATE] to report this incident). The DON said LVN "H" had observed LVN "X" enter R#7's room but the DON did not know whether LVN "H" saw LVN "X" assess R#7. When asked about R#7's requests to go to the hospital due to R#7's abdominal pain, the DON said that "no abnormalities" were identified when an assessment was done by LVN "X" (6:00 a.m. - 2:00 p.m. shift). The DON was asked to show evidence of LVN "X" assessments of R#7 dated [DATE]. The DON said LVN "X" did not document any assessments for R#7 on [DATE] and said that was the reason LVN "X" was terminated. The DON said when R#7 began to have more symptoms, "the coffee ground vomitus," then the facility sent R#7 to the hospital (during the 2:00 p.m. - 10:00 p.m. shift.) When asked about R#7 specifically requesting to go to the hospital, the DON said, "If a resident says they don't feel good, you have to believe them and if you can't pinpoint anything, you have to send them out." When DON was asked if "neglect" occurred if a resident expressed need to go to the hospital and was refused by staff, the DON said, "I would say yes." When the DON was asked about the "Inconclusive" finding of the allegation of neglect investigation for R#7's care on [DATE], the DON said the "Inconclusive" finding result was reached because the Administrator could not speak with R#7 to determine if R#7 had asked to be sent to the hospital. When the DON was asked whether LVN "X" had notified R#7's Physician about R#7's abdominal pain and requests to go to the hospital, the DON said, "I don't know." Several attempts to interview LVN "X" were unsuccessful. In an interview with the facility's Administrator on [DATE] at 9:57 a.m., the Administrator said she was the Abuse/Neglect Coordinator for the facility. The Administrator defined "Neglect" as "not providing basic care for residents." The Administrator gave examples of neglect to include not providing showers to residents, not providing hydration for residents, not providing skilled care if needed or ordered by a physician, and not providing the resident medications as ordered by the physician. The Administrator revealed allegations of Abuse/Neglect were investigated by her and said, "I make the final decision on Abuse/Neglect investigations." The Administrator also stated, "I would consider a license staff member to give a resident an unordered medication as neglect." When the Administrator was asked whether residents were allowed to go to the hospital if the resident requested it, the Administrator said "Yes." The Administrator said, "If a resident tells me or the staff that they are hurting, then we will immediately send them out per Resident Rights." When the Administrator was asked if a licensed staff ignored or denied a resident's request to see a doctor or go to the hospital based on resident pain, would the Administrator consider the licensed staff's actions to be neglect, the Administrator answered, "Yes." The Administrator revealed LVN "X" did not follow facility's policy of Resident Rights to send R#7 to the hospital on [DATE]. Administrator also revealed LVN "X" did not document any of her (LVN "X") assessments of R#7's abdominal pain, medication administration of [MEDICATION NAME], and notification to physician of R#7's abdominal pain and requests to go to the hospital. When the Administrator was asked whether LVN "X" neglected R#7's requests to be sent to the hospital based on abdominal pain and neglected to provide services to avoid physical harm, the Administrator said, "Yes." Review of Resident Rights Policy dated [DATE] revealed the facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Facility staff will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her right. Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety. When the Administrator was asked why she concluded an "Inconclusive" finding for the Abuse/Neglect Investigation dated [DATE] of LVN "X" on the allegation of "Neglect, " the Administrator revealed that two staff members had conflicting information during the (Administrator) interviews. The Administrator said the conflicting information from the staff was whether bowel movement information for R#7 was relayed to LVN "X" by RCS "F" and whether a "BOMB" was administered by LVN "X." The Administrator also said she did not have an opportunity to interview R#7 and did not have "two eye witnesses" to substantiate an allegation of "Neglect." The Administrator then said, "If I have one eye witness, then I can substantiate." The Administrator said she was not aware R#7 called FM "G" on [DATE] and did not interview FM "G." On a follow up interview with the Administrator on [DATE] at 10:25 a.m., the Administrator indicated she wanted to clarify her statements to surveyor from an interview on [DATE]. The Administrator said R#7 was assessed by LVN "X" on [DATE] "to the best of her nursing judgment. She thought she (R#7) was constipated." The Administrator was asked whether LVN "X" was required by facility policy to call the Physician when R#7 complained of pain and requested to go to the hospital. The Administrator said "Yes." The Administer was asked whether LVN "X" was required to document any and all abdominal pain assessments and whether LVN "X" was required to document any medications administered to R#7 by facility policy. The Administrator answered "Yes." The Administrator was asked whether the actions of LVN "X" were considered neglect of R#7. The Administrator said, "Yes." The Administrator then said, "I feel that I have answered all your questions over and over. I feel that I am being interrogated." In an interview with the DON on [DATE] at 3:35 p.m., the DON stated all the nurses were charge nurses. Each charge nurse was responsible for two halls and the CNA's on those halls. The DON stated that on [DATE], LVN "X" was responsible for Hallway "200" and Hallway "400." R#7 resided on Hallway "200" on [DATE]. Record Review of the facility's Abuse & Neglect Prohibition Policy dated ,[DATE] revealed that "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property," and defined Neglect as, "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." It was determined the facility's failure to implement facility policy and procedures that prohibited neglect ---recognizing and acting on change of condition --- placed R#7 in an Immediate Jeopardy (IJ) situation on [DATE]. The facility took the following actions to correct the non-compliance. On [DATE] the facility conducted in-services for facility staff on Abuse and Neglect Prohibition which addressed the resident right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The in-service on Medication Management, Scope of Practice, and Proper Documentation revealed that the Nurse would not administer any medication without a Physician's order; "It is not within the Nursing scope of practice to administer medications without first getting a Physician's order, and documentation of all meds is mandatory." The in-service on Interventions to Reduce Acute Care Transfers was InterACT II ("Early Warning Tool," "Stop and Watch," "Change of Condition File Cards," "Acute Care Transfer Envelope with checklist," and "Quality Improvement Tool for Review of Acute Care Transfers"). The in-service discussed changes of resident condition and the symptoms of mental status change, fever, lower respiratory infection, [MEDICAL CONDITIONS], Urinary Tract Infection [MEDICAL CONDITION], and dehydration. In an interview with the Administrator on [DATE] at 4:05 p.m. revealed the Administrator was a member of the Quality Assessment & Assurance (QA&A) Committee that met monthly. The Administrator said a QA&A meeting was held on [DATE] with agenda items from the previous month including resident "Change of Condition" and would further discuss the reportable incident that occurred on [DATE] and the in-services conducted with the staff on [DATE] at the next scheduled QA&A meeting on [DATE]. During the exit conference meeting on [DATE] at 4:45 p.m., the Administrator, the DON, and the Corporate RN Consultant were informed of the facility's IJ PNC during the period of [DATE] to [DATE]. Opportunity was given to the facility on [DATE] at 10:46 a.m. and [DATE] at 4:45 p.m. during the exit conference to present further evidence regarding implementing the facility's policy. None was given. Based on the Resident Roster dated [DATE] there were 20 residents on Hallway "200" and 14 residents on Hallway "400."

Based on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for three Residents (R#1, 4, and 10) of seven Residents with diabetes whose care was reviewed for medications. The facility failed to administer insulin as ordered by the Physician for: ? Resident #1 (R#1) had diabetes, was receiving both long-acting and rapid-acting insulin to manage blood sugars, and was on [MEDICAL TREATMENT] for kidney disease. ? R#1 did not receive long-acting insulin, [MEDICATION NAME], for 17 days in August, 2011, including the period of time from 08/24/11 to 08/30/11. ? In the last seven days of August, 2011, R#1's blood sugar was measured 19 times; of the 19 measurements, 11 readings were in the 300 to 400's and four readings were so high that the glucose machine read "HI" (high). ? On two of the last seven days in August, 2011, R#1 attended [MEDICAL TREATMENT] where her blood sugars were tested as being over 600 and R#1's blood was also positive for [MEDICATION NAME] which taken along with R#1's high blood sugars could be signs of diabetic ketoacidosis, a condition that could result in coma. ? R#1 had an elevated potassium level in August, that was flagged by the lab as being an "Alert High," related to low insulin that could have resulted in death. ? R#4 did not receive blood sugar measurements and possible doses of rapid-acting insulin 16 times in August 2011. Based on blood sugar measurement, R#4 received the wrong dose of rapid-acting insulin on 8/07/11 at 4:00 p.m. ? R#10 did not receive blood sugar measurements and possible rapid-acting insulin 6 times in August 2011. An IJ was identified on 09/01/11. While the IJ was removed on 09/02/11, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm but less than IJ, because all staff had not been trained on administering and documenting diabetic medications, specifically insulin, as ordered by physicians. The failure to measure blood sugar levels and administer diabetic medications is likely to cause 35 diabetic residents living in the facility to have elevated blood sugar levels which could result in long term complications of diabetes. The findings were: Resident #1 R#1's Face Sheet dated 12/07/2010, revealed that R #1 was [AGE] years old. R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#1's last comprehensive Minimum Data Set 3.0 ((MDS) dated [DATE] described R #1 as: -able to understand others and being understood by others -requiring extensive assistance from one person for transfers, dressing, and personal hygiene -continent of bowel and bladder -for the previous seven days, had received insulin injections seven days -receiving [MEDICAL TREATMENT] treatments -requiring supervision with set up help only for eating and drinking -requiring limited set up assistance for locomotion on the unit R#1's Care Plan initially dated 12/08/10 and reviewed 07/28/11 revealed a plan for "Hypo/Hyper Glycemia" (low/high blood sugar) related to [DIAGNOSES REDACTED]." Additional interventions included: -"observe for signs and symptoms of hypo/[MEDICAL CONDITION], excessive thirst, frequent urination, clammy skin, confusion -finger stick blood sugars as ordered -sliding scale insulin as ordered -diet as ordered -observe for dietary compliance -educate individual and caregivers regarding risks of hyper/hypo glycemia -RD (Registered Dietician) consult as needed -monitor labs as ordered -notify MD (Medical Doctor) as indicated" R#1's Comprehensive Care Plan initially dated 12/28/10 and reviewed 07/28/11 revealed the facility identified "Problem" with "Short and Long Term Memory" for R #1. Review of R#1's Physician's Telephone Orders revealed an order dated 08/09/11 for: -"Start [MEDICATION NAME] (long-acting form of insulin that is given once a day and is absorbed slowly into the body over 24 hours) 70U (units) SQ (subcutaneous, under the skin, injection) Q (every) AM (morning)" -"Start Humalog (rapid-acting form of insulin that starts to take effect in 15 minutes and lasts approximately 2 - 3 hours) SQ per S/S (sliding scale - amount of insulin given depending on a person's blood sugar as measured immediately before giving the insulin)." Review of R#1's Physicians Order Sheet revealed an order dated 08/09/11 for "Humalog R 100 units/ml (milliliter) Vial Subcutaneous (SQ)" BID (twice a day). Fingersticks BID Per S/S:" "-150-200=0U insulin -201-250=2U insulin -251-300=4U insulin -301-350=6U insulin -351-400=8U insulin -for bg (blood glucose) (less than) 70 if res.(resident) is alert & responsive adm (administer) 8oz (ounces) orange juice w/2tbs (with 2 tablespoons) sugar then check bg after 15 min. - for bg (less than) 70 if res. is unresponsive adm. glucogen (sugar) 1gm (gram) im (intramuscular injection) then call m.d. (medical doctor) if (greater than) 400" (if the resident's blood sugar is low and the resident is alert, have resident drink orange juice with sugar added and re-check blood sugar after 15 minutes; if the resident's blood sugar is low and the resident is unconscious, give a shot of sugar in a muscle then call resident's doctor) Review of R#1's Physicians Order Sheet for August, 2011, revealed an order for [REDACTED]. Review of R#1's Blood Glucose Tracking/Sliding Scale Insulin Administration Record" dated August, 2011 revealed that fingerstick procedures to measure blood sugar were to be done "Before and After Meals" and that Humalog insulin was to be given at 5 a.m. and 5 p.m. only. Physician was to be called for blood sugar measurements over 400 and 10U of insulin was to be given. Diabetes is a condition caused when the body does not make enough of a chemical, insulin, needed to help sugar, glucose, to enter the cells of the body. Sugar stays in the blood and can cause symptoms like blurred vision, fatigue, and nausea. The individual with high blood sugar can be at risk for infections and for a slower recovery from infections. Long term complications of diabetes can include problems with blood circulation to the feet and lower legs and to the kidneys. Problems with the kidneys may need [MEDICAL TREATMENT] treatments (removal of liquid and chemicals by a machine that would normally be removed by the kidneys). One of the treatments of diabetes is the use of the medicine insulin. Insulin helps sugar move from the blood into the body's cells where sugar can be used for energy. Insulin also helps the mineral potassium to stay in the body's cells and to keep it from moving from the cells into the blood. When insulin levels in the blood are low, potassium levels may become high. If potassium levels in the blood are too high, the heart may be affected. The movement of the heart can become abnormal and can result in death. (Information on diabetes summarized above was found in "The Merck Manual of [DIAGNOSES REDACTED].) On 08/30/11 at 11:35 a.m., Licensed Vocational Nurse (LVN) "D" was observed performing a fingerstick procedure on R #1 to measure blood sugar level. The glucometer (small portable machine used to measure blood sugar) read "HI." On 08/30/11 at 11:35 a.m., LVN "D" said that a blood sugar reading of "HI" meant that the blood sugar was measuring over 400mg/dl. LVN "D" said that she was going to call R#1's Physician regarding the reading and would administer insulin based on R#1's physician's orders [REDACTED]. On 08/30/11 at 11:35 a.m., R#1 said that she had been feeling nauseated earlier that day and had been given a "pill" for the nausea. R#1 said that she was feeling better at that moment. On 08/30/11 at 11:45 a.m., LVN "D" said that she had called R#1's Physician and that she would be giving R#1 10U of Humalog (rapid-acting insulin). LVN "D" was observed measuring 10U of Humalog insulin into a syringe. LVN "D" located R#1 in the dining room and took R #1 back to her room. As R#1 was being taken to her room, she was telling LVN "D" to "hurry." Upon arrival in R#1's room, LVN "D" handed R#1 a basin into which R #1 vomited. R #1 did not report having any other symptoms at that time. At 11:53 a.m., LVN "D" administered 10U of Humalog insulin to R#1. LVN "D" took R #1 back to the dining room for lunch. R#1 waited for lunch in the dining room. On 08/30/11 from 11:59 a.m. until 12:25 p.m., during medication pass, LVN "D" was observed performing fingerstick procedures for blood sugar measurements on four additional residents. LVN "D" administered rapid-acting insulin to two of these residents. LVN "D" was not observed administering [MEDICATION NAME] to R#1 at that time. R#1 was observed eating lunch without any further observed episodes of vomiting. In an interview on 08/31/11 at 7:40 a.m., R#1 said that she would get nauseated and vomited when her blood sugar was high. R#1 said that she would receive one shot of insulin before going to [MEDICAL TREATMENT] but did not remember receiving both [MEDICATION NAME] and Humalog before going to [MEDICAL TREATMENT] R#1 said that she relied on the staff at the facility to give her care in regard to her medications and diet. R#1 could not say how often she would experience nausea and vomiting. In an interview on 09/01/11 at 11:50 a.m., LVN "H" who worked on the day shift, 6:00 a.m. to 2:00 p.m., said that she had not given R#1 [MEDICATION NAME] at 6:00 a.m., during the month of August. In a telephone interview on 09/01/11 at 11:58 a.m., LVN "M" said that she had been working at the facility for seven months on the 10:00 p.m. to 6:00 a.m., shift. LVN "M" said that insulins scheduled for 6:00 a.m., such as R#1's [MEDICATION NAME], were given by nurses working on the day shift (6:00 a.m. to 2:00 p.m.). LVN "M" said that R#1 usually went to [MEDICAL TREATMENT] at 5:00 to 5:30 a.m. and that R#1's blood sugar was measured at 5:00 a.m. LVN "M" said that she had given R#1 Humalog insulin at 5:00 and had called R#1's Physician if R#1's blood sugar was over 400. Review of R#1's record revealed that there were two separate record sheets for documenting R#1's two types of insulin. The Medication Administration Record documented administration of [MEDICATION NAME] and the Blood Glucose Tracking/Sliding Scale Insulin Administration Record documented administration of Humalog insulin. Additionally, the Blood Glucose Tracking/Sliding Scale Insulin Administration Record was used to document R#1's blood sugar measurements. Review of R#1's Blood Glucose Tracking/Sliding Scale Insulin Administration Record for August, 2011, revealed the Blood Glucose Order (for measuring glucose) was transcribed as: "FS (fingerstick) Before and After Meals." At the top right corner "[MEDICATION NAME] R" was written in but had a line drawn through it and "Humalog" was written in above "SQ S/S @ 5A/5P only." At the bottom of the medication/blood sugar reading graph under the 11:00 a.m., reading space, the following was written in, "[MEDICATION NAME] only" and next to this "F/S only [MEDICATION NAME] insulin." Nurses had documented blood sugar readings at 5:00 a.m., 11:00 a.m., and 5:00 p.m. Nurses had documented giving only Humalog insulin on this medication record. [MEDICATION NAME] was not documented on this record as having been given at any time. From 08/25/11 through 08/31/11, R#1's blood glucose was measured three times a day for a total of 19 times. R#1's blood sugar measurements were: 08/25/11 5AM 247 11AM 398 5PM 390 08/26/11 5AM HI 11AM 400 5PM 400 08/27/11 5AM --- 11AM --- 5PM 400 08/28/11 5AM 398 11AM 305 5PM 400 08/29/11 5AM HI 11AM 420 5PM 408 08/30/11 5AM 147 11 AM HI 5PM 400 08/31/11 5AM HI Review of the Blood Glucose Tracking/Sliding Scale Insulin Administration Record and the Medications Administration Record revealed that [MEDICATION NAME] was not documented as having been given to R#1 on any day from 08/24/11 to 08/30/11. Review of R#1's Medication Administration Record (MAR) for August, 2011, revealed that an order for [REDACTED]. Starting on 08/10/11, the administration entry blocks for the following dates were filled by circled initials: 08/11/11, 08/12/11, 08/15/11, 08/17/11, 08/18/11, 08/22/11, 08/23/11, and 08/24/11. The administration entry blocks were empty for 08/16/11, 08/19/11, 08/21/11, and 08/25/11 through 08/30/11. Review of the MAR Nurses' Notes revealed no documentation of reasons for the administration entry blocks left either blank or filled by circled initials. Long-acting insulins are given to maintain steady levels of insulin over a long period of time, such as 24 hours. Rapid-acting insulins are given to lower high levels of blood sugar for a short period of time; they may be given prior to a meal in anticipation of food consumed further elevating the blood sugar. The two forms of insulin may be used in combination to manage blood sugars. (Information on diabetes summarized above was found in "The Merck Manual of [DIAGNOSES REDACTED].) Interviews with LVN "C" and LVN "T" on 09/01/11 at 6:30 p.m. and 6:38 p.m., revealed that both said either an empty administration entry block or one filled with a circled initial meant that a medication was not given. LVNs "C" and "T" both said that when a medication was not given, documentation should be entered in the MAR Nurses' Notes explaining the reason for not giving a medication. In an interview on 09/07/11 at 11:00 a.m., LVN "D" said that insulins scheduled for 6:00 a.m. administration were given by the night shift. LVN "D" said that if R #1's [MEDICATION NAME] administration had been changed from 6:00 a.m. to 11:00 a.m., she did not remember giving R #1 any [MEDICATION NAME] at 11:00 a.m. in August. LVN "D" did remember giving R #1 Humalog insulin with the 11:35 a.m., blood glucose measurement on 08/30/11. LVN "D" said that circled initials on a medication entry block meant that medication was not given. LVN "D" said that she would not document reason for not giving a medication. In an interview on 08/31/11 at 1:35 p.m., LVN "H" said that she had been working at the facility for two years. LVN "H" said that 6:00 a.m., scheduled doses of insulin were given by the night shift (10:00 pm. to 6:00 a.m.) nurses. In an interview on 08/31/11 at 8:15 a.m., [MEDICAL TREATMENT] center Registered Nurse (RN) "U" said that R#1 would arrive at the [MEDICAL TREATMENT] center at 6:00 a.m., or earlier and that many times her blood sugar was elevated. RN "U" said that it was the practice of the [MEDICAL TREATMENT] center to test R#1's potassium levels at least once a month. RN "U" provided information from R #1's August, 2011 [MEDICAL TREATMENT] record from the [MEDICAL TREATMENT] center. The facility would send a [MEDICAL TREATMENT] Communication Record with R #1 that documented R #1's blood sugar measurements immediately before transfer to the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] Communication Record also documented medications, including insulin, given to R #1 prior to transfer to the [MEDICAL TREATMENT] center. The following information for R#1 was noted in [MEDICAL TREATMENT] center record and the facility Blood Glucose Tracking/Sliding Scale Insulin Administration Record for the R #1's visits from 08/12/11 to 08/29/11: --08/12/11 -- R#1 arrived at 6:06 a.m., blood sugar at 6:38 a.m., was 242. (blood sugar at 5:00 a.m., at the facility was 395 -- no [MEDICATION NAME] or Humalog insulin documented given) --08/15/11 -- R#1 arrived at 6:07 a.m., blood sugar at 6:09 a.m., was 59; R #1 was given [MEDICATION NAME] (sugar) through an IV (intravenous line) and food to eat. Blood sugar at 10:29 a.m., was 98. (blood sugar at 5:00 a.m., at the facility was 139 -- no [MEDICATION NAME] or Humalog insulin documented given) --08/17/11 -- R#1 arrived at 5:55 a.m. [MEDICAL TREATMENT] physician on call was notified regarding R #1's laboratory - potassium level of 9.0 mEq/L (normal range 3.5 to 5.1). Blood sugar at 6:10 a.m., was 77. R#1 was given food to eat. Blood sugar at 10:34 a.m., was 98. R#1 was scheduled for an extra treatment the next day. (blood sugar at 5:00 a.m., at the facility was 112 -- no [MEDICATION NAME] or Humalog insulin documented given) --08/18/11 -- R#1 arrived at 6:19 a.m., blood sugar at 7:25 a.m., was 130 (blood sugar at 5:00 a.m., at the facility was 400 -- 8U Humalog insulin given, no [MEDICATION NAME] documented given) --08/19/11 -- R#1 arrived at 6:15 a.m., blood sugar was 215. Note made that R#1's blood sugar was measured at the facility prior to transfer to [MEDICAL TREATMENT] and was 390; the facility did not provide documentation (on the [MEDICAL TREATMENT] Communication Record) to the [MEDICAL TREATMENT] unit that insulin was given to R #1 prior to transfer. (blood sugar at 5:00 a.m., at the facility was 390 -- 8U Humalog insulin given, no [MEDICATION NAME] documented given) --08/24/11 -- R#1 arrived at 5:49 a.m., blood sugar at 5:52 a.m., was 454. Blood sugar at 6:48 was 241. (blood sugar at 5:00 a.m., at the facility was 490 -- 10U Humalog insulin given, no [MEDICATION NAME] documented given) --08/26/11 -- R#1 arrived at 6:36 a.m. Note entered at 6:37 a.m., documented that facility LVN "M" had told the [MEDICAL TREATMENT] staff that R#1's blood sugar was "high" and that R#1's Physician had been notified and ordered that R#1 be given 10U of Humolog insulin. LVN "M" told the [MEDICAL TREATMENT] staff that 45 minutes after receiving the insulin, R #1's blood sugar measurement was still reading "high" and that R#1's Physician had given an order that R #1 was to be transferred to the [MEDICAL TREATMENT] unit for scheduled treatment. Blood sugar at 6:40 a.m., was measured as reading "HI with keytones ([MEDICATION NAME])" (clarification was given by RN "U" that a "HI" reading meant over 600). Blood sugar at 7:11 a.m., was "HI" with [MEDICATION NAME]. Blood sugar at 8:07 a.m., was 407 with [MEDICATION NAME]. Blood sugar at 8:11 a.m., was 425. Blood sugar at 9:03 a.m., was 355 with [MEDICATION NAME]. R #1 was scheduled for an additional [MEDICAL TREATMENT] treatment the next day (blood sugar at 5:00 a.m., at the facility was "HI" -- 10U of Humolog insulin given, no [MEDICATION NAME] documented given) (Low insulin levels can cause the body to start using fat for energy. When fat is used by the body for energy chemicals called [MEDICATION NAME] are formed that can cause an abnormal condition called diabetic ketoacidosis. Diabetic ketoacidosis can cause an individual to go into a coma. In diabetic ketoacidosis, the blood sugar levels may be as high as 400 to 800mg/dl (milligrams per deciliter; normal blood sugar levels are 70 to 100mg/dl) and potassium may be high (normal potassium levels are 3.5 to 5.1 mEq/L - milliequivalents per liter). Lab findings in people who are having diabetic ketoacidosis include high blood sugars and the presence of the chemical [MEDICATION NAME]. Information on diabetes summarized above was found in "The Merck Manual of [DIAGNOSES REDACTED].) --08/27/11 -- R#1 arrived at 11:21 a.m., blood sugar at 12:40 p.m., was measured as being "high with [MEDICATION NAME]." Blood sugar at 3:02 p.m., was 385. (blood sugar at 5:00 a.m., at the facility was not documented and no [MEDICATION NAME] or Humalog insulin was documented as having been given. Blood sugar also was not documented at 11:00 a.m., or prior to R#1 leaving the facility to go to [MEDICAL TREATMENT]) --08/29/11 -- R#1 arrived at 6:32 a.m. Note made at 7:06 a.m., documented that facility LVN "D" had called the [MEDICAL TREATMENT] unit to inform them that R #1's blood sugar that morning had read "high" and that no insulin had been given. LVN "D" told the [MEDICAL TREATMENT] staff that R#1's Physician had given an order to send R #1 for scheduled [MEDICAL TREATMENT] treatment. Blood sugar at 7:30 a.m., was 486. Blood sugar at 8:09 a.m., was 438. Blood sugar at 9:03 a.m., was 370. Blood sugar at 10:16 a.m., was "323, [MEDICATION NAME]?" Blood sugar at 10:59 a.m., was "331, [MEDICATION NAME]?" [MEDICAL TREATMENT] staff consulted one of their Physicians and obtained an order to transfer R #1 to an emergency room for evaluation after completing [MEDICAL TREATMENT] treatment. Note was made at 2:35 p.m., [MEDICAL TREATMENT] staff contacted the facility and spoke with LVN "D" who said that R#1 was playing Bingo and was asymptomatic. LVN "D" told [MEDICAL TREATMENT] staff that she was not aware of R#1 having gone to the emergency room that day. (blood sugar at 5:00 a.m. at the facility was "HI" -- no [MEDICATION NAME] or Humalog insulin documented given) [MEDICAL TREATMENT] "Biochemical Lab Report" dated 08/31/11 revealed R#1's potassium readings to be: -08/15/11 -- 9.0 AH (Alert High) -08/17/11 -- 6.9 H (High) -08/26/11 -- 5.7 In an interview on 08/31/11 at 2:17 p.m., the Director of Nurses (DON) was shown R#1's MAR and Sliding Scale Insulin Administration Records. The DON said that she was not aware that R#1 may not have received insulin as ordered by her Physician. The DON was also shown a copy of R#1's [MEDICAL TREATMENT] facility lab report documenting the potassium level of 9.0., a copy of which was on R#1's facility record. The DON said that she was surprised that R #1 had not shown signs of heart problems with her potassium at that level. In reviewing the Sliding Scale Insulin Administration Record showing R#1's blood sugar readings of "HI", the DON said that "HI" meant the blood sugar was greater than 500. When asked if R#1's Physician had been notified of R#1 not receiving [MEDICATION NAME] in August, the DON said that he had not. The DON said that she had been the DON of the facility for five months and was learning the facility systems. In an interview on 09/01/11 at 10:12 a.m., the DON said that she had found out from interviewing nurses working on the 10:00 p.m. to 6:00 a.m., shift that the scheduled time for R#1's [MEDICATION NAME] had been moved from 6:00 a.m., to 11:00 a.m. and that this was noted at the bottom of the Sliding Scale Insulin Administration Record graph. The DON said that all insulin received by R #1 at 11:00 a.m., in August had been [MEDICATION NAME]. The DON did not respond when surveyor told her that insulin observed given to R#1 on 08/30/11 at 11:53 a.m. was Humalog not [MEDICATION NAME]. When asked who had changed the [MEDICATION NAME] administration time from 6:00 a.m., to 11:00 a.m., the DON said that she did not know. During the interview with the DON on 09/01/11 at 10:30 a.m., LVNs "H" and "I" were called into the DON's office. They were asked if they had given R#1 [MEDICATION NAME] at 11:00 a.m. in August. LVN "H" said that she had not given R#1 [MEDICATION NAME] at 11:00 a.m. in August. LVN "I" said that he had given R#1 [MEDICATION NAME] a couple of times in August at approximately at 7:00 a.m., but not at 11:00 a.m. In an interview on 09/01/11 at 11:43 a.m., the DON was asked if R#1's Physician had been informed of R#1 not receiving [MEDICATION NAME] as ordered in August and that R#1 had experienced a potassium level of 9.0 in August. The DON said that there was no documentation of a call having been made to R#1's Physician. In an interview on 09/01/11 at 11:53, the DON was asked a second time if R#1's Physician had been informed of R#1 not receiving [MEDICATION NAME] as ordered in August and of R#1 having had a potassium level of 9.0 in August. The DON said that the call to R#1's Physician was being made by a nurse at that moment. An Immediate Jeopardy (IJ) was called on 09/01/11 at 5:45 p.m. Present at the IJ meeting were the facility Administrator, the DON, and the facility Clinical Consultant. The facility presented a plan at 7:00 p.m. that listed steps the facility would follow that evening and the next day to monitor that diabetic residents would have blood sugar testing and medications administered per their individual physician's orders [REDACTED]. The facility's plan of removal for the IJ was accepted on 09/02/11 and included the following: -evaluation and implementation of a plan of care for diabetics made the facility interdisciplinary team -nurses would obtain and document blood glucose measurements according to Physicians' orders -nurses would administer and document medications according to Physicians' orders -residents leaving for [MEDICAL TREATMENT] treatments would have blood glucose measurements prior to leaving the facility and upon returning to the facility. Diabetes medications would be given according to Physicians' orders -care of diabetic residents would be monitored during the Care Management Risk Review weekly meetings for six months -the DON would ensure that medication administration records and care plans were updated as needed -nurses would be given in-services regarding facility policy on "Diabetic Management," documenting blood glucose measurements, administration of insulin injections, use of sliding scale insulin, and [MEDICAL TREATMENT] residents blood sugar measurements and insulin administration -nurse managers would monitor insulin administration records on a daily basis -the Quality Assessment and Assurance Committee would monitor compliance with the plan of removal weekly for four weeks, then monthly In an interview on 09/02/11 at 10:25 a.m., R#1's Physician, the facility's Medical Director, was asked if he had been notified that R #1 did not receive [MEDICATION NAME] as ordered in August, including none for the last consecutive seven days of the month. He said that R#1 was a "brittle diabetic" (individual whose diabetes is difficult to manage and who can have blood glucose levels that vary widely between very low and very high). R#1's Physician said that he had not been made aware that R #1 had not received [MEDICATION NAME] during part of August, 2011. When asked if the facility staff had informed him of R #1's potassium level being 9.0 in August, 2011, R#1's Physician said that such a reading was "not compatible with life." R#1's Physician said that the facility staff had not called him to inform him of R#1's potassium level. In an interview on 09/07/11 at 11:15 a.m., Physician "L", a Nephrologist (doctor who specializes in disorders of the kidneys), and the Medical Director of the [MEDICAL TREATMENT] center where R#1 was receiving [MEDICAL TREATMENT], said that low insulin blood levels could result in high potassium levels. Physician "L" said that high potassium levels could result in death. In a follow-up interview on 09/22/11 at 3:35 p.m., the DON was asked why an IJ was called for the facility on 09/01/11. The DON said she was confused about the IJ and said she thought the IJ was called because R#1's high potassium level was not reported to R#1's doctor in August, 2011. DON was asked whether she was following the facility's IJ Plan of Removal dated 09/02/11. DON said yes. The DON said, "I'm one person. I do the best I can." The DON also said, "It (following facility policy and procedures for medication administration) was implemented before, but if you don't stay on top of them, they (nurses) do what they want." DON was asked if she was ensuring that facility staff were following facility policy and procedures (medication administration, proper documentation, and notifying doctors of resident change of condition) after surveyor intervention. DON said "yes" and referred to the facility's IJ Plan of Removal dated 09/02/11. Resident #4 Review of R#4's Face Sheet dated 07/06/11 revealed that R#4 was admitted to the facility on [DATE]. R#4's admitting [DIAGNOSES REDACTED]. R#4's comprehensive MDS 3.0 dated 08/25/11 described R#4 as: -able to understand others and being understood by others -requiring extensive assistance for transfers, dressing, and personal hygiene -requiring insulin injections every day for the previous seven days -was receiving [MEDICAL TREATMENT] treatments August, 2011 Physician's admission orders [REDACTED] -BS (blood sugar) accu (check) AC & HS (blood sugar measurements by fingerstick before meals and at bedtime) with -[MEDICATION NAME]SQ per S/Scale: 151-200=3 units 201-250=5 units 251-300=7 units 301-350=9 units 351-400=11 units >(greater than) 400 call M.D. (physician) Review of R#4's Blood Glucose Tracking/Sliding Scale Insulin Administration Record for August, 2011 revealed missed blood glucose measurement times. If blood sugars had been greater than 150, insulin should have been given: -blood glucose was to be measured and insulin given at 5:00 a.m., 11:00 a.m., 5:00 p.m., and 8:00 p.m. -08/05/11 missed 11:00 a.m. -08/06/11 missed 11:00 a.m. -08/07/11 missed 11:00 a.m., blood sugar at 4:00 p.m. was 200 and 7 units [MEDICATION NAME] given (for a blood sugar of 200, 5 units [MEDICATION NAME] should have been given) -08/19/11 missed 11:00 a.m. -08/20/11 missed 11:00 a.m., 5:00 p.m., and 8:00 p.m., -08/21/11 missed 5:00 p.m. and 8:00 p.m. measurements -08/22/11 missed 5:00 p.m. -08/23/11 missed 5:00 p.m. -08/25/11 missed 11:00 a.m. and 8:00 p.m. -08/26/11 missed 11:00 a.m. -08/27/11 missed 5:00 a.m. -08/28/11 missed 5:00 p.m. -08/30/11 missed 5:00 p.m. There was no documentation on the Nurses' Notes of R#4's Medication Administration Record as to the reason for the missed blood sugar measurement. Review of facility Medication Variance Report dated 09/01/11 and completed by LVN "E" documented that the above missed glucose measurements and possible missed insulin doses were caused by a "policy and procedure issue." In an interview on 09/08/11 at 9:55 a.m., the DON said that nurses had been counseled regarding medications not given in August. When asked the reasons that nurses gave for not giving medications, the DON said that some nurses said they had become busy, they forgot to document, and some nurses did not give any reason for not administering medications. R#10 Record review of R#10's Face Sheet dated 07/29/11 revealed R#10 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of R#10's September/2011 MAR revealed a [DIAGNOSES REDACTED]. R#10's MAR August/2011 revealed an order, dated 8/22/11, for [MEDICATION NAME] Insulin subcutaneous (under the skin injection) AC (before every meal) and HS (at the hour of sleep). Based on AC and HS FS (fingerstick) blood sugar measurement results, [MEDICATION NAME] Insulin would be administered using the following Blood Glucose Mild Sliding Scale: -150-200 (BG)= 0 units of [MEDICATION NAME] Insulin -201-250 (BG)= 2 units of [MEDICATION NAME] Insulin -251-300 (BG)= 4 units of [MEDICATION NAME] Insulin -301-350 (BG)= 6 units of [MEDICATION NAME] Insulin -351-400 (BG)= 8 units of [MEDICATION NAME] Insulin -Over 400 notify physician. Record review of R#10's Blood Glucose Tracking/Sliding Scale Insulin Administration Records dated July/2011 and August/2011 revealed blank spaces for FS values and blank spaces for [MEDICATION NAME] Insulin subcutaneous injections for the following times and dates with no documentation on the back of the MARs indicating reasons for missed FS(s) and missed [MEDICATION NAME] Insulin injections. -08/23/11 at 5:00 p.m. -08/24/11 at 5:00 p.m. -08/25/11 at 5:00 p.m. -08/27/11 at 5:00 a.m. -08/29/11 at 5:00 p.m. -08/30/11 at 11:00 a.m. Record review of the facility's Medication Variance Report dated 09/01/11 confirmed missed blood sugar measurements and possible missed doses of [MEDICATION NAME]for the dates listed from 08/23/11 to 08/30/11 as ordered by the physician for R#10. The Medication Variance Report stated that staff did not follow the facility's policy and procedure for medication administration and documentation. Facility's Management Action for the medication variances was "counseling of all LVNs." R#10's Responsible Party (RP) "Y" was notified on 09/01/11 at 8:00 p.m. by LVN "A" of R#10's missed insulin injections with no documentation of the missed insulin injections on the MAR. R#10's August/2011 Blood Glucose Tracking/Sliding Scale Insulin Administration Record revealed R#10 consistently required multiple daily [MEDICATION NAME] Insulin Subcutaneous Injections per mild sliding scale per blood glucose readings. Interview with LVN "A" on 09/07/11 at 10:45 aXX

Based on observation, record review, and interview the facility failed to implement facility written policies and procedures to prohibit neglect for one Resident (R#7) of 10 Residents whose care was reviewed. ? The facility nurse failed to document assessments for R#7 who complained of abdominal pain, did not consult R#7's physician, and did not immediately transfer R#7 to the hospital when at approximately 10:30 a.m. R#7 said she did not feel well, had abdominal pain and requested to be seen by a Physician in the hospital. ? R#7 was alert and oriented with a history of gastrointestinal (GI) problems who had not eaten breakfast or lunch and complained of abdominal pain to facility staff during the 6:00 a.m. - 2:00 p.m. shift and the 2 p.m.-10 p.m. shift on [DATE]. ? R#7 was transferred to the hospital at approximately 4:25 p.m. after R#7 began to throw up coffee ground vomitus (dark brown vomitus with the color and consistency of coffee grounds, composed of [MEDICAL CONDITION] acids and old blood and indicative of slow upper [MEDICAL CONDITION]) with a [DIAGNOSES REDACTED]. ? R#7 expired at the hospital on [DATE]. This facility failure was determined to be past non-compliance (PNC) due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the complaint investigation. The facility's failure to implement their policy and procedures that prohibit neglect could have affected all 34 residents in hallway "200 and 400" where Licensed Vocational Nurse (LVN) "X" was scheduled to work and could result in their medical condition deteriorating and lead to death. Findings included: After administrative review the investigation was reopened on [DATE]. The original exit date was [DATE]. Review of Changes in Resident Condition Policy dated [DATE] and revised [DATE] revealed the resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. The Change of Condition Forms also documented that the forms were used to assess and document changes in condition in an efficient and effective manner; provide assessment information to the physician, and provide clear comprehensive documentation. R#7's Face Sheet dated [DATE] indicated R#7 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#7 was allergic to [MEDICATION NAME], and [MEDICATION NAME]. Physician's Order dated [DATE] revealed R#7 had a [DIAGNOSES REDACTED]. Record review of R#7's (MDS) minimum (MDS) data set [DATE] revealed R#7 had the ability to express ideas and wants, understood verbal content, had clear speech with distinct intelligible words, and had the ability to understand others with clear comprehension. Cognitive Pattern section indicated R#7 did not have any inattentive behaviors, disorganized thinking, altered level of consciousness, or any evidence of acute change in mental status from R#7's baseline. R#7 was able to report correct day, month and year. Record review of the Provider Investigation Report (PIR) Department of Aging and Disability Services (DADS) Form 3613-A dated [DATE] indicated an Incident Investigation was conducted by the facility for an allegation of Neglect. The PIR documented Licensed Vocational Nurse (LVN) "X" to be the alleged perpetrator and R#7 as the alleged victim. The PIR documented Resident Care Specialist (RCS) "F" notified LVN "X" on [DATE] during the 6:00 a.m. - 2:00 p.m. shift that R#7 complained of abdominal pain and requested to go to the hospital. RCS "F" reported to LVN "X" that R#7 did not eat breakfast or lunch and R#7 had had a bowel movement on [DATE], that same morning. The PIR documented LVN "X" notified LVN "H" that R#7 had abdominal pain and requested to go to the hospital. The PIR documented LVN "H" told LVN "X" that R#7 needed to be assessed. The PIR documented LVN "H" later saw LVN "X" in the hallway with a stethoscope around her neck and LVN "X" reported to LVN "H" that R#7 had slow bowel sounds, vital signs were within normal limits (WNL) and R#7 appeared to be constipated. The PIR documented LVN "X" gave R#7 [MEDICATION NAME] (stool softener). The PIR documented LVN "X" did not document R#7's gastrointestinal assessment. The PIR documented that R#7 continued to complain of stomach pain on the 2:00 p.m. - 10:00 p.m. shift and vomited coffee ground vomitus. The PIR documented LVN "C" (2:00 p.m. - 10 p.m. shift) sent R#7 to the hospital. The facility's PIR dated [DATE] indicated LVN "X" did not remember RCS "F" telling LVN "X" that R#7 did not eat breakfast that morning ([DATE]) but LVN "X" (personally) remembered R#7 did not eat lunch that day. The PIR indicated LVN "X" did not remember RCS "F" telling LVN "X" R#7 had a bowel movement on [DATE] during 6:00 a.m. - 2:00 p.m. shift. The PIR revealed LVN "X" said she never called R#7's Physician about R#7's abdominal pain and did not document any of her (LVN "X") assessments in R#7's chart. The PIR documented LVN "X" said she gave R#7 MOM (milk of magnesium) "from the blue bottle" but did not remember whether R#7 had an order for [REDACTED]. Review of R#7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"AA." R#7's MAR indicated [REDACTED]. The facility Administrator suspended LVN "X" pending the investigation. In-services on Abuse and Neglect, Medication Management and InterACT II were conducted for facility staff on [DATE]. The facility Administrator's Investigative Findings for LVN "X" were "Inconclusive" for the allegation of Neglect. The PIR Provider Action Taken Post-Investigation was the termination of LVN "X" for the lack of documentation of her assessment of R#7 on [DATE]. Review of the facility's PIR dated [DATE] documented LVN "C" was notified by LVN "X" during shift change that R#7 was "constipated" and LVN "X" had given R#7 a "BOMB" which was a mixture of Milk of Magnesium, [MEDICATION NAME], and prune juice. The facility's Interview Record documented LVN "X" told LVN "C" to give R#7 another "BOMB" if R#7 complained again. Record review of R#7's Physician's Orders dated [DATE] revealed R#7 was ordered to receive [MEDICATION NAME] 10 grams by mouth (gm) /15 mililiters (ml) solution every day at 8:00 a.m. for constipation. Review of the Physician's Orders did not contain any order for Milk of Magnesium, prune juice, "BOMB", or to administer a "BOMB" if R#7 complained of abdominal pain. In an interview with LVN "C" on [DATE] at 4:55 p.m. revealed LVN "C" was the 2:00 p.m. - 10:00 p.m. charge nurse for hallways "200" and "400" on [DATE]. LVN "C" said LVN "X" was the charge nurse for hallways "200" and "400" who worked the 6:00 a.m. - 2:00 p.m. shift on [DATE]. LVN "C" said LVN "X" reported to her during shift change at 2:00 p.m. on [DATE] that R#7 had been complaining of stomach pain during the day. LVN "C" said LVN "X" gave R#7 a "BOMB." LVN "C" said LVN "X" described the "BOMB" to be a mixture of laxatives including prune juice, [MEDICATION NAME] (stool softener) and milk of magnesirum. LVN "C" said she had "never heard of a BOMB before," and said the "BOMB" was not ordered on R#7's MAR. LVN "C" said after report with LVN "X", she started to check residents at 2:30 p.m. LVN "C" said RCS "F" approached her in the hallway and asked her to check R#7 because R#7 "didn't look like herself." LVN "C" said RCS "F" also notified LVN "E" about R#7's condition. LVN "C" said she found R#7 to have pale skin, intense abdominal pain, crying, and was throwing up coffee ground emesis (vomit). LVN "C" said R#7 notified her she wanted to go to the hospital. LVN "C" said R#7 also told RCS "F" she wanted to go to the hospital. LVN "C" said she notified her supervisor immediately and asked LVN "E" for assistance. LVN "C" said R#7's physician was called and R#7 was sent to the hospital. Interview with LVN "E" on [DATE] at 2:07 p.m. revealed she (LVN "E") was notified by RCS "F" on [DATE] during the 2:00 p.m. - 10 p.m. shift that R#7 felt ill and to "please check on her." LVN "E" went to R#7's room and observed LVN "C" entering R#7's room. LVN "E" said she heard R#7 say she did not feel well and observed an emesis basin half full with black emesis next to R#7. LVN "E" said the amount of black vomit in the basin was substantial and probably accumulated from an extended period of several hours. LVN "E" said she obtained R#7's blood pressure, respirations, and pulse rate (vital signs) and called her supervisor. LVN "E" then notified R#7's Physician. R#7's Physician gave order to send R#7 to hospital. LVN "E" said LVN "X" was the charge nurse responsible for R#7 that day on the 6:00 a.m. - 2:00 p.m. shift and LVN "X" did not call R#7's Physician about R#7's abdominal pain and R#7's requests to go to the hospital throughout the 6:00 a.m. - 2:00 p.m. shift. LVN "E" revealed she and LVN "C" assessed R#7 to be in distress, have an immediate need to go to the hospital and responded accordingly. LVN "E" said R#7 was alert, crying in obvious pain, and requested several times to go to the hospital. In an interview on [DATE] at 1:38 p.m., RCS "F" said he worked the 6:00 a.m. to 2:00 p.m. shift on [DATE] and had taken care of R#7. RCS "F" said R#7 had refused to eat breakfast and RCS "F" notified the charge nurse, LVN "X". RCS "F" said at approximately 10:30 a.m., R#7 said she felt sick and wanted to go to the hospital. RCS "F" said he reported R#7's statement of feeling sick and request to go to the hospital to LVN "X". RCS "F" said LVN "X" responded by saying "Are you serious? She wants to go to the hospital?" RCS "F" said LVN "X" went to R#7's room. RCS "F" said LVN "X" later told him R#7 was constipated and she (LVN "X") would not send her (R#7) to the hospital "for that." RCS "F" said LVN "X" told RCS "F" she (LVN "X") was going to give R#7 "something for constipation." RCS "F" said LVN "X" asked RCS "F" for information regarding R#7's bowel movements. RCS "F" said he informed LVN "X" that R#7 had passed two formed, regular bowel movements (stools of this nature are not consistent with constipation). RCS "F" said the bowel movements passed by R#7 were not dry or hard. RCS "F" said he notified LVN "X" that R#7 refused to eat breakfast and lunch. RCS "F" said R#7's refusal to eat both breakfast and lunch was unusual behavior for R#7 because R#7 always ate her meals and would frequently ask for second helpings. RCS "F" said shortly after lunchtime on [DATE], R#7 began to vomit clear phlegm. RCS "F" said he notified LVN "X." RCS "F" said he later walked in R#7's room and observed R#7 vomiting coffee ground vomitus and immediately notified new-coming ,[DATE] shift charge nurse LVN "C" and LVN "E" of R#7's symptoms of vomiting. RCS "F" said LVNs "C" and "E" assessed R#7 and sent her to the hospital during the ,[DATE] shift. In a telephone interview with R#7's family member (FM) "G" on [DATE] at 10:41 a.m., FM "G" said R#7 told him she had complained to facility staff that her stomach "really" hurt and told staff several times that day that she "wanted to go to the hospital" on [DATE] during the 6:00 a.m. - 2:00 p.m. shift. FM "G" said R#7 complained to him that staff "wouldn't get to her and she would yell to get their attention." FM "G" said R#7 told him she "pushed the call light but nobody would answer." FM "G" said R#7 told him she thought she was going to die. FM "G" said after R#7 was transferred to Hospital #1 from the nursing facility, R#7 went into [MEDICAL CONDITION]. FM "G" indicated R#7 was then put on a mechanical life support instrument and "halo flighted" to Hospital #2. FM "G" said R#7 did not regain consciousness and was discharged to hospice care where she expired on [DATE]. Review of the facility's PIR dated [DATE] revealed LVN "X" did not notify R#7's physician on [DATE] after R#7 complained of abdominal pain and requested to go to the hospital. Review of Nurses Notes for R#7 dated [DATE] and R#7's chart revealed LVN "X" did not document R#7's requests to go to the hospital, any abdominal or pain assessments, or any change of condition on [DATE]. Review of the facility's PIR dated [DATE] documented RCS "F" asked LVN "E" to "please check" R#7 on [DATE] during the 2:00 p.m. - 10:00 p.m. shift. The Interview Record documented LVN "E" witnessed R#7's "coffee ground vomit" when she entered R#7's room and notified the facility's Registered Nurse (RN) Coordinator to transfer R#7 to the hospital. PIR dated [DATE] revealed LVN "E" was told by RCS "F" on [DATE] during the 6:00 a.m. - 2:00 p.m. shift that LVN "X" ignored R#7's requests to be transferred to the hospital for stomach pain. Record review of R#7's 24 Hour Report/Change of Condition Report on night shift (10:00 p.m. - 6:00 a.m.) dated [DATE] documented R#7 complained of heartburn. The day shift report (6:00 a.m. - 2:00 p.m.) documented R#7 had constipation and to give Tylenol for pain. The evening shift (2:00 p.m. - 10:00 p.m.) documented R#7 was sent to the emergency room for "abdominal pain and coffee ground emesis." Hospital #1 emergency room (ER) records dated [DATE] at 6:20 p.m. revealed R#7 was clinically assessed with [REDACTED]. R#7 was transferred to the Intensive Care Unit (ICU) on [DATE]. Review of Hospital #1 records dated [DATE] revealed R#7 went into cardiopulmonary arrest (heart stopped) and required CPR (Cardiopulmonary Resuscitation). R#7 subsequently required a life-sustaining ventilator. R#7 was later transferred by helicopter to Hospital #2. In an interview on [DATE] at 11:58 a.m., LVN "E" said RCS "F" notified LVN "E" and LVN "C" that R#7 "was not looking good" on [DATE] at approximately 2:30 to 2:45 p.m. LVN "E" said she entered R#7's room and observed R#7 vomiting black vomitus into a basin. LVN "E" said R#7 told her sobbingly, "Miss, I don't feel good." LVN "E" said R#7 requested to see a doctor and wanted to go to the hospital. LVN "E" said R#7 did not normally like doctors and made "every excuse in the book" to miss doctor's appointments. LVN "C" notified R#7's Physician, Physician gave R#7's transfer order to the hospital and R#7 was sent to the hospital. LVN "E" said RCS "F" told her R#7 had passed a soft medium bowel movement earlier that day. LVN "E" said while she and RCS "F" assisted R#7 change clothes, R#7 passed another soft light brown stool. RCS "F" told LVN "E", that he notified LVN "X" "all day long" that R#7 was not feeling well and wanted to go to the hospital. LVN "C" said RCS "F" said he notified LVN "X" that R#7 had not eaten breakfast or lunch and had had a bowel movement that morning ([DATE]). LVN "E" said R#7 was transferred by ambulance to the hospital around 4:30 p.m. LVN "E" said on [DATE] R#7 frequently gagged, moved her head back and forth anxiously and crying, and continued to say "Miss" as R#7 was being transferred to the ambulance outside the facility. In a second interview on [DATE] at 4:44 p.m., LVN "E" said according to her Resident Rights training, a resident had the right to go to the hospital if resident felt that they needed to. LVN "E" said LVN "X" did not respond to R#7's request to go to the hospital and said LVN "X" neglected R#7's pain and requests to go to the hospital. LVN "E" said she did not become aware of R#7's health status until LVN "X" was relieved by LVN "C" and gone for the day. LVN "E" revealed she had concerns with the care R#7's care on [DATE] during the 6:00 a.m. - 2:00 p.m. shift. Review of R#7's Resident Transfer Form dated [DATE], R#7 was transported to the hospital at 4:25 p.m. via ambulance. In an interview on [DATE] at 2:14 p.m., RCS "O" said she helped RCS "F" with R#7 on [DATE]. RCS "O" said R#7 clutched her mid- to low abdomen and said "tengo dolor" (I have pain) and "llevame al hospital" (take me to the hospital). RCS "O" said she told RCS "F" to report R#7's pain to a nurse. RCS "O" said RCS "F" informed RCS "O" that he told the charge nurse. RCS "O" said RCS "F" then spoke to LVN "E". RCS "O" said she (RCS "O") did not see LVN "X" interact or assess R#7. RCS "O" said she helped RCS "F" change R#7 and observed R#7 pass a bowel movement that was not hard or dry. In a second interview on [DATE] at 5:10 p.m., RCS "O" said she considered the care R#7 received on [DATE] to be "neglect." In an interview on [DATE] at 9:55 a.m., the Director of Nurses (DON) said there were many definitions for neglect, including "patient not being attended to or listened to." When the DON was asked about training received on abuse and neglect prevention, the DON said she had received training while in nursing school. The DON said she had not attended any seminars specifically addressing abuse and neglect. When the DON was asked how she identified "Neglect" the DON said if an allegation was brought to her, she would investigate. The DON said, "If I were to see it, I would do an investigation. I have never seen it." When the DON was asked about conditions in which neglect might occur, the DON said "I have never seen it." When the DON was asked about specific conditions in which neglect might be alleged, the DON said "Something might always be alleged." The DON said she had "never seen neglect in its true phase." When the DON was asked how she monitored staff to assure neglect was not occurring in the facility, the DON said she "made rounds frequently" and maintained an "open door policy" to staff and residents. The DON said investigations for possible abuse and neglect were conducted by the facility's Administrator as the Abuse Prevention Program Coordinator. The DON said she assisted with abuse/neglect investigations by gathering information and "sitting in" on interviews. The DON said she "sat in and listened" to two interviews related to the allegation of neglect for the delay in R#7's transfer to the hospital. When asked about an employee counseling form she signed for LVN "X" in which "neglected resident care" was documented, the DON indicated the Administrator documented the finding and she (DON) signed LVN "X" 's counseling form. The DON said the phrase "neglected resident care" referred to a section from the employee handbook on categories of employee misconduct and LVN "X" was terminated from employment at the facility for not documenting. When asked if not documenting was neglect, the DON said "that is why we called you guys" (referencing PIR dated [DATE] to report this incident). The DON said LVN "H" had observed LVN "X" enter R#7's room but the DON did not know whether LVN "H" saw LVN "X" assess R#7. When asked about R#7's requests to go to the hospital due to R#7's abdominal pain, the DON said that "no abnormalities" were identified when an assessment was done by LVN "X" (6:00 a.m. - 2:00 p.m. shift). The DON was asked to show evidence of LVN "X" assessments of R#7 dated [DATE]. The DON said LVN "X" did not document any assessments for R#7 on [DATE] and said that was the reason LVN "X" was terminated. The DON said when R#7 began to have more symptoms, "the coffee ground vomitus," then the facility sent R#7 to the hospital (during the 2:00 p.m. - 10:00 p.m. shift.) When asked about R#7 specifically requesting to go to the hospital, the DON said, "If a resident says they don't feel good, you have to believe them and if you can't pinpoint anything, you have to send them out." When DON was asked if "neglect" occurred if a resident expressed need to go to the hospital and was refused by staff, the DON said, "I would say yes." When the DON was asked about the "Inconclusive" finding of the allegation of neglect investigation for R#7's care on [DATE], the DON said the "Inconclusive" finding result was reached because the Administrator could not speak with R#7 to determine if R#7 had asked to be sent to the hospital. When the DON was asked whether LVN "X" had notified R#7's Physician about R#7's abdominal pain and requests to go to the hospital, the DON said, "I don't know." Several attempts to interview LVN "X" were unsuccessful. In an interview with the facility's Administrator on [DATE] at 9:57 a.m., the Administrator said she was the Abuse/Neglect Coordinator for the facility. The Administrator defined "Neglect" as "not providing basic care for residents." The Administrator gave examples of neglect to include not providing showers to residents, not providing hydration for residents, not providing skilled care if needed or ordered by a physician, and not providing the resident medications as ordered by the physician. The Administrator revealed allegations of Abuse/Neglect were investigated by her and said, "I make the final decision on Abuse/Neglect investigations." The Administrator also stated, "I would consider a license staff member to give a resident an unordered medication as neglect." When the Administrator was asked whether residents were allowed to go to the hospital if the resident requested it, the Administrator said "Yes." The Administrator said, "If a resident tells me or the staff that they are hurting, then we will immediately send them out per Resident Rights." When the Administrator was asked if a licensed staff ignored or denied a resident's request to see a doctor or go to the hospital based on resident pain, would the Administrator consider the licensed staff's actions to be neglect, the Administrator answered, "Yes." The Administrator revealed LVN "X" did not follow facility's policy of Resident Rights to send R#7 to the hospital on [DATE]. Administrator also revealed LVN "X" did not document any of her (LVN "X") assessments of R#7's abdominal pain, medication administration of [MEDICATION NAME], and notification to physician of R#7's abdominal pain and requests to go to the hospital. When the Administrator was asked whether LVN "X" neglected R#7's requests to be sent to the hospital based on abdominal pain and neglected to provide services to avoid physical harm, the Administrator said, "Yes." Review of Resident Rights Policy dated [DATE] revealed the facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Facility staff will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her right. Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety. When the Administrator was asked why she concluded an "Inconclusive" finding for the Abuse/Neglect Investigation dated [DATE] of LVN "X" on the allegation of "Neglect, " the Administrator revealed that two staff members had conflicting information during the (Administrator) interviews. The Administrator said the conflicting information from the staff was whether bowel movement information for R#7 was relayed to LVN "X" by RCS "F" and whether a "BOMB" was administered by LVN "X." The Administrator also said she did not have an opportunity to interview R#7 and did not have "two eye witnesses" to substantiate an allegation of "Neglect." The Administrator then said, "If I have one eye witness, then I can substantiate." The Administrator said she was not aware R#7 called FM "G" on [DATE] and did not interview FM "G." On a follow up interview with the Administrator on [DATE] at 10:25 a.m., the Administrator indicated she wanted to clarify her statements to surveyor from an interview on [DATE]. The Administrator said R#7 was assessed by LVN "X" on [DATE] "to the best of her nursing judgment. She thought she (R#7) was constipated." The Administrator was asked whether LVN "X" was required by facility policy to call the Physician when R#7 complained of pain and requested to go to the hospital. The Administrator said "Yes." The Administer was asked whether LVN "X" was required to document any and all abdominal pain assessments and whether LVN "X" was required to document any medications administered to R#7 by facility policy. The Administrator answered "Yes." The Administrator was asked whether the actions of LVN "X" were considered neglect of R#7. The Administrator said, "Yes." The Administrator then said, "I feel that I have answered all your questions over and over. I feel that I am being interrogated." In an interview with the DON on [DATE] at 3:35 p.m., the DON stated all the nurses were charge nurses. Each charge nurse was responsible for two halls and the CNA's on those halls. The DON stated that on [DATE], LVN "X" was responsible for Hallway "200" and Hallway "400." R#7 resided on Hallway "200" on [DATE]. Record Review of the facility's Abuse & Neglect Prohibition Policy dated ,[DATE] revealed that "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property," and defined Neglect as, "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." It was determined the facility's failure to implement facility policy and procedures that prohibited neglect ---recognizing and acting on change of condition --- placed R#7 in an Immediate Jeopardy (IJ) situation on [DATE]. The facility took the following actions to correct the non-compliance. On [DATE] the facility conducted in-services for facility staff on Abuse and Neglect Prohibition which addressed the resident right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The in-service on Medication Management, Scope of Practice, and Proper Documentation revealed that the Nurse would not administer any medication without a Physician's order; "It is not within the Nursing scope of practice to administer medications without first getting a Physician's order, and documentation of all meds is mandatory." The in-service on Interventions to Reduce Acute Care Transfers was InterACT II ("Early Warning Tool," "Stop and Watch," "Change of Condition File Cards," "Acute Care Transfer Envelope with checklist," and "Quality Improvement Tool for Review of Acute Care Transfers"). The in-service discussed changes of resident condition and the symptoms of mental status change, fever, lower respiratory infection, [MEDICAL CONDITIONS], Urinary Tract Infection [MEDICAL CONDITION], and dehydration. In an interview with the Administrator on [DATE] at 4:05 p.m. revealed the Administrator was a member of the Quality Assessment & Assurance (QA&A) Committee that met monthly. The Administrator said a QA&A meeting was held on [DATE] with agenda items from the previous month including resident "Change of Condition" and would further discuss the reportable incident that occurred on [DATE] and the in-services conducted with the staff on [DATE] at the next scheduled QA&A meeting on [DATE]. During the exit conference meeting on [DATE] at 4:45 p.m., the Administrator, the DON, and the Corporate RN Consultant were informed of the facility's IJ PNC during the period of [DATE] to [DATE]. Opportunity was given to the facility on [DATE] at 10:46 a.m. and [DATE] at 4:45 p.m. during the exit conference to present further evidence regarding implementing the facility's policy. None was given. Based on the Resident Roster dated [DATE] there were 20 residents on Hallway "200" and 14 residents on Hallway "400."

Based on interview and record review, the facility failed to consult with the Physician of one of five Sample Residents (SR) #1 with wounds who were listed by facility as non-pressure sore wounds . SR #1 demonstrated a deterioration in health status for which facility nurses failed to initiate consultation with the resident's Physician. From 11/26/10 to12/15/10, there was no evidence that Licensed Vocational Nurses (LVN) "A" and "B" and Registered Nurse (RN) "E" initiated calls to SR #1's Physician or followed through with calls that had been made regarding observations that SR #1's incisional wound to a right above the knee amputation (RAKA) site was not healing. The non-healing wound site progressed to gangrene (necrosis or death of tissue due to deficient or absent blood supply) and SR #1 was readmitted to the hospital for surgical intervention to remove additional skin and deep muscle from SR #1's right leg. The failure to consult with SR #1's Physician resulted in the delay of the physician's ability to assess and intervene in a timely manner. Failure to consult with Physicians could affect the five (5) residents in the facility who had surgical incisions. Findings were: SR #1's acute care hospital Operative Report dated 10/28/10, revealed SR #1 underwent surgery to amputate the right leg above the knee on 10/22/10. His [DIAGNOSES REDACTED]. Review of SR #1's rehabilitation hospital's History and Physical form dated 10/29/10, revealed that SR #1 was admitted to that hospital for administration of intravenous antibiotics. SR #1's Face Sheet indicated SR #1 was admitted on [DATE], his admitting [DIAGNOSES REDACTED]. SR #1's Face Sheet did not identify Ischemia as a diagnosis (decreased supply of [MEDICATION NAME] blood to a body part). SR #1's Initial Plan of Care form dated 11/18/10 noted the following: problem area of surgical site; with the goal being that SR #1's "wound will show signs of healing." Interventions to be initiated included "provide wound care/preventive skin care per order", "observe wound healing", and "notify Medical Doctor (MD) of changes in wound." The Plan of Care was initiated by RN "E." During an interview on 01/08/11 at 11:12 a.m., LVN "D" reported that she had performed the admission assessment on SR #1 on 11/18/10. LVN "D" stated that the incisional wound was clean, had light brown scabs and no signs of infection which she defined as having no drainage, redness, or blackness. The incision had no staples holding it closed. A Nursing Admission Assessment form was completed by LVN "D" on 11/18/10 at 9:15 p.m.. Entry written in the Nurse's Notes section indicated, "skin assessment complete. . . RAKA incision scabbed, without signs/symptoms infection." On 11/25/10 at 11:45 a.m., LVN "A" initiated a Change of Condition form to notify SR #1's Physician that signs of "redness to the incision line on right stump" had been observed and that the resident had "pain to the right stump." The contact was initiated by fax. An order was obtained from SR #1's Physician Assistant (PA) to apply TAO (triple antibiotic ointment) to the stump incision line daily. Oral [MEDICATION NAME] 5/500 ([MEDICATION NAME] 5 mg. (milligrams) with [MEDICATION NAME] 500 mg.) every 4 to 6 hours was ordered for pain. SR #1's Telephone Order dated 11/25/10, (time not written), read "Right stump incision line. Cleanse with wound cleanser, pat dry with 4x4 gauze, apply TAO, cover with ABD (thick cushion) pad and wrap with bandage gauze daily and as needed (PRN)." During an interview on 01/08/11 at 9:55 a.m., LVN "A" stated that on 11/24/10, she was called to SR #1's room where RN "E", the Treatment Nurse for the day, was performing wound care to SR #1's RAKA site. RN "E" showed LVN "A" that SR #1's RAKA incision site was reddened and directed her to notify SR #1's Physician as she was the Charge Nurse on duty. LVN "A" placed the call to SR #1's PA on call for the day. The result was the order for the TAO and [MEDICATION NAME]. When asked if the Charge Nurses looked at SR #1's wounds, LVN "A" stated that the usual facility practice was for the nurse performing wound treatments to assess the wound sites. In the absence of a Treatment Nurse, the Charge Nurses performed wound treatments and assessed the sites. SR #1s Treatment Administration Record (TAR) for November and December, 2010, revealed that SR #1 continued to receive wound care to the RAKA site. Wound care was initialed as done, according to PA's orders, daily from 11/25/10 until 12/15/10 except for 11/28/10, 12/3/10, and 12/13/10. Treatment was not initialed as performed on those three days. No notes were made on observations regarding the condition of the site until 12/06/10. On that date, RN "E" noted on SR #1's TAR "stable eschar (Black)" (eschar -dead matter or necrosed tissue separated from living tissue) was present at the site. Surveyor observed there was no documentation in the note regarding the size of the eschar. During an interview on 01/07/11 at 4:25 p.m., LVN "C" stated she performed wound care and dressing changes for SR #1 on 11/28/10, 12/04/10, and 12/05/10. LVN "C" reported that the first time she saw SR #1's incisional wound, there were reddened areas at the site; an order for [REDACTED].#1's RAKA incisional wound, it had developed a black scab that was approximately 2 inches by 7 millimeters (approximately 1/4 inch) in size. LVN "C" stated that she notified the Treatment Nurse, RN "E", who told her that he would look at the wound. SR #1's Nurse's Notes did not reveal documentation of the observations made by LVN "C." A Head To Toe Skin Check was performed on SR #1 by LVN "A" on 12/06/10 which included a notation that SR #1 had a right [MEDICAL CONDITION] (RBKA) incisional wound. A description of the wound site was not given. SR #1's Face Sheet dated 11/18/10 listed the admitting [DIAGNOSES REDACTED]. During an interview on 01/08/11 at 9:55 a.m., LVN "A" was asked about the condition of SR #1's right amputation site on 12/06/10. LVN "A" reported the site "looked about the same" as it had on 11/24/10; she stated that on 11/25/10 the site had an "angry" red appearance and that on 12/06/10, it was reddened, but not an "angry" red. LVN "A" did not state she had observed the presence of eschar on the wound. When asked if an incision that was almost six weeks old should look red, LVN "A" said "no" but staff thought the site might be getting infected. LVN "A" did not remember if SR #1 was on an antibiotic or if the doctor's office had called back when notified on 11/25/10 of the presence of redness to the RAKA site. LVN "A" stated that other staff members might have taken the call. LVN "A" stated that RN "E" was concerned about SR #1's incisional site because RN "E" had asked her to call the doctor on 11/24/10. When asked if RN "E" had asked LVN "A" to call the doctor's office on 12/06/10, LVN "A" replied that she was unsure if RN "E" had been at work on that day. When asked if she had notified SR #1's Physician on 12/06/10, LVN "A" reviewed the Nurses' Notes in SR #1's chart and stated that she had not documented anything either in the Nursing Daily Skilled Summary or on a Change of Condition Report. LVN "A" said that she had not called SR #1's Physician on 12/06/10. SR #1's TAR showed that on 12/08/10 and 12/10/10, notes were made by RN "E" that SR #1 was "refusing dressing over stump"; the reason for refusing the dressing was not written. Description of the site was not made. On 12/12/10, RN "E" noted on the TAR "right stump with open area eschar on some areas" and "right stump open area 4 cm (centimeters) x 2 cm x 2.5 cm" (approximately 1 1/2 inches by 3/4 inch by 1 inch). SR #1's 12/13/10, Head To Toe Skin Check form was blank. Review of the Nursing Daily Skilled Summary form for 12/13/10, showed that LVN "B" was on duty and assigned to care for SR #1 on that day; this form showed a notation that SR #1 had an incision to the above knee amputation. There was no description given of the incisional wound site. During an interview on 01/08/11 at 10:40 a.m., LVN "B" was asked about the Head To Toe Skin Check form for 12/13/10. She stated that "I was not oriented to the Head To Toe Skin" assessment form and did not fill it in. LVN "B" reported that she had done a head to toe assessment of SR #1 and noticed that his surgical site was closed and it was necrotic (had dead tissue). LVN "B" stated she reported the finding to the Treatment Nurse and verbally to SR #1's Physician. When asked which Physician she had reported to, LVN "B" answered that she did not remember if she had actually reported to the "PA" (Physician's Assistant). LVN "B" stated that she told the PA that SR #1 had to be seen "immediately because it was necrotic." LVN "B" was told to schedule the resident with a Physician. LVN "B" stated that she did not call for an appointment. When asked if she had filled in a Change of Condition Report, LVN "B" replied that she did not know about this form as she had been gone the whole month of November, 2010 and that this form was new to her. When asked where the nurse's note regarding the necrotic area to SR #1's amputation incision was, LVN "B" answered, "I don't remember." LVN "B" was asked if she had made a nurse's note regarding the amputation incisional site, LVN "B" said "Yes, it's what I know what to do." LVN "B" could not locate the Nurse's Note that she said she had made in December 2010 that addressed SR #1's amputation site. LVN "B" stated that she had also reported the condition of the amputation site to a Treatment Nurse; when asked which Treatment Nurse that was, LVN "B" replied "I don't remember." LVN "B" stated one of the Treatment Nurses told her that the amputation incisional site was being "treated in the TAR." LVN "B" took no further action to schedule an appointment for SR #1 to see a Physician. During an interview on 01/08/11 at 11:35 a.m., Treatment Nurse, RN "E", reported that he performed wound tretments in the facility "on occasion"; RN "E" stated there was no designated Treatment Nurse during the months of November and December, 2010. RN "E" said all the nurses in the facility were performing wound treatments during those two months and on "some days that was delegated to me." RN "E" stated that he first started performing wound treatments for SR #1 on 11/19/10. RN "E's"documentation was his initials on the TAR and notes made on the Nurse's Notes section of the TAR. When asked what SR #1's RAKA incisional wound looked like on 11/19/10, RN "E" answered that he could not recall. RN "E" stated it (the incisional wound) progressed to get an eschar or redness that was reported and a treatment order was obtained. RN "E" said staff had sent a Change of Condition Report to SR #1's Physician on 11/25/10. When asked what the result of that report was, RN "E" replied an order was given by the PA to "cleanse and apply triple antibiotic ointment." When asked how SR #1's wound fared after this, RN "E" said it developed "more of an infection." RN "E" added that another staff RN called to make an appointment with a physician, saying that "it takes time to get residents in." RN "E" added "that's when he (SR #1) got a revision (of amputation)." When asked if this occurred in November, RN "E" said "no, let me see here" as he searched through SR #1's medical record. After looking through the record, RN "E" said that not all forms/paperwork from November and December had been filed in SR #1's medical record. When asked if anyone had called SR #1's Physician in November, RN "E" answered that somebody had called the Physician as evidenced by the order given by the PA for treatment. RN "E" stated he had made the note, dated 12/06/10, on the TAR reporting "right stump with stable eschar (black)." When asked if RN "E" had notified a Physician at that time, RN "E" answered he had not but that he was sure someone did a Change of Condition Report. When asked who would have made that report, RN "E" replied that it would have been the Charge Nurse for the day, LVN "A." RN "E" reported he occasionally was assigned to be the Supervisor for the facility. When asked if he had been the facility Supervisor on 12/06/10, RN "E" said, "that was a Monday, it might have been me or someone else." RN "E" said, "I should have notified the doctor or someone else." RN "E" said that he did not know if a Change of Condition Report had been initiated on that day. RN "E" added the PA had been called as a note was made to that effect in the Nursing Daily Skilled Summary. RN "E" was asked what happened to SR #1's RAKA incisional wound site after12/06/10. RN "E" answered it "looks like it opened on the 12th" and that the eschar became unstable. When asked about wound care, RN "E" stated he had been performing wound care throughout his nursing career starting as an LVN in 1987 and then as an RN from 1993 on. RN "E" stated in wound care, stable eschar was left alone. When asked if this applied to all wounds, RN "E" answered "any kind of pressure wounds." When asked if SR #1's incisional wound was a pressure wound, RN "E" said, "no, it was not." When asked if he had requested SR #1's PA to come and evaluate SR #1's RAKA incisional wound, RN "E" did not respond. Surveyor reviewed with RN "E" the issue that SR #1 had come into the facility with a clean incision that turned red then black and asked RN "E" what the significance of this information was, RN "E" stated that "he (SR #1) was having some problems"; RN "E" again pointed out that the PA had been called. When asked about actions that RN "E" had taken to ensure that SR #1 would be evaluated by a Physician, RN "E" answered "I guess that I didn't do any -- according to these documents." RN "E" added "you can't get into the doctor's office that easily." When asked about actions taken if a resident's condition was getting worse and they could not get into see a Physician, RN "E" responded, "well, I guess that you send them to the ER (emergency room ) and they just send them back." When asked if the facility had sent SR #1 to the ER, RN "E" answered, "no, we didn't." Review of the Nursing Daily Skilled Summary for 12/14/10, revealed that SR #1 had an appointment with a surgeon on 12/15/10. This surgeon had performed the original amputation surgery on 10/22/10. During a telephone interview on 01/07/11 at 11:15 a.m., the surgeon's Geriatric Nurse Practitioner (GNP) reported the following regarding SR #1's exam findings during his appointment on 12/15/10: GPN described an area, approximately 4 inches in length and 2 inches in width, of black non-healing tissue to the right above knee amputation incision site. When asked if a revision would have been needed if SR #1 had been evaluated before 12/15/10, GPN replied this measure might not have been necessary. GPN did not elaborate on interventions that might have been done if SR #1 had been evaluated sooner than 12/15/10. Review of an acute care hospital's Operative Report dated 12/17/10, revealed that SR #1 underwent surgery, a right above the knee amputation stump revision with wedge excision (removal or amputation). The removal of necrotic (dead) tissue went into the deep layers of muscle where there was healthy tissue. Review of the laboratory Histology Report dated 12/17/10 of tissue removed from SR #1's right above the knee amputation site on 12/17/10 revealed clinical information of "gangrene right above knee amputation"; tissue removed from SR #1's right leg measured 11 x 4.5 centimeters with a depth of 3 centimeters (approximately 4-1/4 inches by 1-3/4 inch with a depth of 1-1/4 inch). The Histology Report's final [DIAGNOSES REDACTED]." The facility's Admission/Readmission Assessment Form revealed that SR #1 was re-admitted to the facility on [DATE]. SR #1's Non-Pressure Skin Condition Record dated 01/03/11 revealed that the RAKA revision incisional wound site had 29 staples, was clean and dry and had no signs of infection. SR #1's Physician's Admitting Orders included one for follow-up appointment with the surgeon two weeks from the admission date of [DATE]. During an interview on 01/04/11 at 10:50 a.m., SR #1 stated that he did not remember the events of November and December 2010 that led to his hospitalization . Review of the facility's Skin Management Protocol provided by the facility (Copyright 2010 ) revealed the Practice Guidelines specified that "if any abnormalities are observed, document a descriptive note of findings AND the Licensed Nurses response in the Nurses Notes section of the resident's medical record." "A Change of Condition form is to be completed and new physician's orders [REDACTED]." "The nurse will assure that treatments, interventions, Care Plan, and the appropriate skin documentation records are initiated in a timely manner. . ." Five residents were identified by facility staff as having non-pressure sore wounds. The facility was provided an opportunity to provide additional documentation prior to exit. No additional evidence was provided.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical well being, in accordance with the plan of care for one of five Sampled Residents (SR) #1, with wounds who were listed by the facility as non-pressure sore wounds. From 11/26/10 to12/15/10, Licensed Vocational Nurses (LVN) "A" and "B" and Registered Nurse (RN) "E" failed to consistently act on observations that SR #1's incisional wound to a right above the knee amputation (RAKA) site was not healing by not notifying SR #1's Physician and failing to follow-up with necessary services . The non-healing wound site progressed to gangrene (necrosis or death of tissue) and SR #1 was readmitted to the hospital to receive surgical intervention to remove additional skin and deep muscle from his right leg. The failure to act on observations that SR #1's incisional wound was not healing affected SR #1 by delaying physician assessment and intervention resulting in readmission to hospital on [DATE] which resulted in further removal of deep muscle and skin tissue from SR #1's leg. Failure to act on observations that surgical incisions were not healing could affect five residents in the facility who had surgical incisions. Findings were: SR #1's acute care hospital Operative Report dated 10/28/10, revealed SR #1 underwent surgery to amputate the right leg above the knee on 10/22/10. His [DIAGNOSES REDACTED]. Review of SR #1's rehabilitation hospital's History and Physical form dated 10/29/10, revealed that SR #1 was admitted to that hospital for administration of intravenous antibiotics. SR #1's Face Sheet indicated SR #1 was admitted on [DATE], his admitting [DIAGNOSES REDACTED]. SR #1's Face Sheet did not identify Ischemia as a diagnosis (decreased supply of [MEDICATION NAME] blood to a body part). SR #1's Initial Plan of Care form dated on 11/18/10 noted the following: problem area of surgical site with the goal being that SR #1's "wound will show signs of healing." Interventions to be initiated included "provide wound care/preventive skin care per order", "observe wound healing", and "notify Medical Doctor (MD) of changes in wound." The Plan of Care was initiated by RN "E." During an interview on 01/08/11 at 11:12 a.m., LVN "D" reported that she had performed the admission assessment on SR #1 on 11/18/10. LVN "D" stated that the incisional wound was clean, had light brown scabs and no signs of infection which she defined as having no drainage, redness, or blackness. The incision had no staples holding it closed. A Nursing Admission Assessment form was completed by LVN "D" on 11/18/10 at 9:15 p.m. Entry written in the Nurse's Notes section indicated, "skin assessment complete. . .RAKA incision scabbed, without signs/symptoms infection." On 11/25/10 at 11:45 a.m., LVN "A" initiated a Change of Condition form to notify SR #1's Physician that signs of "redness to the incision line on right stump" had been observed and that the resident had "pain to the right stump." The contact was initiated by fax. An order was obtained from SR #1's Physician Assistant (PA) to apply TAO (triple antibiotic ointment) to the stump incision line daily. Oral [MEDICATION NAME] 5/500 ([MEDICATION NAME] 5 mg. (milligrams) with [MEDICATION NAME] 500 mg.) every 4 to 6 hours was ordered for pain. SR #1's Telephone Order dated 11/25/10, (time not written), read "Right stump incision line. Cleanse with wound cleanser, pat dry with 4x4 gauze, apply TAO, cover with ABD (thick cushion) pad and wrap with bandage gauze daily and as needed (PRN)." During an interview on 01/08/11 at 9:55 a.m., LVN "A" stated that on 11/24/10, she was called to SR #1's room where RN "E", the Treatment Nurse for the day, was performing wound care to SR #1's RAKA site. RN "E" showed LVN "A" that SR #1's RAKA incision site was reddened and directed her to notify SR #1's Physician as she was the Charge Nurse on duty. LVN "A" placed the call to SR #1's PA on call for the day. The result was the order for the TAO and [MEDICATION NAME]. When asked if the Charge Nurses looked at SR #1's wounds, LVN "A" stated that the usual facility practice was for the nurse performing wound treatments to assess the wound sites. In the absence of a Treatment Nurse, the Charge Nurses performed wound treatments and assessed the sites. Review of the SR #1s Treatment Administration Record (TAR) for November and December, 2010, revealed that SR #1 continued to receive wound care to the RAKA site. Wound care was initialed as done, according to PA's orders, daily from 11/25/10 until 12/15/10 except for 11/28/10, 12/3/10, and 12/13/10. Treatment was not initialed as performed on those three days. No notes were made on observations regarding the condition of the site until 12/06/10. On that date, RN "E" noted on SR #1's TAR "stable eschar (Black)" was present at the site (Eschar-dead matter or necrosed tissue separated from living tissue). Surveyor observed there was no documentation in the note regarding the size of the eschar. During an interview on 01/07/11 at 4:25 p.m., LVN "C" stated she performed wound care and dressing changes for SR #1 on 11/28/10, 12/04/10, and 12/05/10. LVN "C" reported that the first time she saw SR #1's incisional wound, there were reddened areas at the site; an order for [REDACTED].#1's RAKA incisional wound, it had developed a black scab that was approximately 2 inches by 7 millimeters (approximately 1/4 inch) in size. LVN "C" stated that she notified the Treatment Nurse, RN "E", who told her that he would look at the wound. SR #1's Nurse's Notes did not reveal documentation of the observations made by LVN "C." A Head To Toe Skin Check was performed on SR #1 by LVN "A" on 12/06/10 which included a notation that SR #1 had a right [MEDICAL CONDITION] (RBKA) incisional wound. A description of the wound site was not given. SR #1's Face Sheet dated 11/18/10 listed an admitting [DIAGNOSES REDACTED]. During an interview on 01/08/11 at 9:55 a.m., LVN "A" was asked about the condition of SR #1's right amputation site on 12/06/10. LVN "A" reported the site "looked about the same" as it had on 11/24/10; she stated that on 11/25/10 the site had an "angry" red appearance and that on 12/06/10, it was reddened, but not an "angry" red. LVN "A" did not state she had observed the presence of eschar on the wound. When asked if an incision that was almost six weeks old should look red, LVN "A" said "no" but staff thought the site might be getting infected. LVN "A" did not remember if SR #1 was on an antibiotic or if the doctor's office had called back when notified on 11/25/10 of the presence of redness to the RAKA site. LVN "A" stated that other staff members might have taken the call. LVN "A" stated that RN "E" was concerned about SR #1's incisional site because RN "E" had asked her to call the doctor on 11/24/10. When asked if RN "E" had asked LVN "A" to call the doctor's office on 12/06/10, LVN "A" replied that she was unsure if RN "E" had been at work on that day. When asked if she had notified SR #1's Physician on 12/06/10, LVN "A" reviewed the Nurses' Notes in SR #1's chart and stated that she had not documented anything either in the Nursing Daily Skilled Summary or on a Change of Condition Report. LVN "A" said that she had not called SR #1's Physician on 12/06/10. SR #1's TAR showed that on 12/08/10 and 12/10/10, notes were made by RN "E" that SR #1 was "refusing dressing over stump"; the reason for refusing the dressing was not written. Description of the site was not made. On 12/12/10, RN "E" noted on the TAR "right stump with open area eschar on some areas" and "right stump open area 4 cm (centimeters) x 2 cm x 2.5 cm" (approximately 1 1/2 inches by 3/4 inch by 1 inch). SR #1's 12/13/10, Head To Toe Skin Check form was blank. Review of the Nursing Daily Skilled Summary form for 12/13/10, showed that LVN "B" was on duty and assigned to care for SR #1 on that day; this form showed a notation that SR #1 had an incision to the above knee amputation. There was no description given of the incisional wound site. During an interview on 01/08/11 at 10:40 a.m., LVN "B" was asked about the Head To Toe Skin Check form for 12/13/10. She stated that "I was not oriented to the Head To Toe Skin" assessment form and did not fill it in. LVN "B" reported that she had done a head to toe assessment of SR #1 and noticed that his surgical site was closed and it was necrotic (had dead tissue). LVN "B" stated she reported the finding to the Treatment Nurse and verbally to SR #1's Physician. When asked which Physician she had reported to, LVN "B" answered that she did not remember if she had actually reported to the "PA" (Physician's Assistant). LVN "B" stated that she told the PA that SR #1 had to be seen "immediately because it was necrotic." LVN "B" was told to schedule the resident with a Physician. LVN "B" stated that she did not call for an appointment. When asked if she had filled in a Change of Condition Report, LVN "B" replied that she did not know about this form as she had been gone the whole month of November, 2010 and that this form was new to her. When asked where the nurse's note regarding the necrotic area to SR #1's amputation incision was, LVN "B" answered, "I don't remember." LVN "B" was asked if she had made a nurse's note regarding the amputation incisional site, LVN "B" said "Yes, it's what I know what to do." LVN "B" could not locate the Nurse's Note that she said she had made in December 2010 that addressed SR #1's amputation site. LVN "B" stated that she had also reported the condition of the amputation site to a Treatment Nurse; when asked which Treatment Nurse that was, LVN "B" replied "I don't remember." LVN "B" stated one of the Treatment Nurses told her that the amputation incisional site was being "treated in the TAR." LVN "B" took no further action to schedule an appointment for SR #1 to see a Physician. During an interview on 01/08/11 at 11:35 a.m., Treatment Nurse, RN "E", reported that he performed wound tretments in the facility "on occasion"; RN "E" stated there was no designated Treatment Nurse during the months of November and December, 2010. RN "E" said all the nurses in the facility were performing wound treatments during those two months and on "some days that was delegated to me." RN "E" stated that he first started performing wound treatments for SR #1 on 11/19/10. RN "E's"documentation was his initials on the TAR and notes made on the Nurse's Notes section of the TAR. When asked what SR #1's RAKA incisional wound looked like on 11/19/10, RN "E" answered that he could not recall. RN "E" stated it (the incisional wound) progressed to get an eschar or redness that was reported and a reatment order was obtained. RN "E" said staff had sent a Change of Condition Report to SR #1's Physician on 11/25/10. When asked what the result of that report was, RN "E" replied an order was given by the PA to "cleanse and apply triple antibiotic ointment." When asked how SR #1's wound fared after this, RN "E" said it developed "more of an infection." RN "E" added that another staff RN called to make an appointment with a physician, saying that "it takes time to get residents in." RN "E" added "that's when he (SR #1) got a revision (of amputation)." When asked if this occurred in November, RN "E" said "no, let me see here" as he searched through SR #1's medical record. After looking through the record, RN "E" said that not all forms/paperwork from November and December had been filed in SR #1's medical record. When asked if anyone had called SR #1's Physician in November, RN "E" answered that somebody had called the Physician as evidenced by the order given by the PA for treatment. RN "E" stated he had made the note, dated 12/06/10, on the TAR reporting "right stump with stable eschar (black)." When asked if RN "E" had notified a Physician at that time, RN "E" answered he had not but that he was sure someone did a Change of Condition Report. When asked who would have made that report, RN "E" replied that it would have been the Charge Nurse for the day, LVN "A." RN "E" reported he occasionally was assigned to be the Supervisor for the facility. When asked if he had been the facility Supervisor on 12/06/10, RN "E" said, "that was a Monday, it might have been me or someone else." RN "E" said, "I should have notified the doctor or someone else." RN "E" said that he did not know if a Change of Condition Report had been initiated on that day. RN "E" added the PA had been called as a note was made to that effect in the Nursing Daily Skilled Summary. RN "E" was asked what happened to SR #1's RAKA incisional wound site after12/06/10. RN "E" answered it "looks like it opened on the 12th" and that the eschar became unstable. When asked about wound care, RN "E" stated he had been performing wound care throughout his nursing career starting as an LVN in 1987 and then as an RN from 1993 on. RN "E" stated in wound care, stable eschar was left alone. When asked if this applied to all wounds, RN "E" answered "any kind of pressure wounds." When asked if SR #1's incisional wound was a pressure wound, RN "E" said, "no, it was not." When asked if he had requested SR #1's PA to come and evaluate SR #1's RAKA incisional wound, RN "E" did not respond. Surveyor reviewed the issue that SR #1 had come into the facility with a clean incision that turned red then black and asked RN "E" what the significance of this information was, RN "E" stated that "he (SR #1) was having some problems"; RN "E" again pointed out that the PA had been called. When asked about actions that RN "E" had taken to ensure that SR #1 would be evaluated by a Physician, RN "E" answered "I guess that I didn't do any -- according to these documents." RN "E" added "you can't get into the doctor's office that easily." When asked about actions taken if a resident's condition was getting worse and they could not get into see a Physician, RN "E" responded, "well, I guess that you send them to the ER (emergency room ) and they just send them back." When asked if the facility had sent SR #1 to the ER, RN "E" answered, "no, we didn't." Review of the Nursing Daily Skilled Summary for 12/14/10, revealed that SR #1 had an appointment with a surgeon on 12/15/10. This surgeon had performed the original amputation surgery on 10/22/10. Review of the facility's 24 Hour Report/Change of Condition Report (a communication form shared among staff that addresses all the residents in the facility and is not a part of any resident's Medical Record) revealed that from 12/05/10 - 12/15/10 entries were made indicating SR #1's condition was stable. 12/05/10 Day Shift - MCR Stable, Monitor Vital; Evening Shift - MCR Med for pain, [MEDICATION NAME] with effect; Night Shift - MCR Stable, Monitor Visitors 12/06/10 Day Shift - MCR Stable, Med for Pain; Evening Shift - [MEDICATION NAME] at 10 PM; Night Shift - MCR Stable, Monitor reddened area around stump. 12/07/10 Day Shift - MCR Stable, Wound worsening; Evening Shift - MCR Med with [MEDICATION NAME] for pain; Night Shift - MCR Stable 12/08/10 Day Shift - MCR Stable; Evening Shift - Med with [MEDICATION NAME]; Night Shift - Stable 12/09/10 Day Shift - MCV Stable req Psych eval (unclear if req Psych eval note was made on the day shift or evening shift); Evening Shift - req Psych eval; Night Shift - MCR Stable 12/10/10 Day Shift - MCR requesting psych awaiting eval visit time; Evening Shift - (no entry); Night Shift - MCR requests psych eval, sent change of condition (for psych eval) 12/11/10 Day Shift - MCR psych evaluation complete today Dr. ....; Evening Shift - Dr. ---- in to see pt. new orders; Night Shift - Stable, awaiting pt. requested psych eval 12/12/10 Day Shift - Need to set up apt. with Dr. .... for F/U to wound, 4 x2 wide long 2.5 depth and nectic.; Evening Shift - Stump wd opened up F/U with ...., * Pls make appt. in AM; Night Shift - (unclear abbreviations precede following) psych eval, stable, psych papers to be signed, [MEDICATION NAME] at 5 am 12/13/10 Day Shift - MCR need apt. with Dr.---- ; Evening Shift - MCR ref to shower, bed bath given, pls. make appt with (name of physician) re: stump wd. opened; Night Shift - MCR stump wd. opened up F/U with Dr. -----, *please make apt in AM 12/14/10 Day Shift - Dr. ---- office will not give me appt. without medicaid card, appt. with Dr. ------ 12/15/10 @ 3:15 pm; Evening Shift - Appt. Dr. ----- 12/15/10 @ 3:15 p re: opened incision to stump. Mrs ---- was called no ret. call, "Name of Company" amb to take, ----. ret'd call & stated unable to go with pt.; Night Shift - need apt with Dr. ----- 12/15/10 Day Shift - MCC apt. Dr. ----; Evening Shift - n/o 12 lead EKG (electrocardigram), CXR PA & lat (chest x-ray - posterior/anterior) , ( Name of x-ray company)needs to be here in AM; BMP (basic metabolic panel), CBC (complete blood count), PT (prothombin time), PTT (partial [MEDICATION NAME] time), INR (international ratio) to be done in AM; NPO (nothing by mouth) 12/16/10 BP meds, N/O [MEDICATION NAME] 20mg QD, re-draw CBC; Night Shift - need medicaid card for appt with (Dr. name), Appt with Dr. ----- at 3:15 for wound to stump. need to call d/t daughter being unable to attend, does Dr. OK coming alone d/t med During a telephone interview on 01/07/11 at 11:15 a.m., the surgeions Geriatric Nurse Practitioner (GNP) reported the following regarding SR #1's exam findings during his appointment on 12/15/10: GPN described an area, approximately 4 inches in length and 2 inches in width, of black non-healing tissue to the right above knee amputation incision site. When asked if a revision would have been needed if SR #1 had been evaluated before 12/15/10, GPN replied this measure might not have been necessary. GPN did not elaborate on interventions that might have been done if SR #1 had been evaluated sooner than 12/15/10. Review of SR #1's acute care hospital's Operative Report dated 12/17/10, revealed that SR #1 underwent surgery, a right above the knee amputation stump revision with wedge excision (removal or amputation). The removal of necrotic (dead) tissue went into the deep layers of muscle where there was healthy tissue. Review of the laboratory Histology Report dated 12/17/10 of tissue removed from SR #1's right above the knee amputation site on 12/17/10 revealed clinical information of "gangrene right above knee amputation"; tissue removed from SR #1's right leg measured 11 x 4.5 centimeters with a depth of 3 centimeters (approximately 4-1/4 inches by 1-3/4 inch with a depth of 1-1/4 inch). The Histology Report's final [DIAGNOSES REDACTED]." The facility's Admission/Readmission Assessment form revealed that SR #1 was re-admitted to the facility on [DATE]. SR #1's Non-Pressure Skin Condition Record dated 01/03/11 revealed that the RAKA revision incisional wound site had 29 staples, was clean and dry and had no signs of infection. SR #1's Physician's Admitting Orders included one for follow-up appointment with the surgeon two weeks from the admission date of [DATE]. Surveyor observation of wound care/skin assessment to SR #1's incisional wound was done with LVN "D" on 01/07/11 at 2:50 p.m. Skin clips (staples) were in place, the incision was clean and dry, there were areas of reddness at the clips and one small, approximately 1/8 inch dark brown scab. Surveyor observation of SR #1's incisional wound was repeated with RN "E" on 01/08/11 at 1:40 p.m. Skin at clips was slightly more reddened. The one small scab was still in place. The wound was clean and dry. Review of SR #1's medical record on 01/08/11, revealed that a follow-up appointment with the surgeon had been scheduled for 01/10/11 at 11:30 a.m. During an interview on 01/04/11 at 10:50 a.m., SR #1 stated that he did not remember the events of November and December 2010 that led to his hospitalization . Review of the facility's Skin Management Protocol provided by the facility (Copyright 2010..., Revision Date: February 2010) revealed the Practice Guidelines specify that "if any abnormalities are observed, document a descriptive note of findings AND the Licensed Nurses response in the Nurses Notes section of the resident's medical record." "A Change of Condition form (Briggs) is to be completed and new physician's orders [REDACTED]." "The nurse will assure that treatments, interventions, Care Plan, and the appropriate skin documentation records are initiated in a timely manner." The facility identified five residents with non-pressure sore wounds on 01/04/11. The facility was provided an opportunity to provide additional information prior to exit. No additional evidence was provided.