**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (Resident #1) reviewed for pressure sores, in that: The facility failed to ensure Resident #1 received wound care and treatment as ordered by a physician. -Resident #1's right great toe was not monitored daily for changes once per day as ordered by a physician. -Resident #1's right heel was not monitored daily for changes once per day as ordered by a physician. -Resident #1's skin tear to the left upper leg was not monitored every shift for signs of infection as ordered by a physician. -Resident #1's pressure ulcer to her left buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right gluteal fold was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1 had a significant weight from August 2023 to September 2023. Resident #1 was admitted to the hospital with sepsis presumed to be from an infected sacral decubitus ulcer. An IJ was identified on 9/27/2023 at 6:00 p.m., and a template was provided to the facility at this time. While the IJ was removed on 10/1/2023, the facility remained out of compliance at a scope of pattern and a scope of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place additional residents at risk for a delay in treatment, hospitalization, loss of limb and/or a significant decline in heelth. The findings included: Record review of Resident #1's face sheet dated 9/28/2023 revealed she was [AGE] years of age with an admission date of 1/2/2022 and a readmission date of 6/1/2023 with diagnoses which included: Type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, major depressive disorder, mild cognitive impairment, dysphagia, cognitive communication deficit, urinary tract infection, degenerative disease of nervous system, lack of coordination, morbid obesity, muscle wasting, anemia in chronic kidney disease, fluid overload, anxiety disorder, cerebral infarction, nausea with vomiting, diarrhea. Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS score of 10 indicating moderate impairment. Further review under category, Skin Conditions, revealed Resident #1 was indicated as having zero venous and arterial ulcers, and no other ulcers, wounds and skin problems. Record review of Resident #1's Care Plan, start date 6/1/2023, stated, (Resident #1) has potential impairment to skin integrity r/t incontinence and decreased mobility. (Resident #1) will be free from skin break down through the review date Interventions included, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to left toe. (Resident #1's) Pressure ulcer will show signs of healing and remain free from infection by/through review date. (Resident #1) will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to right great toe. The (Resident #1s) will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated,(Resident #1) has DTI to right heel. (Resident #1's) pressure ulcer will show signs of healing and remain free from infection by/through review date. PHYSICIAN ORDERS Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI to Right heel-monitor daily for changes. Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI - right great toe monitor daily for changes. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated, DTI-right great toe monitor daily for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: DTI to Right heel-monitor for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: Stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 9/9/2023 stated: Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 9/11/2023 stated: Stage 2 to R gluteal fold cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. TREATMENT ADMINISTRATION: Record review of Resident #1's TAR September 2023 stated, DTI - right great toe monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, TI to Right heel-monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR on the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled every shift -Start Date 09/09/2023 Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/9, 9/11 thru 9/15 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, Stage 2 to R gluteal fold cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 09/11/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13, 9/14, 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 0 missed SKIN ASSESSMENTS Record review of Resident #1's Weekly Skin Evaluation, effective date, 9/14/2023, revealed: What type of wound(s) does patient have? - A. Pressure Ulcer(s). Further review revealed there these were new since last skin assessment. Type of wound was, Right gluteal fold - Stage 2 to R gluteal fold measuring 2cmx4cm. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 -Right Great Toe, length 1.5 cm, width 1.5 cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Heel, length 4cm, width 4.5cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Buttock pressure ulcer, length 5cm, width 6cm, depth .1cm, stage N/A. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Left Buttock pressure ulcer, length 3.5cm, width 4cm, depth .1cm, stage II. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. PROGRESS NOTES Record review of Resident #1's progress note, dated 6/1/2023 - 6:18 PM, stated, Note Text: Received resident via stretcher by Amistad ambulance. (Resident #1) is a [AGE] year-old female with PMH of HTN, DM, CAD, neuropathy, anxiety, depression, seizure, CVAx2, ESRD on HD M, W, F, with Fresenius, morbid obesity. (Resident #1) is A/Ox4, skin intact, respirations even and unlabored, lung sounds clear to all lobes, active BS to all 4 quadrants, abdomen non distend, non-tender. Left upper extremity shunt functioning properly. (Resident #1) unable to ambulate due to extreme weakness. (Resident #1) is able to help with transfer with assistance, incontinent X2. (Resident #1) with no belongings. RP and MD made aware. (Resident #1) voices no concerns at this time. (Resident #1)) orientated to room, call bell and bed remote control. Record review of a typed summary drafted by Resident #1's Hospital Physician, received by email on 9/27/2023, stated: Regarding patient (Resident #1) from (Nursing Facility) (Resident #1) arrived to (Hospital B) as a transfer from (Hospital A) on 9/19/2023 for the evaluation and management of altered mental status in the setting of sepsis which was presumed to be caused by an infected sacral decubitus ulcer. Upon my initial evaluation the patient was very lethargic and disoriented and there was a very strong odor. After turning her to the side there was a large unstageable sacral decubital ulcer and other surrounding decubital ulcers of varying stage with some noted purulence. The wounds were also noted in the perineal and groin areas near the skin folds. Photos of the wounds are available in the medical record if needed. Due to low blood pressure/shock (Resident #1) was transferred to the ICU to be placed on pressors to maintain blood pressure. She underwent a CT of the abdomen and pelvis with IV contrast to further assess the wound for surgical planning. Incidentally found on the CT scan was the presence of blood clots in both lungs (bilateral pulmonary embolism). Since clots in the lungs typically originate in the legs we next obtained US dopplers of both legs to assess for any further clots and was found to have blood clots in both legs. An echocardiogram was performed to assess for any strain on the heart caused by the blood clots in the lungs, the study did not indicate any strain to the heart.Since her cardiac function was stable the surgeon and anesthesiologist agreed to proceed with debridement of the sacral wound. The wound was extensively debrided to removed any nonviable tissues which required resecting tissue down to the sacral bones (stage 4 pressure ulcer). I have not seen the wound personally since the surgery was performed but per discussion with (Resident #1's) nurse, the wound is approximately the diameter of a basketball. [sic]Due to the location of the wound, near the anus, there is high risk of stool entering and subsequently causing infection within the wound. For this reason (Resident #1) had to be taken back to the operating room for placement of a colostomy to divert stool away from the wound. Once the wound heels it will be possible to reverse the colostomy. A wound vac is to be placed to assist in wound healing. Due to the extent of the injury, this wound will take significant time and optimal conditions in order to heel. I am unable to provide more specific details on prognosis/outcome. A specialist in wound care may be able to provide more information.(Resident #1) is to remain on blood thinners for at least 3 months for the management of blood clots in the legs and lungs.The wound on (Resident #1's) back/buttock/perineal area is caused by prolonged pressure to the skin and underlying tissue which results in poor blood flow to the affected tissue. These injuries can be made worse or more likely to get infected when patients are incontinent of urine or stool and are not promptly cleaned. In patients who are bed bound or with limited mobility, these injuries can be avoided or made less likely to occur by frequent repositioning to offload pressure on a particular area for prolonged periods of time. Other measures include making sure the skin is regularly cleaned and dried. For patients at risk for developing pressure injuries, the skin should be regularly monitored for signs of injury so that it can be addressed early in the course of the injury. I am unaware of the care that was being provided at the nursing home to address the decubital ulcers or what measures were being implemented to heel or prevent these injuries. (Resident #1) presented to our facility/care at a late stage in the course of this injury process. If this was the first presentation for evaluation of these injuries then it would be an unusually late recognition on the part of the party responsible for her care and would suggest that she was not being adequately monitored or that the injuries were possibly noted but not being adequately tended to. The presence of clots in the legs and lungs also would indicate that she has been very immobile given that immobility is the greatest risk factor for development of these types of blood clots. Interview and attempted observation on 9/22/2023 at 10:51 AM at a hospital ICU (Intensive Care Unit) with Resident #1: Resident #1's Family Member A, revealed Resident #1 had just left for dialysis treatment and would return in approximately 4 hours. During this interview, Family Member A stated the resident had been residing at a nursing facility for the last 3 months. Family Member A said she used to work at a nursing facility and was familiar with protocol specific to resident care. Family Member A indicated staff at the Nursing Facility were not turning, repositioning, or transferring Resident #1 to her wheelchair on the occasions she would visit the resident. Family Member A further stated the Resident #1 was obese and confused and that facility staff had skipped several of the resident's dialysis appointments and also said staff were not adequately feeding the resident and that she had had a significant weight loss. Additionally, Family Member A said Resident #1 had a severe infection in her brain and large pressure wound to sacral area which required surgical intervention at the hospital. Family Member A said Resident #1's wound, .smelled like a dead animal, and that hospital staff had to make special interventions in Resident #1's ICU room in an attempt to mask the odor. Finally, Family Member A said she had signed a DNR for Resident #1 and indicated Resident #1's medical team informed her there was a good chance Resident #1 would not survive much longer. Additionally, Family Member A said medical imaging revealed blood clots in Resident #1's lungs and lower extremities as well as an infection to her brain. Finally, Family Member A mentioned a representative from the facility had just left and was attempting to determine if Resident #1's family was under the impression the facility was responsible for the Resident #1's deteriorating condition. Family Member A showed this investigator a business card whom she purported was a representative of the facility at which time this investigator took a photograph of the business card. A review of this business card revealed an RN D. Telephone interview 9/22/2023 at 1:11 PM with Resident #1's Hospital Physician revealed, Resident #1 appeared , .extremely unkempt . upon her admission to the hospital and was discovered to have .blood clots in both her legs and lungs . The doctor explained that he would typically see these symptoms in patients that, .had not been moved enough . or, .kept in one place for extended periods of time. The doctor further stated it was obvious Resident #1, .had not been turned enough . and that, . her wounds were pretty extensive, specific to Resident #1's peri area. The doctor further stated Resident #1 was, .septic upon arrival. Interview and record review on 9/26/2023 at 9:55 AM, LVN A was asked to describe Resident #1, and replied that Resident #1 came to the facility for physical therapy, was a dialysis patient, was a diabetic, and was alert and oriented times 4 upon admission. LVN A said the Resident #1 had to go to San [NAME] one time because staff thought she had a stroke. LVN A said when Resident #1 returned to the facility, she became totally dependent on staff for assistance. LVN A said Resident #1 seemed to fail to thrive. LVN A said Resident #1 had a referral for psych services and started to take Zoloft. LVN A also said Resident #1 had to downgrade her diet from regular to puree. When asked if Resident #1 had any wounds, LVN A said that Resident #1 had a stage II to her bottom. When asked why Resident #1 was recently discharged , LVN A said she was not sure. When asked how Resident #1 acquired her wound, LVN A said she was unsure. During a record review at this time, LVN A agreed that multiple wound treatments were missed for Resident #1 during the month of September 2023. When asked why, LVN A indicated she did not know because Resident #1 was not combative and was bedbound so she couldn't run away. LVN A agreed this was a concern and that missed wound treatments could lead to serious infection. When asked again what the breakdown was as to why residents were missing so many treatments, LVN A said there really was no good reason as the treatment nurse would typically administer treatments for wounds and then nursing staff would also divide treatments up if and when the treatment nurse was out of the facility. When asked who the treatment nurse was, the LVN said it was LVN B. Interview and record review on 9/26/2023 at 10:31 AM, Treatment Nurse, LVN B was asked to describe Resident #1, LVN B responded that Resident #1 came to the facility with a DTI to her right heel and tip of her right great toe. LVN B said (Resident #1's) bottom started breaking down, and that the, .area between her brief and her leg started breaking down as well. LVN B said Resident #1 started getting another area on her left gluteal fold, and then she went to dialysis on 9/18/2023 and from there was sent to the hospital for low blood pressure, and said (Hospital A) sent Resident #1 to a hospital Hospital B with a diagnosis of encephalopathy. When asked what encephalopathy was, LVN B responded that, it was something in the brain where you get confused, and, get an altered mental status. LVN B said Resident #1's wounds to her peri area were acquired at the facility and that the resident was refusing to be turned. When asked why the resident was refusing to be turned, LVN B said it was because, (Resident #1) wasn't comfortable. When asked why the Hosptial A sent Resident #1 to Hospital B, LVN B responded that she was unsure. When asked if Resident #1's wound was getting infected, the LVN responded that, it wasn't looking great but it didn't have a smell or anything. During this interview, LVN B was shown Resident #1's September 2023 TAR, at which time LVN B confirmed that multiple entries for Resident #1's skin treatments were blank and responded that she may have been working the floor those days. LVN B said that she would have to work the floor if someone called in and would have to also attend to wounds simultaneously. When asked if that posed a problem because she was having to do 2 jobs during a shift, LVN B said she would delegate to other nurses to handle the lower category wounds. When asked what could be done to ensure treatments could never be missed, LVN B said a lot of the 2pm-10pm nurses moved to the hospital which had caused a bit of a strain on staffing. When asked if the facility utilized agency staff, LVN B responded that the facility did not. Interview and record review on 9/26/2023 at 11:03 AM, RN C stated she was filling in for the DON as the DON was out of the facility. During this interview, the RN C said she was not that familiar with the residents as she currently only worked PRN. RN C said staffing had been short and she was frequently asked to work. RN C was shown September 2023 TARs for Resident #1 and agreed they had missing entries. When asked what that meant, the RN C said it meant the treatments, didn't occur. When asked what the concern was specific to wound treatments, RN C said it was a concern because the missed treatments could cause the wounds to evolve into serious infections which could lead to sepsis and or death. RN C said this facility had difficulty retaining staff because other facilities in the area were paying more and believed staffing was the reason some of these treatments were being missed. RN C said that if the treatment nurse is required to work the floor, other nurses on the shift will be delegated to do wound care. Interview and record review on 9/26/2023 at 2:00 PM, the DON said the facility had the staff they need but had been overlapping their shifts. The DON agreed that if there was a missed entry in the TAR it didn't happen. The DON said Resident #1 was very sick and she said the staff tried to get her family to sign a DNR. The DON said facility staff would fear that when (Resident #1) would go to dialysis, they would send her to the hospital and said that is exactly what happened. The DON said Resident #1 was previously discharged from dialysis because she didn't look right. The DON said Resident #1 was, very young and they were having to spoon feed her. The DON said Resident #1 was much more motivated when she was admitted but started to decline. At this time, the DON was shown Resident #1's September TAR, the DON agreed it was a concern that there were missed wound treatments and that missed wound treatments had the potential to evolve into more serious issues like infections. Interview on 9/26/2023 at 3:09 PM, the Medical Director, said he found out recently that there had been missed treatments relative to wound care and that he was very surprised. When asked who was supposed to be doing wound treatments between his visits, the Medical Director responded, LVN B. When asked if he was noticing the decline in Resident #1 and if he would have given different orders, the Medical Director responded that he was not aware of a decline specific to Resident #1's wounds. The Medical Director said he had only heard that another resident had been sent to the ER and insisted on not coming back to the facility and that the resident alleged she was not being provided care for her wounds. The Medical Director further stated this resident had a wound vac. The Medical Director said Resident #1's name came up a couple of times but he could not recall the reason. The Medical Director said Resident #1 was not eating well and had to have IV fluids once or twice and said DON or charge nurse would typically be the one who contacted him when there was a decline. When asked if the Medical Director would come in more than just monthly if a resident experienced a decline, the Medical Director said that he would. The Medical Director said he expected residents would receive nursing care and that he knew skin care was important because a lot of the residents have a lot of vulnerabilities. The Medical Director also stated that staff should be documenting and not missing treatments because the ultimate concern would be that the wounds would get worse. The Medical Director said, A soft tissue wound can lead to infection and lead to hospitalization. The whole idea of being in a nursing home is to avoid hospitalizations. The Medical Director said he was not responsible for training the facility staff. The Medical Director said he was notified and aware of concerns with resident wound care but could not remember the names of the residents for which he had been notified. The Medical Director stated, I probably would have called the DON and asked what was going on with the care the resident was not receiving, when asked what he would have done if he had been notified that a resident did not receive wound care as ordered. The doctor said he, wouldn't like to think there was willful neglect. Finally, the Medical Director stated, there has got to be someone who has to be responsible if the treatment nurse is away so staff have to be more pro-active than reactive. Interview on 9/26/2023 at 4:40 PM, LVN B, when asked about training, said she would get relias training quarterly or if and when an incident of abuse and neglect occurred, and said those trainings, occur frequently. When asked if there were any training the last several weeks, LVN B said there was training for covid, hand washing, abuse and neglect and said that was all. LVN B said that staff were told daily that they need to clear their MARs and TARs, meaning to complete all prompted tasks for their shift. When asked if there had been any trainings specific to Resident #1 since she had been discharged to the hospital, the LVN B said training occurred only when the resident started to decline. When asked when this was, the LVN B said it was after the resident came back from one of her admissions from the hospital. When asked if any trainings occurred in response to the Resident #1's most recent discharge, the LVN B indicated there had been no trainings specific to this incident since Resident #1 discharged on 9/19/2023. When asked if any other nurses were qualified to do wound treatment, LVN B said that LVN A and several other LVNs had become qualified. LVN B said those LVN staff do a rotation with me when they get hired. LVN B said staff typically get evaluated annually. LVN B was asked if she had her wound treatment skills evaluated, she responded, yes, by the DON. LVN B was asked when this evaluation took place and said it was in in March or April 2023 and said the evaluations would occur annually. Interview on 9/26/2023 at 5:07 PM, DON, stated Resident #1 was sent from dialysis to the hospital. When asked what diagnosis Resident #1 was sent out for the DON responded that she was not sure. The DON said she guessed it was encephalopathy and found out Resident #1 was going to the ER when dialysis called to inform her. When asked if staff had any training since Resident #1 was sent to the hospital relative to encephalopathy or other issues related to the Resident #1's incident the DON responded, no. The DON said Resident #1 was unpredictable and her alert and oriented status would frequently change. The DON said Resident #1 was continent when she arrived to the facility but once she became incontinent, staff noticed Resident #1 had genital warts upon changing her. Interview on 9/27/2023 at 5:02 PM, the DON stated the facility's Medical Director came to the facility monthly and talked to residents, reviewed charts/meds, would look at wounds if staff requested. The DON said she was informed of residents' wound status by reviewing a weekly skin report and would check to see who was progressing or declining and who needs what type of interventions.The DON said staff communications began with the CNAs who would inform their charge nurse of concerns and the charge nurse would put those concerns on the 24-hour report and contact physician to get orders. The DON was made aware by staff Resident #1's wounds were getting worse. The last time she had seen the resident had been a little while, and she was under the impression the resident's sacral pressure ulcer had evolved into a stage II pressure ulcer. When asked what facility staff could have done differently for this resident, the DON said facility staff should have sent the resident to the hospital more frequently but said the hospital would just send her back and we had to have a van on standby to pick her up, implying the resident was frequently sent to the hospital. (note: Resident #1 was only sent out 3 times in 3 months including most recent visit). Interview on 9/27/2023 at 5:14 PM, the Administrator revealed information obtained during the previous interview with the DON. Additionally, when asked what could have been done differently for Resident #1, the Administrator said, We should have added the resident to patients at risk, and could have sent her to the hospital for slightest decline. Interview on 9/28/2023 at 10:42 AM, the Administrator revealed LVN B did not have Wound Care Certification. Telephone interview on 9/29/2023 at 12:30 PM, the Medical Director said that had he been made aware that Resident #1's wound status had changed, he would have wanted to have found out the last time Resident #1 saw the vascular surgeon, would have wanted to talk to the treatment nurse, and would have looked for any signs of infection. Record review of facility policy, Job Description for Treatment Nurse, revised 3/2015, stated, The Treatment Nurse will provide quality of care to prevent and promote healing of alterations in skin integrity of each resident as determined by resident assessments and individual plans of care . 12. Initiate and continue treatments on residents in the facility with skin breakdown and other conditions requiring treatment. 13. Modify and/or change treatments as necessary and notifying physician for approval. 14. Inform the DON and the assessment nurse of resident change of condition. Record review of facility policy, Pressure Injury Prevention and Management, dated 8/15/2022, stated, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatmen[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** POST MPRO Based on interviews and record reviews the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 1 of 32 residents (Resident #140) reviewed for infections / infestations, in that: 1. Resident #140 was diagnosed with a urinary tract infection with 2 different microbial pathogens for which Resident #140 was not treated for over 25 days 04/08/2023 to 05/07/2022 and resulted in Resident #140's hospitalization with a diagnosis of urinary tract infection sepsis [the body's extreme response to an infection] and passed away. An Immediate Jeopardy (IJ) situation was identified on 04/07/2023. While the IJ was removed on 04/08/2023, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. This failure placed residents at risk for not receiving necessary care and services resulting in worsening of condition, hospitalization and/or death. The findings included: 1. Record review of Resident #140's admission record revealed an admission date of 05/23/2020, and a hospital emergency discharge date of 05/07/2022, and diagnoses which included neuromuscular dysfunction of bladder and bladder neck obstruction [when a person lacks bladder control due to brain, spinal cord or nerve problems]. A record review of Resident #140's quarterly MDS, dated [DATE], revealed Resident #140 was a [AGE] year-old male without cognitive mental impairment evidenced by a 15 out of 15 score on a BIMS. Resident #140 had a suprapubic catheter [a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow] and a history of urinary tract infections. Resident #140 was frequently incontinent of bowels. Resident #140 was not weight bearing and used a wheelchair to ambulate. A record review of Resident #140's care plan, dated 04/06/2023, revealed, The resident had an activities of daily life self-care performance deficit related to contractures to the left leg and above knee amputation; toilet use; the resident is totally dependent on staff for toilet use. Resident is incontinent of bowel and required staff to check every two hours. staff to help provide catheter care and empty out the urine collection bag. The resident has suprapubic catheter at risk for UTI sepsis. The resident has suprapubic catheter; position catheter bag and tubing below the level of the bladder . monitor record report to medical doctor for signs and symptoms of urinary tract infection pain burning blood thinning hearing cottages fever chills altered mental status. A record review of Resident #140's nursing progress notes, dated 04/01/2022 , at 03:12 AM, revealed RN A documented, Resident c/o pain to bladder area. c/o burning to stoma area. noted with leakage from stoma area around foley catheter. Catheter irrigated with NS but noted to drain poorly and leak more around stoma area. Unable to aspirate urine residual from catheter with 60cc syringe. Area around stoma cleaned and TAO applied generously around catheter. Belly bag repositioned below resident's scrotum to provide better drainage to gravity. plan to collect urine for ua /c & s this am. A record review of Resident #140's nursing progress notes revealed LVN B documented on 04/06/2022 , at 09:35 PM resident back from urology appt. NP E requested for resident to have SP drain to gravity and no belly bag. facility to collect UA and send to [local hospital] for C/S. and to continue with current medications. Follow up in four months [DATE], at 01:50 PM. This SN advised resident that I needed to change foley bag [urine collection] to either a leg bag or normal foley bag, resident refused and stated he wants AM shift to change it. A record review of Resident #140's laboratory report, dated 04/08/2022, revealed Resident #140, collected 04/03/2022 .reported 04/08/2022 .detected urinary tract assay results organism's enterococcus faecalis .proteus mirabilis. A record review of Resident #140's nurse progress notes revealed LVN C documented on 04/12/2022 , at 10:25 AM, UA with CS results dated 04/07 faxed to Dr. F [urologist] office for review. Culture revealed 2 organisms. Proteus mirabilia and enterococcus faecalis. Pending MD response. A record review of Resident #140's laboratory report, dated 04/12/2022, revealed Resident #140, collected 04/07/2022, urine culture final organism 1 proteus mirabilis .organism 2 enterococcus faecalis. [Proteus mirabilis a bacterium known to cause serious infections in humans. Enterococcus faecalis a bacterium can cause life-threatening infections]. A record review of Resident #140's nurse progress notes, dated 04/13/2022 , at 12:08 PM, revealed LVN C documented, called and left voicemail on Dr. F's office line to follow up with urinalysis results. Pending call back. A record review of Resident #140's nurse progress notes, dated 04/19/2022 , at 11:31 AM, revealed LVN C documented, spoke with [medical office person] regarding residents UA with CS results. states she will look into it and relay message to the nurses. A record review of Resident #140's nurse progress notes revealed LVN C documented on 05/07/2022, at 08:15 AM, resident noted with severe AMS and complaining of pain. RP has been notified and EMS has been dispatched .resident admitted to [local hospital] med surge room [xxx], DX: UTI, Sepsis as per RN G. During an interview on 04/05/2023 at 10:20 AM, LVN C stated nurses enter lab orders into the facility's lab contractor's portal website, then document on the nurses' 24-hr. report and from there the nurse checks the lab's website for the results, print out the results, and then the DON recovers the lab reports and gives them to LVN J the MDS nurse. LVN C was given a report of the survey finding for Resident #140 where on 04/12/2023, 04/13/2023, and 04/19/2023 LVN C attempted to contact Dr. F.; once faxed abnormal lab results to Dr. F's office, then called and left a message for Dr. F, and then called and left a message for Dr. F with office personnel. LVN C was asked if she escalated the inability to provide Dr. F an SBAR to her supervisors, Resident #140's attending physician Dr. H, and ultimately to the facility's medical director; LVN C stated she could not recall the details of a year ago, however LVN C stated, if it was not documented it was not done. LVN C stated the review of her documentation on the dates 04/12/2022, 04/13/2022, and 04/19/2022 appeared as if she was attempting, unsuccessfully, to SBAR Dr. F for Resident #140's UTI infections evidenced by the UA C&S abnormal lab results. During an interview on 04/05/2023 at 2:25 PM, LVN B received a report of her documentation for Resident #140 on 04/06/2022 where she documented Resident #140 had returned from their urology appointment and had a new order for a UA with a CS. LVN B stated she could not recall the details but stood on the accuracy of her note. LVN B was asked to demonstrate her documentation for the physicians' order for the UA with C&S. LVN B stated she reviewed Resident #140's record and could not find any order for Resident #140 to have a UA with a C&S on 04/07/2022. In response to the lack of a documented order for the UA with C&S LVN B stated, I am human and I can make mistakes. During an interview on 04/07/2023 at 03:48 PM, with the DON and the ADON, the DON stated Resident #140 had a need for a suprapubic catheter related to a neurogenic bladder, which was to drain via gravity to a dependent urine collection bag positioned below the bladder. Resident #140 was non-compliant with the position of the dependent urine collection bag positioned below the bladder and would often reposition the collection bag in between his legs where the bag could be exposed to bacteria related to incontinence of bowels. Resident #140 was assessed by LVN C, on 03/30/2022, with s/s of a UTI and received an order for a UA and CS from NP E which was executed, and the facility received results on 04/05/2022. Resident #140 was seen on 04/06/2022 by Dr. F and returned to the facility with new orders from Dr. F's NP E, for a UA w/ CS to be collected and sent to the local hospital, no order for the UA was evidenced in the record, however the UA sample was collected and sent to the local hospital on [DATE]. The facility received the UA results on 04/12/2022 to reveal 2 urinary bacterium and the report was faxed to Dr. F office at 10:30 AM, on 04/12/2022. The DON stated Resident #140 received a 1-time dose of amoxicillin 2000mg on 04/12/2022 for dental extraction, and the ADON stated amoxicillin is a broad-spectrum antibiotic which the 04/12/2022 UA CS revealed Amoxicillin could treat the infection. The DON stated LVN C attempted three separate times to reach Dr. F and Dr. F's office could not be reached, once by fax, and once with a voice message, and once with an actual call to Dr. F's office with Dr. F's office person who stated she would relay the message to the nurses. The ADON stated Resident #140 was alert and oriented x3, without a fever, no nausea, no vomiting, no diarrhea. The DON stated and read from the hospital admission record dated 05/07/2022, on arrival patient communicated well states he feels fine, he follows commands appropriately, denies any nausea and vomit, abdominal pain, patient is non tachycardic [a heart rate over 100 beats a minute], no distress noted and afebrile [no fever]. He was sent for confusion and facility stated he was talking in word salad [a confused or unintelligible mixture of seemingly random words and phrases]. when the DON was asked what should have happened the DON stated she refused to answer. During an interview on 04/07/2023 at 10:50 AM, the Medical Director stated he was familiar with Resident #140 and recalled Resident #140 had a history of recurrent UTI's related to his suprapubic catheter. The Medical Director was given a report of survey findings to include Resident #140 was recognized with a urinary tract infection on 04/06/2022 and again on 04/12/2022, specifically the pathogens enterococcus faecalis and proteus mirabilis, without any documentation for communication with a physician, without any documented order for a urinalysis lab, and no report to a physician for the 2 pathogens identified. The Medical Director was given a report of survey findings to include Resident #140 was assessed with altered mental status on 05/07/2022 and was transferred to the local hospital where Resident #140 was admitted with the diagnosis urinary tract infection sepsis and passed away during his hospital stay. The Medical Director stated Resident #140 should have been supported with an opportunity for a physician to intervene and possibly provide various supports to address the infections prior to Resident #140's hospital transfer. The Medical Director was given survey evidenced data to include the facility unsuccessfully attempted to report to Dr. F, the urologist, on 04/12/2022, 04/13/2022, and again on 04/19/2023. The Medical Director stated the expectation was for the facility staff to have given a report of the double pathogen infection to the next escalated physician to include a report to Resident #140's attending physician, Dr. H, and ultimately himself, the medical Director. The Medical Director stated he could not recall if he had been given a report but if he had been given a report, he would have intervened. The Medical Director stated sepsis is a serious infection where the infection has spread from its origin to the systemic body to possibly include the blood and could have serious injury potentials to include death. The Medical Director stated the report of a double pathogen urinary infection was a serious result and would not have been ignored and required a physician's intervention. The Medical Director stated he has intervened in similar infections and could have treated the infection at the resident's home to include many possible interventions to include, pushing fluids, monitoring for signs and symptoms of infection, oral and intravenous antibiotics, and to ultimately transfer a patient to the hospital. The Medical Director stated there could have been an advantage to treat residents in their home and in theory reduce the possibility for cross contamination of pathogens which could happen at the hospital. The Medical Director was given a report of survey findings to include Resident #140 was assessed during his time at the facility with the infection to be free from signs and symptoms of infection to include Resident #140 was without a fever, and had vital signs within normal limits; the Medical Director stated the fact was Resident #140's urinalysis lab revealed a serious double pathogen infection and was enough to warrant treatment. The Medical Director stated in his medical practice he has encountered a patient without any signs and symptoms of infection other than a positive infection lab result and he would not ignore the lab result and would intervene with some type or types of treatment to eliminate the infection. During an interview on 04/07/2023 at 03:48 PM, the DON stated the expectation is for nurses to document all communications with physicians, new orders, and follow ups in the residents' medical records. During an interview on 04/07/2023 at 10:50 AM, The medical director stated the expectation was for all physician communications, orders, and nursing follow ups to be documented accurately in the resident's medical record. A record review of the National Institute of Aging's website, an official website of the United States government, https://www.nia.nih.gov/health/taking-medicines-safely-you-age , accessed, 04/24/2023, Taking Medicines Safely as You Age revealed, It can be dangerous to combine certain prescription drugs, OTC medicines, dietary supplements, or other remedies .To avoid potentially serious health issues, talk to your doctor about all medicines you take, including those prescribed by other doctors, and any OTC drugs, vitamins, supplements, and herbal remedies. Mention everything, even ones you use infrequently. Starting a new medicine: Talk with your health care provider before starting any new prescription, OTC medicine, or supplement, and ensure that your provider knows everything else you are taking. Discuss any allergies or problems you have experienced with other medicines. These might include rashes, trouble breathing, indigestion, dizziness, or mood changes. Make sure your doctor and pharmacist have an up-to-date list of your allergies so they don't give you a medicine that contains something that could cause an allergic reaction. You will also want to find out whether you'll need to change or stop taking any of your other prescriptions, OTC medicines, or supplements while using this new medicine. Mixing a new drug with medicines or supplements you are already taking might cause unpleasant and sometimes serious problems. For example, mixing a drug you take to help you sleep (a sedative) and a drug you take for allergies (an antihistamine) can slow your reactions and make driving a car or operating machinery dangerous. A record review of the manufactures lice shampoo treatment's website, https://ridlice.com/wp-content/uploads/2022/04/RID_Complete_Kit_Insert_English.pdf , accessed 04/24/2023, revealed, WARNINGS: For External use only Do not use near the eyes, inside nose, mouth, vagina, or on lice in eyebrows or eyelashes. See a doctor if lice are present in these areas. Ask a doctor before use if you are allergic to ragweed. May cause breathing difficulty or an asthmatic attack. When using this product keep eyes tightly closed and protect eyes with a washcloth or towel. If product gets in eyes, flush with water right away. Scalp itching or redness may occur. Stop use and consult a doctor if breathing difficulty occurs, eye irritation occurs, skin or scalp irritation continues, or infection occurs. Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away .Use towels to protect eyes and clothes from treatment. Apply RID® Lice Killing Shampoo to DRY HAIR or affected area. Apply enough product to saturate. Thoroughly massage product into scalp, behind ears and onto back of neck. Allow product to remain on hair for 10 minutes, but no longer. Add warm water and massage to form lather. Rinse thoroughly, e.g., in a sink. Repeat this step in 7-10 days to kill any newly hatched lice. A record review of the facilities Laboratory Services and Reporting policy dated, 04/08/2023, Revealed, the facility must provide or obtain laboratory services in ordered by a physician, positions assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. policy and explanation and compliance guidelines: the facility must provide or obtain laboratory services to meet the needs of its residents. the facility is responsible for the timeliness of the services. should the facility provide its own laboratory services the services must meet the applicable requirement for laboratories. if the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of service in accordance with requirements. assist the resident in making transportation arrangements to and from the laboratory if necessary. all laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the residence clinical record. promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. if unable to reach the ordering prescriber with abnormal lab results the medical director will be notified. This was determined to be an Immediate Jeopardy (IJ) on 04/07/2023 at 08:00 PM. The administrator was notified. The Administrator was provided with the IJ template on 04/07/2023. The following Plan of Removal was accepted on 04/08/2023 at 3:30 PM. Plan of Removal Verification, April 8, 2023 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Issue: F-Tag: 684 The facility failed to notify MD/Medical director of change in condition and abnormal lab values. Resident #140 no longer resides in the building. A record review of Resident #140's admission record dated, 04/07/2023, revealed an admission date of and discharge hospital date of 05/07/2022. During an interview on 04/07/2023 at 03:40 PM the DON stated Resident #140 was discharged to the hospital on [DATE] for altered mental status. Director of Nursing and/ or designee completed a Lab audit, consisting of 39 residents with 5 lab orders from March 1, 2023- April 7, 2023, on 4/8/2023 looking for abnormal values, transcription, and MD/Medical Director notification. Medical Director will be notified if Primary MD does not respond. During an interview on 04/08/2023 at 3:53 PM the ADON stated the facility assessed all 39 residents for changes of condition, PCP SBARs, new orders, and lab results for the last month up to 04/07/2023. And discovered 5 residents (#1, #4, #8, #26, and #29), with new orders for labs, SBARS, and progress notes to detail the changes of conditions. AON stated, During an audit we did a lab audit on every single Resident, reviewed for accuracy, specific to include, Progress notes, PCP, communications, orders, lab results, follow with next nurse. A record review of Resident #1's medical record revealed orders for labs, dated 03/01/2023. A record review of the resulted labs revealed abnormal results. Continued review of the medical record revealed a progress note by the DON which read, phoned doctor T to discuss resident lab values CBC, Keppra, mag, CMP, phenobarbital, A1C. no new orders received resident to keep appointment to reestablish care next week. A record review of Resident #4's medical record revealed lab orders for PT/INR dated 03/18/2023 revealed the Medical Director ordered, recheck in 2 weeks. A record review revealed a progress note dated 03/18/2023 by LVN C, PT/INR results reviewed with medical director. new order to continue same strength and recheck PT INR in two weeks. A record review of the lab result dated 03/31/2023 revealed abnormal results for PT/INR. A record review revealed a progress note, dated 04/05/2023, LVN C documented, PT/INR results from 03/30/2023 reviewed with the medical director. PT - 32.9, INR, 3.3. recheck PT/INR in three weeks. PT INR updated on the log. A record review revealed a new order, dated 04/05/2023, from the medical director, PT/INR in three weeks 04/25/2023. A record review of Resident #8's medical record revealed an order, dated 03/27/2023, CBC, CMP, iron, TIBC, ferritin, magnesium. a record review of the lab results revealed an abnormal lab, dated 03/31/2023. A record review of the progress notes revealed the DON documented on 04/08/2023, reviewed lab results CBC, CMP, ferritin, magnesium, iron, with doctor H. no new orders. A record review of resident #26's medical record revealed an order dated 03/14/2023 revealed CBC, CMP, lipid, TSH, microalbumin, UA with C&S to be drawn today 03/14/2023 and take into the local hospital laboratory. A record review revealed a progress note dated 03/30/2023, by LVN I, over the phone appointment with doctor W, medical director will refer resident to kidney specialist both referral and lab orders will be faxed to the facility tomorrow morning once the medical director closes the note the medical director verbalized no new orders for 03/14/2023 urinalysis results resident asymptomatic. resident aware and representative stated understood. Director of Nursing was reeducated by the Regional Clinical Specialist on 4/8/23 regarding the below education. After receiving the training the Director of Nursing Service or designee will re-educate the current Licensed Nursing (24 Licensed Nurses) staff and any new Licensed Nurses hires prior to working their next assigned shift regarding notification of MD/Medical director of abnormal lab values, change of condition and correct transcription of lab orders. The Medical Director will be notified if Primary MD does not respond in a timely manner. Notification efforts will be documented in progress notes. Current Licensed Nurse staff (24 Licensed Nurses) and any new Licensed Nurse hires will also be re-educated on Abuse, Neglect and Exploitation prior to working their next assignment shift. No staff will be allowed to work until the re-education is completed. Re-education will be completed as of 4/8/23. A policy was developed in regard to the above education on Laboratory Services and Reporting which includes notifying the Medical Director if unable to contact the ordering Physician, Physician extenders, including NP and PA with abnormal lab results. A record review of the facility's in-service dated 04/07/2023, revealed the DON received a 1 hr. education to cover orders for UA and CNS should be transcribed to PC in order form. medical director nurse practitioners' physicians' assistants and medical doctors must be informed of abnormal lab results. If no response escalates to the medical director. all efforts to be documented in PCC. all abnormal labs must be called to a physician. changes in condition are called to physician and documented and followed up. Further review revealed the DON's signature and printed name. During an interview on 04/08/2023 at 08:18 PM the DON stated she received the 1 hr. in-service and returned the education to all 24 of her nurses. The DON stated any new Licensed Nurses hires prior to working their next assigned shift regarding notification of MD/Medical director of abnormal lab values, change of condition and correct transcription of lab orders. The Medical Director will be notified if Primary MD does not respond in a timely manner. Notification efforts will be documented in progress notes. Current Licensed Nurse staff (24 Licensed Nurses) and any new Licensed Nurse hires will also be re-educated on Abuse, Neglect and Exploitation prior to working their next assignment shift. No staff will be allowed to work until the re-education is completed. Re-education will be completed as of 4/8/23. During an interview on 04/08/2023, at 04:04 PM, LVN B stated she was a charge nurse at the facility and usually worked the 02:00 PM to 10:00 PM shift on either the 100-200 hall or the 300-400 hall. LVN B stated she worked 04/08/2023 and received an in-service prior her LVN duties on the floor. LVN B stated the in-services included abuse, neglect, and exploitation prevention, documenting in residents' medical records, to include physicians' communications, SBAR's, orders, lab results, and continuity of care documentation. During an interview on 04/08/2023, at 03:54 PM, LVN D stated she was the treatment nurse for the facility from 08:00 AM to 05:00 PM and last worked 04/08/2023. LVN D stated she received in-service training prior to working her shift and included documenting in a residents record any changes of condition, communication with physicians, new orders, lab results, and if a physician cannot be contacted the medical director should be included in a report to include new orders documented in the residents' permanent record. Monitoring of the plan of removal included: During an interview on 04/08/2023, at 03:54 PM, LVN K stated she is the MDS nurse, works Monday through Friday, 8-5 PM and occasionally works the floor. LVN K stated she was in-serviced 04/08/2023 to include a communication w/ document in the resident's permanent record any change of condition, SBAR to the PCP, and if the PCP is unavailable to escalate the communication to the next PCP to ultimately include the Medical Director. LVN K stated the in-services also included documenting in the Resident's permanent record all orders documenting the communication with the doctor. LVN K stated all lab results are to be reported to the PCP and critical labs are to be immediately reported to a physician up and including the Medical Director. LVN K stated she was also in-serviced on ANE allegations and ANE preventions. During an interview on 04/08/2023 at 04:34 PM LVN X stated she worked as an LVN charge nurse and her usual shift was 02:00 PM to 10:00 PM. LVN X stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the residents permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress notes, LVN X stated if she could not report to any PCP's she would escalate the order to the Medical Director. During an interview on 04/08/2023 at 04:40 PM LVN W, stated she worked the 10:00 PM to 06:00 Am shift as a charge nurse in the facility and received in-service training on 04/08/2023 which included 2 in-services for ANE allegations, ANE prevention, to which a report would be given to the ANE prevention coordinator the Administrator, LVN W stated she received an in-service which included education to document in the residents permanent record any and all communications with the PCP and if the PCP was not available to escalate the SBAR to the Medical Director. During an interview on 04/08/2023 at 05:00 pm RN N stated she works as a RN supervisor on the weekends from 06:00 to 02:00 PM. RN N stated she was in-serviced on 04/08/2023 to include education for ANE prevention to include reporting to the Administrator. RN N stated she received an in-service which included education to document in the resident's permanent record any and all communications with the PCP and if the PCP was not available to escalate the SBAR to the Medical Director. During an interview on 04/08/2023 at 05::33 PM LVN O stated she worked as an LVN charge nurse and her usual shift was 02:00 PM to 10:00 PM. LVN O stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the residents permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress notes, LVN O stated if she could not report to any PCP's she would escalate the order to the Medical Director. During an interview on 04/08/2025 at 04:57 PM LVN I stated she last worked 04/07/2023 and was responsible for Resident #4, on 03/18/2023 she received PT/INR lab results for Resident #4, SBAR'ed the Medical Director, received new order from the medical Director, entered the new order into Resident #4's permanent record, entered the new lab order in the facility's lab contractor's website portal, and documents the details in Resident #4's progress notes. LVN I stated on 04/08/2023 she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the residents permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress notes, LVN I stated if she could not report to any PCP's she would escalate the order to the Medical Director. During an interview on 04/08/2023 at 05:39 PM RN R stated she was the weekend RN supervisor and worked 06:00 AM - 02:00 PM. RN R stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the resident's permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress note. RN N stated if she could not report to any PCP's she would escalate the order to the Medical Director. During an interview on 04/08/2023 at 05:39 PM RN S stated she was the weekend RN supervisor and worked 10:00 PM to 06:00 AM. RN R stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the resident's permanent record all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress note. RN N stated if she could not report to any PCP's she would escalate the order to the Medical Director. [TRUNCATED]