**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not thoroughly investigate 2 of 4 allegations of abuse involving residents (R) (R5 and R1) and did not take steps to prevent further potential abuse while an investigation was in progress. The facility was made aware of an incident involving allegations of abuse that occurred involving R5 and two staff members. The facility did not investigate the incident causing R5 to be fearful and cautious. R5 sought evaluation and treatment for left knee pain following the incident. The staff member alleged to have abused R5 was allowed to work approximately 46 shifts following the incident, resulting in R5 and other residents to not be safeguarded from additional potential abuse. The facility's failure to thoroughly investigate allegations of abuse allowed accused staff to continue working with residents following the incident resulting in the failure to safeguard residents from potential further abuse. These failures created a finding of Immediate Jeopardy that began on 01/13/2025 . Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the Immediate Jeopardy on 03/19/2025 at 12:16 PM. The Immediate Jeopardy was removed on 3/20/25, however the deficient practice continues at a scope/severity of D (potential for harm/isolated) due to the following example: *On 3/3/2025, the facility investigated allegations of sexual abuse for R1. The CNA was allowed to work 2 additional weeks at the facility while the investigation was in progress. These deficient practices has the potential to affect the residents on the unit which CNA-J was working on after the alleged incident. Findings include: The facility's policy titled Abuse, Neglect and Exploitation, dated as reviewed/revised on 10/2024, documents: Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others that has not yet been investigated and if verified, could be an indication of noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse . Mistreatment means inappropriate treatment or exploitation of a resident . Physical Abuse includes, but is not limited to hitting slapping punching biting and kicking. It also includes controlling behavior through corporal punishment. Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; . The components of the facility abuse prohibition plan are discussed herein: . V. Investigation of alleged abuse, neglect and exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur VI. Protection of resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after an investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim in integrity of the investigation: . D. Room or staffing changes, if necessary, to protect the residents from the alleged perpetrator; E. Protection from retaliation by perpetrator. 1.) R5 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified dementia without disturbance, psychotic disturbance, mood disturbance and anxiety, pain in right knee, pain in left knee, anxiety disorder, peripheral vascular disease, pain in right wrist, pain in left shoulder, and rotator cuff tear or rupture of left shoulder. R5's Annual Minimum Data Set (MDS), dated [DATE], documents R5 is able to understand and be understood and a staff assessment for mental status was conducted which documented R5 has a memory problem but was able to recall current season, location of own room, staff names and faces, and he/she is in a nursing home/hospital swing bed. The MDS documents R5 has modified independence-some difficulty in new situations only, R5 has no behaviors/rejection of care exhibited, uses a walker, and is not on antipsychotic drug therapy. R5's Quarterly MDS dated [DATE], documents a staff assessment for mental status was conducted and that R5 has a memory problem but was able to recall current season, location of own room, staff names and faces, and he/she is in a nursing home/hospital swing bed. The MDS documents R5 has modified independence-some difficulty in new situations only, R5 has no behaviors/rejection of care exhibited, uses a walker, and is not on antipsychotic drug therapy. On 03/17/2025 at 08:50 AM, Surveyor interviewed R5. R5 informed Surveyor R5 was attacked in the doorway to kitchen by a named staff member, later identified as Certified Nursing Assistant (CNA)-J. Surveyor asked R5 what led up to the incident and R5 indicated being unsure and stated CNA-J is a belligerent and stupid person. R5 indicated that Adult Protective Services (APS) came to the facility and spoke with R5. R5 was unsure who notified APS and indicated there were many witnesses. R5 informed Surveyor CNA-J told R5 that Director of Nursing (DON)-B said R5 could not come in the kitchen. R5 indicated speaking with DON-B regarding the incident and was told it would be taken care of. R5 informed Surveyor R5 was hurt during the incident and had pain to left rib cage, left shoulder, and left foot. R5 stated R5 does not feel safe at the facility, the incident is not taken care of and stated, I was abused! R5 stated R5 is fearful and is very careful with what R5 says and does now in the facility. Surveyor reviewed staff roster for the last name of the staff member R5 identified. Surveyor noted 2 staff with that last name, so Surveyor interviewed one of the two staff members with the same last name and was able to determine that the individual alleged to have been in altercation with R5 was CNA-J. On 03/17/2025 at 10:42 AM, Surveyor spoke with Director of Dietary-N. Director of Dietary-N was not here the day of the incident but knows of incident involving R5. Director of Dietary-N was informed the following day by a DA-M who witnessed the incident between CNA-J and R5. On 03/17/2025 at 10:45 AM, Director of Dietary-N called DA-M via telephone. DA-M indicated on the day of the incident, dietary staff were getting ready to serve dinner, when R5 came to get ice. DA-M stated DA-M heard CNA-J saying, get away from there. DA-M then saw that CNA-J had the resident by the forearm area, then pushed the cart away aggressively trying to get the drink from R5's hand. DA-M stated CNA-J then pushed R5 and the cart, and R5 fell into the door. DA-M stepped in between resident and CNA-J. DA-M asked R5 if R5 was okay and DA-M stated R5 stated R5 was rattled. DA-M observed milk and coffee on the floor, DA-M walked resident back to R5's room. CNA-J kept yelling. DA-M spoke to DON-B and stated DON-B wasn't interested, and DON-B rolled DON-B's eyes. CNA-J proceeded to cause problems in the kitchen slamming doors and talking crap. The next day, Director of Dietary-N and DA-M went to talk to DON-B regarding CNA-J but again DON-B did not seem interested. On 03/17/2025 at 10:54 AM, Surveyor interviewed Lead Cook-P. Lead Cook-P indicated on the evening of the incident, Lead Cook-P heard commotion by the door to the dining room. Lead Cook-P indicated Lead Cook-P did not see what had occurred but indicated milk had fallen off the cart and onto the floor. On 03/17/2025 at 1:26 PM, Surveyor interviewed DON-B. Surveyor asked DON-B if an incident occurred in the dining room involving R5. DON-B indicated there was an incident possibly in December or January, involving two staff members yelling at each other and milk spilled on the floor. DON-B indicated R5 was there, CNA-J was telling R5 that R5 cannot grab milk from the cart due to infection control concerns and told resident DON-B said that. DON-B indicated DON-B spoke with both staff, and they never mentioned R5 being grabbed or pushed. DON-B indicated DON-B spoke to R5 at the time but only talked about not going into the pushcart due to infection control. [Note: R5 told surveyor that DON-B had told him the problem would be taken care of.) DON-B indicated the incident was not reported or investigated due to it being an incident between two staff members and DON-B had informed the staff members to separate. Surveyor reviewed R5's Electronic Medical Record (EMR) and noted an office visit with R5's Orthopedic Doctor on 01/13/2025 that documented, Seen for left knee pain, patient last seen for issue on 10.18.24 where he completed 3 injection series of Synvics injections. Patient was slammed into a door jam [sic] at Grande Prairie approximately 10 days ago which is when the pain began. Describes pain as sharp that radiates from the anterior of the left knee cap that radiates down the left leg. Patient rates the pain a 10/10, Patient states the pain does interfere with sleep. Patient states walking aggravates the pain. The patient does not endorse catching, popping, grinding, clicking. The patient does complain of leg buckling/giving way. Patient is not experiencing numbness/paresthesias, or gross motor weakness. The patient cannot walk for as long as they would like or exercise without pain. The symptoms aren't activity-related and don't improve with rest. The patient does have difficulty with Activities of Daily Living (ADLs) due to current symptoms. Patient denies any fever, chills, or issues with bowel/bladder functions .Assessment and Plan: Primary osteoarthritis of left knee Patient presents in office for an increase in left knee pain following an injury at his rehab facility. According the patient he was forcibly pressed into a wall in the left knee was twisted during the incident and his pain has been increased since. X-rays are negative for fracture; the knee is stable upon exam. Most likely this incident caused a flare in his arthritis for which a cortisone shot was given today .will follow up in our office as needed. On 03/18/2025 at 02:38 PM, Surveyor spoke with Registered Nurse (RN)-O from R5's Orthopedics office. RN-O indicated R5 was seen on 01/13/2025, and per R5's statement, R5 was suffering from left knee pain because of the incident involving CNA-J and R5. RN-O stated R5 called the doctor's office on 03/03/2025 complaining of still having pain in the left knee following the incident. RN-O encouraged R5 to be seen in urgent care and then RN-O then called in the complaint to APS. RN-O informed Surveyor R5 called the doctor's office again on 03/06/2025 with same complaints, and informed Surveyor RN-O called the facility to follow up which led R5 to be sent to emergency room on [DATE] for shortness of breath and edema. On 03/17/2025 at 3:22 PM, Surveyor left voice message for CNA-J requesting CNA-J call Surveyor. No return call was made. On 03/17/2025 at 3:04 PM, Surveyor asked DON-B and NHA-A about R5's Office visit note dated 01/13/2025. Surveyor asked if there was a separate incident or if this would be from the same incident in the kitchen area. DON-B indicated she would guess it is the same incident and indicated no other incidents occurred. DON-B stated the information from the visit was not brought to DON-B's attention. NHA-A stated a good guess of when the incident occurred between CNA-J and R5 would be around the time of the last annual survey. NHA-A indicated police have now been notified. On 03/18/2025 at 07:36 AM, DON-B updated Surveyor regarding the investigation into the incident involving R5 and CNA-J. DON-B stated DON-B thinks the incident occurred near the end of December and is trying to get in touch with CNA-J but has not got a call back. DON-B indicated she is attempting to pinpoint the exact date the incident occurred. Surveyor noted, DON-B stated she found a note dated 01/08/2025 by another CNA indicating kitchen staff was following CNA-J around on unit but DON-B did not follow up because DON-B is not in charge of kitchen staff, per DON-B. DON-B informed Surveyor CNA-J was upset because DON-B told CNA-J to stay out of the kitchen, but did not tell kitchen staff to stay off the unit where CNA-J was working. Surveyor noted CNA-J worked 12/21/24, 12/23/24, 12/25/24 in the dining room per the schedule, but was not scheduled for dining room after those dates. Surveyor noted CNA-J worked a total of 46 shifts from 01/01/2025 through 03/16/2025 and noted CNA-J was scheduled to work on 03/17/2025. On 03/17/2025 at 3:20 PM, DON-B informed Surveyor CNA-J was suspended as of today, pending investigation. On 03/18/2025 at 2:30 PM, Surveyor spoke with Adult Protective Services (APS)-K. APS-K informed Surveyor APS received a call through the elder abuse hotline from R5's doctor's office on 03/03/2025 regarding an abuse allegation. APS-K went to the facility on [DATE] and spoke with R5 whom indicated the incident happened near the kitchen door in the dining room. APS-K informed Surveyor R5 stated that CNA-J pushed R5 against the wall causing R5 foot pain. APS-K informed R5 APS-K would contact the Division of Quality Assurance (DQA). APS-K indicated APS-K did not speak to any staff at the facility because if a complaint is deemed credible, the complaint is sent to DQA. On 03/18/2025 at 2:54 PM, DON-B sent an email to Surveyor documenting R5 goes out for many appointments and does not give the facility the after-visit summaries for nursing to review. DON-B informed Surveyor the medical records person must then call the doctor's office to have the after-visit summaries faxed over. DON-B informed Surveyor the facility received R5's doctor office visit record from the 01/13/2025 visit with orthopedics over a month later, on 02/17/2025. DON-B informed Surveyor at the time, the document was uploaded but not given to a nurse to review. Surveyor noted that the facility did not follow up with R5's orthopedic office despite R5 being seen and reporting pain from the alleged incident on 1/13/25. The facility's failure to thoroughly investigate allegations of abuse allowed accused staff to continue working with residents following the incident resulting in the failure to safeguard residents from potential further abuse. These failures created a reasonable likelihood for serious harm thus leading to a finding of Immediate Jeopardy that began on 01/13/2025. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the Immediate Jeopardy on 03/19/2025 at 12:16 PM. The Immediate Jeopardy was removed on 3/20/25 when the facility completed the following: - R5 was interviewed by the Director of Social Services and Local Law Enforcement on 3/18/25 to verify any adverse outcomes were present. - The resident was interviewed and wants to remain at the facility and declines any referrals for other living arrangements. A thorough investigation was initiated by the Director of Nursing, Administrator, and Regional Nurse. All staff with knowledge of the incident were interviewed. - Residents that still reside at the facility who could have potentially witnessed the incident were interviewed by the Unit Manager. - An in-service education program on Investigations and Reporting will be conducted by the Regional Team Leaders. All Department Heads addressing circumstances that require reporting for timely investigations, and their responsibilities related to investigations. Abuse policies were reviewed to include all sources of abuse, investigations and reporting. - A random audit of five (5) residents/staff weekly for four (4) consecutive weeks was initiated. These residents/staff will be interviewed to ensure that any incidents are identified, properly investigated, and reported to the appropriate people. - Grievances were reviewed at the Clinical Stand-up meeting for any potential investigations, - Compliance will be monitored at the QAPI meeting until such time consistent substantial compliance has been met. The deficient practice continues at a scope/severity level of D (potential for harm/isolated) related to the following example: 2.) R1 was admitted to facility on 7/10/2023 with diagnoses that include hemiplegia and hemiparesis following an unspecified cerebrovascular disease affecting R1's left dominant side, repeated falls, bipolar disorder, depression, dysphasia, cognitive communication deficit, and need for assistance with personal cares. R1's Quarterly Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating that R1's cognition was intact. Section B documented that R1 is understood and understands. Section E documents that R1 did not exhibit any behavioral symptoms. R1's Behavioral care plan, dated 7/17/2023, with a target date of 3/20/2025, documents under the intervention section: Rude, uncooperative behavior, refusals, risks versus benefits completed, caregivers to provide opportunity for positive interaction/attention. Psych services, explain all procedures to resident before starting to allow the resident time to adjust to changes, if reasonable, discuss the resident's behavior explain/reinforce why behaviors inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation intake to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Provide a program of activities that is of interest and accommodates resident's status. Refuse shower in skin check: a resident because of holiday, Staff encouraged to: use the buddy system, at all times, when going into resident's room. Surveyor noted that the facility documented in R1's MDS that no behaviors were exhibited but had mentions of R1's behaviors though out R1's behavioral care plan. On 3/17/2025 at 9:06 AM, Surveyor interviewed R1, who stated that Certified Nursing Assistant (CNA)-H, assisted with washing R1 up for cares. R1 stated that CNA-H washed R1's breast. R1 indicated that everyone at the facility knows R1 will do that independently. R1 stated that R1 told CNA-H, No, you don't wash me there. R1 stated CNA-H stated: Oh (R1's name). R1 indicated that CNA-H continued to wash R1's breast. R1 stated that she told CNA-H, Don't Oh (R1's name) me. R1 indicated telling CNA-H that R1 knows resident rights and that R1 will call the state to report the incident. R1 indicated this occurred on 2/27/2025 and again on 3/3/2025. R1 stated that R1 left a voicemail with the unit manager (UM)-E, and R1 indicated that the notification was left on UM-E's voicemail. R1 said, I will call the state. R1 indicated not hearing back from UM-E. On 3/17/2025 at 11:00 AM, Surveyor interviewed UM-E who indicated that UM-E will receive complaints via telephone or by voicemail. UM-E stated that R1 is one resident that will call her for complaints, but that UM-E did not get a complaint about someone inappropriately touching R1. UM-E indicated that if this was reported to UM-E, this would've been addressed right away. UM-E stated not writing down concerns, but that UM-E will address them verbally when received. UM-E stated not being part of an investigation with this matter but that Social Services (SS)-F indicated that R1 is now on the buddy system. On 3/17/2025 at 11:26 AM, Surveyor received a file from UM-E, which documented that an investigation relating to these allegations was started and that UM-E was unaware of this. Surveyor reviewed R1's electronic record, and reviewed progress notes from March 2025, but Surveyor could not locate any documentation relating to R1's behaviors and nursing staff. Surveyor reviewed behavioral charting from CNA's task list for March 2025 and noted that no behaviors were documented for R1. Surveyor reviewed the facility's investigation file, dated 3/6/2025. Both CNA-H and CNA-I had statements in the file that were similar. Surveyor noted statements from both CNAs indicated that R1 was updated on getting a bed bath and that R1 agreed. Both CNA statements documented, that R1 washed her face and neck area and that both CNA's grabbed washcloths and started to wash R1's arms and under R1's arms. Both CNA statements documented that before cleaning R1's breast, R1 stated nobody has permission to touch her breasts. It is documented on both CNA statements that R1 washed her own breasts. Surveyor reviewed statements from Social Service (SS) -F dated 3/6/2025. SS-F's statement documented that SS-F asked R1 if she had any concerns with staff, residents or cares. The statement from SS-F documented that R1 stated she has no concerns. On 3 /17/2025 at 11:46 AM, Surveyor was informed by the Nursing Home Administrator (NHA)-A, that CNA-H is now suspended. NHA-A indicated that the allegation wasn't reported before because R1 didn't say that R1 was inappropriately touched until today (3/17/25). Surveyor reviewed the complaint file that was dated 3/6/2025, and CNA-H was an active employee, working at the facility from 3/6/2025 until 3/17/2025. On 3/17/2025 at 12:39 PM, Surveyor interviewed SS-F, who indicated that R1's allegation wasn't SS-F's investigation, and that SS-F believes it was Director of nursing (DON)-B that was investigating it. SS-F indicated asking R1 if she had any concerns with cares or staff. SS-F indicated not asking R1 about being inappropriately touched, SS-F indicated only asking R1 about any care and staffing concerns. On 3/17/2025 at 12:49 PM, Surveyor interviewed Human Resources (HR)-G, who indicated CNA-H made concerned statements to HR-G. The above-mentioned statements were regarding CNA-H being worried about R1 reporting CNA-H to the state. HR-G indicated this occurred around 3/6/2025. HR-G indicated asking SS-F to go and speak with R1. HR-G stated that this was reported to Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. HR-G indicated that NHA-A asked HR-G to go retrieve some statements from staff, and HR-G collected statements and then was done with any more involvement with the investigation. On 3/17/2025, at 1:58 PM, Surveyor interviewed DON-B, who stated that all the investigation information was brought to NHA-A. DON-B indicated being informed there was conflicting statements, one CNA stated R1 washed herself and the other CNA something different. DON-B indicated not remembering what the other CNA stated and directed Surveyor to speak with NHA-A. DON-B stated that NHA-A would be the person to decide if the investigation needed to be reported. On 3/17/2025 at 2:09 PM, Surveyor interviewed NHA-A, who stated being the one that decides if something is to be reported to the state agency. NHA-A indicated that R1 denied the statements. Surveyor reviewed SS-F's statement collected from R1 on 3/6/2025 with NHA-A and there were no denied statements of allegation. Surveyor explained that SS-F was interviewed and stated SS-F did not ask R1 about being inappropriately touched. NHA-A indicated R1 wasn't directly asked about being inappropriately touched but R1 was asked about concerns with cares or staff. On 3/17/2025 at 3:09 PM, Surveyor informed NHA-A of having concerns that a thorough investigation into R1's allegation did not occur and was not reported to the state agency. NHA-A indicated NHA-A wouldn't lead someone into making a statement like that. NHA-A indicated the police are currently in the building for other residents and will also be seeing R1 for this reporting. On 3/18/2025 at 10:05 AM, Surveyor Interviewed R1, and asked R1 about feeling safe at the facility. R1 informed Surveyor that R1 is not currently scared and that R1 feels safe at the facility. R1 indicated, that the only reason R1 is not scared is because CNA-H does not work with R1 anymore. R1 stated that the facility had police talk with R1 about R1's allegation yesterday. On 3/18/2025 at 10:22 AM, Surveyor informed DON-B. of the concerns that the facility did not thoroughly investigate or report R1's allegation of potential abuse. Surveyor explained that reporting is for the allegation of abuse not that the abuse occurred. DON-B stated that NHA-A was out today, but that DON-B would pass on the information to NHA-A. No additional information was received regarding why a thorough investigation was not completed after a report from CNA-H and R1's allegation was received. No additional information received as to why CNA-H continued to work around residents and in care of residents at the facility from 3/6/2025 through 3/17/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents received treatment and care based on a comprehensive assessment in accordance with professional standards of practice for residents experiencing changes in condition and failed to assess non-pressure wounds weekly for 2 of 7 residents (R1 and R3) reviewed for changes in condition. *R1 was observed on the floor mat next to their bed covered with emesis on [DATE]. R1 was assisted back to bed. A Registered Nurse did not perform an assessment at the time of R1's fall. R1 was found several hours later in bed with severe facial bruising and lethargy. A Registered Nurse did not conduct an assessment of R1 at this time. R1 was later found pulseless and not breathing. R1 expired at the facility on [DATE]. The facility's failure to have a licensed professional (RN) comprehensively assess residents (R1) who were having a change in condition, the failure of the facility to have licensed professional staff monitoring residents with changes in condition, the failure to closely monitor R1's neurological status after falling out of bed, and failure to update a physician after R1's fall on [DATE] created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on [DATE] at 3:35 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement and monitor the effectiveness of their removal plan and as evidenced by; *R3 fell on [DATE] and on [DATE]. The facility did not conduct neuro checks after the falls. In addition, R3 had multiple non pressure wounds to the left hip, bilateral lower extremities (left shin, right leg, left leg,) and right upper extremity where non pressure wound assessments were not completed. Findings include: R1 was admitted to the facility on [DATE] with diagnoses of left hip dislocation, lymphedema, and malnutrition. R1's MDS (Minimum Data Set) admission Assessment with an assessment reference date of [DATE] documents a BIMS (brief interview mental status) score of 6 which indicates R1 has severe cognitive impairment with daily decision making skills. R1 required extensive assistance with a one person physical assist for bed mobility, transfers, & toilet use, and was non-ambulatory. Surveyor reviewed R1's progress notes. On [DATE], R1 was noted to not have had a bowel movement in approximately 2.5 days. A bisacodyl suppository was administered by LPN (Licensed Practical Nurse)-M. On [DATE] at 4:15 AM, CNA (Certified Nursing Assistant)-N noted R1 on a floor mat next to their bed covered with emesis. CNA-N and LPN-M assisted resident back to bed at this time and cleaned R1's body and face. On [DATE] at 6:36 AM, LPN-M documented, Emesis x2 this shift. PRN (as needed)suppository given w (with) no results. NP updated. Enema x1 given as instructed. No results at this time. Resident positioned on side. HOB (head of bed) elevated. Bed in low position. LPN-M did not notify the on-call NP about resident R1 being observed on the floor mat. LPN-M did not report observations of resident on the floor to oncoming day shift nursing staff. LPN-M is no longer employed by the facility and was not available for interview at the time of this survey. On [DATE] at 11:45 AM, Surveyor conducted an interview with CNA-N. CNA-N told Surveyor R1 had been restless throughout the night shift on [DATE] and they had been checking on R1 approximately every 15 minutes that night to make sure R1 was ok. CNA-N went to take a scheduled break and notified LPN-M that they would be off of the Garden unit where R1 resides. When CNA-N returned from their break at approximately 4:15 AM, they went to check on R1, who was discovered on a floor mat next to their bed covered with emesis. CNA-N notified LPN-M immediately to come to R1's room. CNA-N told Surveyor the night shift LPN-M conducted vital signs and did check resident's neurological status when they were discovered on the floor mat. CNA-N did not note any obvious injuries to R1 at the time of the fall. Surveyor asked CNA-N if they had been asked to complete any sort of witness statement or documentation regarding R1 being observed on the floor? CNA-N told Surveyor they were not asked to write up any statements related to observations of resident on the floor or to participate in a fall investigation. On [DATE] at 12:35 PM, Surveyor conducted an interview with CNA-O. CNA-O had arrived at the facility on [DATE] at approximately 6:40 AM. CNA-O told Surveyor they had asked LPN-M if there was anything new going on with residents on the unit since when CNA-O worked on [DATE] LPN-M did not report anything new to CNA-O. CNA-O recalled arriving to R1's room at approximately 7:45 AM to provide care. CNA-O noted a raised lump and discolorations to the left side of R1's face and R1's lower lip with dried blood. CNA-O told Surveyor that R1 did not look right at all and was very sleepy. CNA-O reported to RN-I immediately about R1's change of condition. RN-I went to R1's room at this time and observed R1's condition including facial injuries. CNA-O saw that RN-I reported R1's status to LPN Unit Manager-D at this time. LPN Unit Manager-D did not go to R1's room at this time but told RN-I they would let DON-B know about R1 at the facility's morning meeting. Surveyor asked CNA-O if RN-I had taken R1's vital signs or conducted an assessment of R1 or any neurological exam? CNA-O told Surveyor they did not witness anyone going to take vital signs or perform any type of assessment until approximately 9:00 AM when LPN-F came to R1's room with a vitals cart. On [DATE] at 1:30 PM, Surveyor conducted interview with LPN-F. LPN-F told Surveyor that they had been assigned to work between 2 units on [DATE]. LPN-F was assigned to work on the [NAME] unit and take a portion of the Garden unit also. R1 was residing on the Garden unit on [DATE]. LPN-F had been working on the [NAME] unit at the beginning of their shift to obtain blood sugar readings and administer insulin to their diabetic patients before breakfast. On [DATE] at approximately 9:00 AM, LPN-F was told by RN-I to go to R1's room and take R1's vital signs. LPN-F noted R1 with extensive facial discolorations and lethargy, and a Blood Pressure reading was taken at this time which showed 110/40. Writer left to speak with LPN Unit Manager-D to report their serious concerns. At approximately 9:15 AM, LPN-F was directed by LPN Unit Manager-D to reach out to R1's power of attorney for further direction and update R1's doctor to see how to further proceed. LPN-F went back to check on R1 to retake vital signs at approximately 10 AM. At this time, LPN-F noted no chest rise when entering and checked for pulse which was absent. LPN-D knew that R1 had a Do Not Resuscitate order in place and did not attempt life saving measures at this time. LPN-F notified R1's doctor and power of attorney at 11:00 AM about resident expiration. R1's remains were released to the funeral home approximately 30 minutes later. Surveyor asked LPN-F if they knew why RN-I had not assessed R1 prior to LPN-F coming into R1's room when CNA-O reported R1's serious change of condition at approximately 7:45 AM? LPN-F told Surveyor that they are not sure why an assessment wasn't conducted when RN-I became aware of R1's change of condition and injuries. LPN-F told Surveyor that as an LPN, they would not be allowed to assess residents as it is out of their scope of practice as an LPN. On [DATE] at 2:30 PM, Surveyor interviewed RN-I. Surveyor asked RN-I if they had conducted any assessment for R1 on [DATE] when CNA-O came with serious concerns related to R1's physical and neurological status? RN-I told Surveyor No. Surveyor asked if a resident is noted with a change of condition whether or not an RN should assess the resident? RN-I told Surveyor that they had not been assigned to R1 that day so when they reported to LPN Unit Manager-D, they figured that LPN Unit Manager-D would take care of the next steps to help R1. Surveyor asked why RN-I wouldn't have decided to assess R1 at this time as LPNs or LPN Unit Manager-D would not be able to assess R1 as they function as LPNs? RN-I told Surveyor that it did not occur to RN-I to conduct an assessment of R1 including vital signs, full body assessment, and neurological checks. Surveyor noted approximately a 1 hour and 15 minutes gap before vital signs were obtained by assigned LPN-F which showed a low blood pressure reading of 110/40. Surveyor reviewed a police report related to R1's expiration at facility on [DATE]. On [DATE], per police report, an Anonymous staff member went to the police department and reported R1's death seemed suspicious and they were concerned about the injuries to R1's face. An investigation was initiated at the facility by the police department. The county medical examiner performed an exam of R1's corpse. The facility confirmed LPN-M did not initiate a fall investigation for R1's fall, failure to perform neurological checks, and did not report the observation of R1 on the floor to oncoming nursing staff. On [DATE] at 12:25 PM, Surveyor conducted interview with DON (Director of Nursing)-B. Surveyor asked DON-B if they had conducted any assessment of R1 on [DATE]? DON-B told Surveyor that they had worked with R1 on the evening of [DATE] and did not note any injuries or any abnormalities in R1's behavior that evening. DON-B did not conduct an assessment of R1 on [DATE]. Surveyor asked if a resident experiences a change of condition or an unwitnessed fall from bed if they should have an assessment conducted by an RN, including neurological checks? DON-B responded that they had not been aware of R1's fall from bed on [DATE] until conducting further investigation into R1's death and that LPN-M did not conduct a fall investigation. Surveyor shared concerns that RN-I did not respond accordingly to R1's unexplained facial discolorations and altered mental status when CNA-O reported concerns on [DATE]. Surveyor shared concerns that no vital signs were obtained for R1 until approximately 1 hour and 15 minutes after change of condition was reported to RN-I. DON-B did not have any additional information at this time. On [DATE] at 12:45 PM, Surveyor made NHA (Nursing Home Administrator)-A aware of concerns related to R1's unwitnessed fall on [DATE] with no RN assessment, no ongoing neurological checks, and the facility's failure to respond to R1's change of condition on [DATE] in accordance with standards of practice. No additional information was provided. The facility's failure to conduct ongoing neurological checks after R1 fell, the failure to notify the MD/NP of resident being found on the floor mat, the failure of the LPN to notify the oncoming first shift of R1's fall, and the failure to complete an RN assessment of R1 when a change in condition was noted created a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when: * The Director of Nursing (DON)/Designee provided education to all nursing staff on recognizing a change in condition. This education includes what is considered a change in condition, reporting and assessment by RN with MD notification. * The Medical Director reviewed the deficient practice and reviewed the facility's policy with recommendation of changes. The Medical Director reviewed the staff education provided. All nursing staff was educated on the facility policy and procedure regarding notification of changes. The training included Nursing staff to complete the SBAR (Situation, Background, Assessment, Recommendation) and notification of change training handouts with competency and any change in condition will be clearly identified in the medical record with plan of action. All changes in conditions will be placed on the 24 hour board for shift to shift communication with follow up with nursing management team. * The DON/Designee provided education to LPNs/RNs on understanding the scope of practice. The LPNs will work under general supervision with delegation of tasks from an RN. RNs are to be consulted for any assessments needed. This will include onsite/phone triage. * The DON/Designee provided education to all licensed nursing staff on falls and management of such. This education included defining details of falls, steps in the procedures, and documentation requirements. Staff completed Relias training on About Falls which included handouts with competency. Education was provided on the policy and procedures including assessing falls and their causes, interventions, notifications, and documentation requirements. * On [DATE], the facility reviewed policies on Changes in Condition, Falls, MD notification, and prompt RN assessments. Policies and systems were reviewed and updated with the Medical Director to ensure they meet the current standards of practice. * Audits have been developed. Change in condition audits consist of the SBAR, prompt RN assessment, MD family/representative notification, orders and follow up. DON/Designee will complete audits daily for two weeks, three times a week for four weeks, and then weekly x three months. * All change in condition/audits will be reviewed at morning meeting and afternoon clinical. Any policy deviations will be immediately corrected. * Audits will be reviewed by the QAPI (Quality Assessment Performance Improvement) committee until such time compliance is achieved as determined by the committee. * The facility assessments/policies will be updated and reviewed as needed with partnership of the Medical Director. The deficient practice continues at a scope and severity level of E (potential for harm/pattern) as evidenced by: 2. R3 was admitted to the facility on [DATE], was hospitalized from [DATE] to [DATE], and expired in the facility on [DATE]. R3 was reviewed as a closed record review. R3's diagnoses included heart failure, atrial fibrillation, depressive disorder, anxiety disorder, diabetes mellitus, hypertension, and fracture of left femur. R3 was receiving IV (intravenous) Vancomycin and oral antibiotics for left hip infection upon admission. The impaired tissue integrity care plan initiated [DATE] has the following interventions: * Assess site of impaired tissue integrity and its condition. Initiated [DATE]. * Monitor site of impaired tissue integrity w (with) tx (treatment) and weekly shower for color changes, redness, swelling, warmth, pain, or other signs of infection. Initiated [DATE]. * Provide skin tissue care as needed. Initiated [DATE]. * Treatments as ordered. Initiated [DATE]. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] documents a BIMS (Brief Interview Mental Status) score of 14 which indicates resident is cognitively intact. R3 requires extensive assistance with one person physical assist for bed mobility, transfers, & toilet use and does not ambulate. R3 is coded yes for fracture related to fall in 6 months prior to admission and has not fallen since admission. R3 is coded as having 0 venous or arterial ulcers. Neuro checks The nurses note dated [DATE] at 10:16 p.m. documents: Writer called to residents room, reported fall. Resident found sitting on the floor on her buttocks with her back against the edge of the bed and legs outward in front of her. Resident stated she was self transferring from the wheelchair to bed and fell, landing on her left hip. Neuro check WNL (within normal limit). Denies hitting her head. ROM (range of motion) to bilateral upper extremities WNL, hand grasps equal. ROM to bilateral lower extremities not attempted, resident yelling out in pain stating pain in her left hip. Foot presses equal. Left hip is residents surgical hip, S/P (status post) non-union of left intertrochanteric femur fracture and removal of hardware on [DATE]. Resident to be sent to [Hospital name] E.R. (emergency room) for evaluation. Husband [name] notified. Call placed to Dr. [name], MD (medical doctor) paged. Awaiting call back. The nurse's note dated [DATE] at 3:52 a.m. documents: Resident back from [Hospital name] ER, VS (vital signs) stable BP (blood pressure) 148/79, P (pulse) 75, Temp (temperature) 97.3, O2 (oxygen) 98%, BS (blood sugar) check 128. Res (Resident) c/o (complained of) pain to L (left) knee at a pain level 8 in a scale from 0-10, PRN (as needed) med (medication) admin (administered). ER imaging showed no fx (fracture). ER Dx (diagnosis) Hypoglycemia, Acute pain to L knee. Res c/o SOB (shortness of breath), R (respirations) 18, PRN breathing tx (treatment) admin. Surveyor reviewed R3's medical record and was unable to locate neuro checks for R3. On [DATE] at 9:55 a.m., Surveyor asked RN (Registered Nurse)/UM (Unit Manager)-E when neuro checks are completed after a resident's fall? RN/UM-E explained if the fall is witnessed and the resident hits their head neuro checks are completed. If a fall is unwitnessed whether they hit their head or not neuro checks are completed. Surveyor inquired how often neuro checks are completed? RN/UM-E replied per the packet. Surveyor inquired what this means? RN/UM-E informed Surveyor every 30 minutes times four, every hour times four, every four hours for twenty four hours and every eight hours for the remainder of the 72 hours. Surveyor inquired if a Resident goes to the emergency room following a fall and returns does the facility do neuro checks upon their return? RN/UM-E informed Surveyor they would complete neuro checks until 72 hours post fall. On [DATE] at 10:15 a.m., Surveyor reviewed R3's fall investigation for the fall on [DATE] which consisted of an incident report, post fall assessment, and pain evaluation all dated [DATE]. Surveyor did not note any neuro checks in this fall investigation packet. The nurse's note dated [DATE] at 5:10 p.m. documents: Writer was called over to Mesa unit in regards to resident fall. Upon entering room the resident was laying on the floor on her right side with her feet next to the bed and body outwards away from the bed. Resident alert. Large hematoma noted to left forehead, ice applied. No other head injury noted. Multiple small skin tears noted on residents right forearm and hand, bleeding stopped. Writer informed staff not to move the resident until paramedics arrived, resident made comfortable. Resident is alert and oriented. Resident demanding a glass of water, instructed resident that no PO (by mouth) intake could be given related to her head injury. Paramedics arrived. Resident demanding they give her a glass of water, demanding her blue cup I'm not going anywhere until I get my blue glass of water. The assigned nurse told resident she would give the blue glass to her husband when he came. Resident transported to [name] E.D. (emergency department) for evaluation and treatment. The nurse's note dated [DATE] at 9:37 p.m. includes documentation of: I placed signs in [R3's first name] room, to use call button, and not get up alone. [R3's first name] returned from the ER. As the EMTs (emergency medical technicians) wheeled her into the facility, she asked me as she passed the nurse station Is it time for my pain pill yet?? The EMTs put her in bed and came to give me report Surveyor reviewed R3's medical record and was unable to locate neuro checks for R3. On [DATE] at 10:15 a.m., Surveyor reviewed R3's fall investigation for the fall on [DATE] which consisted of an incident report, post fall assessment, pain evaluation, risk for falls, SBAR (situation, background, assessment, request,) all dated [DATE] and follow up 72 hours post fall dated [DATE]. Surveyor did not note any neuro checks in this fall investigation packet. On [DATE] at 12:16 p.m., Surveyor asked RN (Registered Nurse)/UM (Unit Manager)-E where Surveyor would be able to locate neuro checks. RN/UM-E informed Surveyor they are in the falls packet. Surveyor informed RN/UM-E Surveyor was unable to locate neuro checks following R3's falls on [DATE] & [DATE]. Surveyor then provided RN/UM-E the fall investigation packet Surveyor had been provided with. RN/UM-E reviewed the fall packets and informed Surveyor he doesn't see the neuro checks. Neuro checks were not completed after R3's falls on [DATE] & [DATE]. Non Pressure Wounds The nurse's note dated [DATE] documents: Resident arrived via ambulance. She was able to pivot transfer off the gurney and she took a few steps to get into bed. She has a dressing to her left hip with a drain. The drain has dark red colored drainage. No edema to her lowers. Her bilateral lowers are discolored and cool to the touch and per resident they are always like that. She has a central line to her right upper arm single lumen. She has upper and lower dentures and does not have them with her. No hearing aides and hearing is adequate. Her abdomen is bruised across the whole lower abdomen. She is alert and oriented and call light within reach. She is able to maneuver the bed with her controls. Family is present. The nurse's note dated [DATE] documents: Resident obtained a skin tear to her left anterior shin area. She self transfers into her wheelchair and during the transfer at approx (approximately) 0730 (7:30 a.m.) she obtained a 1 cm (centimeter) x (times) 1 cm skin tear in a v shape. The area has some bleeding. It was cleaned and dressing applied. The nurse's note dated [DATE] documents: Dressing changed to left hip. Moderate amount of sero-sanguineous drainage to old dressing. There are approximately 41 staples intact to incision. There is no redness, swelling or warmth to incision. The incision is approximated but the proximal area is slightly opened between the staples. Resident denies any pain to the area. Resident skin tear to her left anterior shin area has no active bleeding. Dressing changed and she has some clear drainage from the area. It remains approximately 1 cm x 2 cm in a V shape. No s/sx (signs/symptoms) of infection-no redness, warmth or pain to the area. Order received from Dr. [name] for dressing changes as he is covering for Dr. [name]. The nurse's note dated [DATE] documents: IV ABT (intravenous antibiotic) infused without difficulty. BLE (bilateral lower extremity) dressings chgd (changed). Refused legs to be wrapped. states can't stand them on! Yells out @ (at) x's (times). The nurse's note dated [DATE] includes documentation of .She continues to remove her dressings several times on each shift. Writer just had the staff put bath blankets on her bed to absorb the fluid, as she took her dressings off twice this shift. Staff will continue to monitor as needed. The nurse's note dated [DATE] documents: Writer changed resident L hip dressing. Moderate amt (amount) sero-sanguineous drng (drainage) noted on old dressing. Noted entire incision line slightly reddened. Has 1 area that has dehisced. Packed area with cling, noted area to be deep. receiving IV ABT (antibiotics) for L hip infection. Resident has an appt. (appointment) with [name] wound care 7-15-22. The nurse's note dated [DATE] documents: This Pt. (patient) has an open area to her left hip incision, where the area has dehisced. The Pt. state's that this has been open for awhile. Writer will check with the wound nurse to see if she is aware of this wound. The area does not look infected, however, it does has a small amount of yellowish drainage. The nurse's note dated [DATE] documents: This Pt. dressings are intact to her lower legs. She had no complaints of wet dressings this shift. She stayed in bed most of his shift. Only calling out two to three different times. Staff will continue to monitor her weeping legs. The nurse's note dated [DATE] documents: Patient has been sleeping off and on all shift. Patient removed dressings to right shin and is screaming to get her 6 rolls of gauze to her. patient has called writer names all night. Patient is insisting that writer redo dressing because doctor told her that was the new orders. The nurse's note dated [DATE] documents: BLE (bilateral lower extremity) & L (left) hip open areas tx's (treatments) done as ordered. No behavior issues noted. The nurse's note dated [DATE] documents: Patient has been awake most of shift, leg wounds were redressed at beginning of shift. Patient has tried to take off dressings to have writer redo dressings a second time. Patient will not get into bed when asked. Patient also took supplies for leg wounds and wrapped right arm up with gauze and tape by self. The nurse's note dated [DATE] documents: Resident has a pressure dressing to her left foot. She verbalized her desire to remove the dressing as she wanted to see what it looked like. I educated her on the importance of keeping the pressure dressing in place. It is secure. I updated her husband [name] and also spoke with [name] RN from Dr. [name] office. There are no new concerns and she stated she would let doctor know and get back to me if there were new orders. The nurse's note dated [DATE] documents: Resident had a lot of crying out until HS (hour sleep). Husband asked her what she was doing, stated yelling out, that's what I do. Tx to BLE done. Medicated for pain x 1. R3 was hospitalized [DATE] to [DATE]. The hospital Discharge summary dated [DATE] under physical examination for skin documents multiple wounds over bil (bilateral) lower extremities. Non-healing left hip wound. Buttock wounds/excoriation. Wounds have improved since admission. The skilled nurses note dated [DATE] documents under skin/wound: No new changes to skin integrity noted. Has wounds Resident has treatable wounds. Dressing changed as per treatment orders. Multiple leg wounds, wound to buttocks, surgical wound to L hip. R3 expired in the Facility on [DATE]. Left trochanter (hip) The weekly non pressure condition record dated [DATE] under site for this assessment is other, for describe other documents Left Hip. Date of onset [DATE]. Measurements are length 20, width 0.5, and depth 0.0. Under description of site documents S/P (status post) hip surgery incision edges are approximated with staples, moderate amt. (amount) of serous drainage, no odor, peri wound slight red in color and warm to touch, no s/s (signs/symptoms) of infection Surveyor was unable to locate an assessment during the week of [DATE] to [DATE]. The Orthapaedics NP (nurse practitioner) note dated [DATE] under physical exam includes documentation of Examination of her left posterolateral incision reveals staples that are present. She has two areas of dehiscence about the most proximal aspect of her incision that measures 2 cm (centimeter) most proximally and 1 cm in length distally about her incision. The remainder of her incision is well approximated without signs of infection. There is no erythema, no active or intermittent drainage. The weekly non pressure condition record dated [DATE] documents date of onset [DATE] type is surgical incision. Measurements are length 3.0, width 2.2, and depth 2.5. Under description of site documents S/P (status post) surgical incision to left trochanter of hip, incision line meas (measures) approximately 25 cm (centimeter) in length after staples were removed hip incision dehisced, incision line has attached edges, moderate amt. (amount) serous drainage, no odor, no s/s of infection. Surveyor was unable to locate assessments during the week of [DATE] to [DATE] & [DATE] to [DATE]. The outpatient wound care progress note dated [DATE] Under history of present illness documents Pt. (patient) had left hip replacement on [DATE] by [physician's name], has partial area of incision that is a dehisced wound. Under wound assessment documents Left hip with dehiscence of incision, has granulation, fibrin, has edema, no induration, no purulence, sero sananguineous drainage. Surveyor noted there are no measurements. The weekly non pressure condition report dated [DATE] documents for measurements length 3, width 2, depth 2. Under description of site documents Surgical dehiscence of incision: wound bed has granulation, with fibrin, peri-wound has slight edema, no induration, no drainage, no odor, no s/s of infection. Surveyor was unable to locate an assessment during the week of [DATE] to [DATE]. The outpatient wound care progress note dated [DATE] under wound assessment documents Left hip with dehiscence of incision, has granulation, fibrin, tunneling does not probe to bone. The wound hip/trochanter measurements are length 1.5 cm (centimeters), width 0.2 cm and depth 2.5 cm. Surveyor was unable to locate assessments during the week of [DATE] to [DATE] & [DATE] to [DATE]. The weekly wound evaluation flow sheet dated [DATE] for left hip under type documents surgical incision. Length 1.05 cm, width 0.05 cm and depth 1.00 cm. The outpatient wound care progress note dated [DATE] under wound assessment documents Left hip with dehiscence of incision, has granulation, fibrin, tunneling does not probe to bone. No peri wound induration, erythema, or warmth. The wound hip/trochanter left incision measures length 2.4 cm, width 0.6 cm. & depth 1.5 cm. The wound hip/trochanter left measure length 16.8 cm, width 12 cm, depth 0.2 cm. R3 was hospitalized from [DATE] to [DATE]. The hospital Discharge summary dated [DATE] documents under other diagnoses Nonhealing surgical wound, subsequent encounter. The weekly wound evaluation flow sheet for wound evaluation week 2 dated [DATE] documents length .9 cm, width .1 cm, and depth .7 cm. Under additional notes documents area improving per last assessment. Under other documents patient just returned from hospital. The weekly wound evaluation flow sheet for wound evaluation week 3 dated [DATE] documents length .9 cm, width .1 cm, and depth .6 cm. Wound bed is 75% granulation and 25% slough. Under current wound status/additional comments documents area stable. R3 expired in the facility on [DATE]. Surveyor noted the facility's non pressure assessments were completed by Traveling Wound RN-L who is no longer at the facility. Bilateral Lower Extremities (BLE) The weekly non pressure condition record for site is other. For describe other documents left leg shin. Date of onset is [DATE]. Existing is checked. Under type documents skin tear. Length 0.5 cm, width 1 cm. Description of site documents Skin tear edges are approximated, small amt. (amount) of serous drainage, no s/s of infection, no odor, peri-wound slight edematous. There are no assessments of R3's BLE until [DATE]. The outpatient wound care progress note dated [DATE] under history of present illness documents Pt. (patient) was previously recommended 10-20 mmHg compression but did not have any on for visit today. Pt . Reports BLE with weeping and scattered wounds. Under wound assessment documents BLE with edema, hemosiderin staining (appearance of brownish patches above the ankles), weeping, scattered partial and full thickness wounds, has slough, fibrin, nonviable tissue. Surveyor noted there are no measurements of R3's bilateral lower extremities wounds. Surveyor was unable to locate assessments during the week of [DATE] to [DATE] & [DATE] to [DATE]. The outpatient wound care progress note dated [DATE] under history of present illness includes documentation of: Pt was previously recommended 10-20 mmHg compression but did not have any on for visit today. Under wound assessment documents BLE with edema, hemosiderin staining, weeping, scattered partial and full thickness wounds, has slough, fibrin, nonviable tissue. The wound right leg documents length 4 cm (centimeters), width 4 cm, and depth 0.2 cm. The wound left leg documents length 5 cm, width 4 cm and depth 0.2cm. Surveyor was unable to locate assessments during the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 3 (R11, R4, and R181) of 23 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, that will meet each resident's physical, mental, and psychosocial needs. ~ R181 was admitted [DATE] from the hospital following surgery for a bowel perforation. The facility failed to get orders for her JP drain or the abdominal incision, which had 19 sutures. The facility did not do a follow up to the R181's low potassium level, did not follow up and schedule appointments within a week to general surgery and cardiology, did not get treatment orders for the abdominal incision (including ABD pads and abdominal binder), did not routinely monitor and assess the abdominal incision or the JP drain, did not monitor blood pressure even after low readings, and did not question the nurse practitioner's repeated comments that the resident was stable. The resident was hospitalized due to complications from the JP drain 10 days after admission. The resident was readmitted and again was not monitored for lab values, low BP, GI assessments, surgical incision, dehydration due to nausea, vomiting and loose stools. On [DATE] R181's granddaughter asked that she be sent out because she was in severe pain. The resident was transferred to the emergency room about 2:52 PM. She was hospitalized with diagnoses that included acute respiratory failure with hypoxia, septic shock due to acute kidney injury and micro perforation of intestine, acute peritonitis, lactic acidosis, hypokalemia, syncope due to the above, hypotension, and history of c-diff and acute cystitis. Blood pressure was 66/32. Her right leg was twice the size of her left leg. She was hemodynamically unstable and not a surgical candidate. The resident died on [DATE] at 8:17 PM. The facility's failure to properly care for R181's surgical incision, JP drain, to assess low BPs, GI and incision, to obtain ordered labs, to schedule ordered MD appointments and to monitor and follow up on dehydration created a finding of Immediate Jeopardy beginning on [DATE]. Nursing Home Administrator (NHA)-A was informed of the Immediate Jeopardy on [DATE] at 2:36 PM. The Immediate Jeopardy was removed on [DATE] when the facility implemented an action plan related to standards of practice, MD orders and quality of care for residents. This deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan and as evidenced by the following: ~ R11 developed trauma wounds to the left first, second, third, and fourth toes that were discovered on [DATE]. No comprehensive assessment was made of the wounds, no documentation the physician was notified, no treatment was obtained, and no revision of the care plan was made to prevent further trauma to the areas when discovered. ~ R4 was admitted to the facility on [DATE] with a chronic vascular wound to the left lower leg. No documentation was found of a weekly assessment from [DATE] through [DATE]. R4 had a history of refusing treatments and assessments and no documentation of an assessment or refusal of an assessment was found for [DATE] and [DATE]. Findings include: Surveyor reviewed facility's admission to the Center policy with a revision date of [DATE]. Documented was: .Admission-Nursing 1. If not already initiated, the licensed nurse creates the resident's Electronic Health Record (EHR). 2. The licensed nurse obtains and verifies the physician's admitting orders. 3. Orders for medications and/or care are entered into the Electronic Health Record (EHR) . 5. The licensed nurse notifies the attending physician of the resident's admission and completes an initial assessment of the resident using the Nursing admission Data Collection (UDA). 6. The nursing staff develops and initiates the Baseline Care Plan (UDA) within 48 hours of admission . Surveyor reviewed facility's Skin Management policy with a revision date of [DATE]. Documented was: .NON-PRESSURE WOUNDS . 5. Wounds will be assessed weekly and status/progress documented on the Weekly Non-Pressure Skin Condition Record (UDA). 6. The resident is assessed for pain, and appropriate interventions are implemented and care planned . 8. The resident is added to the 24-Hour Report via Progress Note. Care Plan interventions are implemented and discussed during shift report with members of the care team. 9. The nurse will monitor the area closely during treatment to evaluate appropriateness of treatment regimen . 11. Consult with rehabilitation services for evaluation and options for treatment intervention, such as edema management. 12. Consultation with a certified wound care nurse, wound consultant, or surgeon may be appropriate. EDEMA REDUCTION 1. Consult with the attending physician for treatment plan. 2. Consult with rehabilitation services for treatment interventions for edema management . Surveyor reviewed facility's Diagnostic Services Management policy with a revision date of [DATE]. Documented was: POLICY Residents requiring laboratory, radiology or other diagnostic services will receive accurate and timely testing services from certified diagnostic facilities in accordance with Federal regulations to support diagnosis, treatment, prevention, and assessment. The facility is responsible for quality and timely services whether or not services are provided by the facility or an outside agency. Medically necessary diagnostic services may be ordered by the resident's physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with State law and scope of practice laws. Diagnostic testing results are promptly reported to the ordering physician/licensed practitioner or in accordance with the physician's/licensed practitioner's orders. Abnormal or results showing critical values are reported immediately to the ordering physician/licensed practitioner. The resident and/or resident representative will be notified of abnormal findings promptly. Diagnostic reports are maintained in the resident's medical record . Surveyor reviewed facility's Change in Resident's Condition policy with a revision date of February 2017. Documented was: The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. Communication with the Interdisciplinary Team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. GUIDELINES: 1. For life-threatening events, call 911 if initial assessment indicates that such action is necessary. 2. Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's attending physical, mental, or psychosocial status, including a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications; or a need to alter treatment significantly. 3. If the attending physician cannot be reached, nursing attempts to contact the following providers in this order until a physician has been contacted: the physician on call, the facility Medical Director, the Division Medical Director and emergency services. 4. The SBAR Communication Form and the Progress Note are used to: a. Assess and document changes in condition in an efficient and effective manner; b. Provide assessment information to the physician, and c. Provide clear comprehensive documentation. [5.] Changes in condition are communicated from shift to shift through the 24 Hour Report. [6.] Changes in the resident status that affect the problem(s)/goal(s) or approach(es) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers. Surveyor reviewed facility's Assessment, General Survey policy with a date of February 18, 2022. Documented was: Introduction The goal of an assessment is to determine the care, treatment, and services that will meet the patient's initial and continuing needs. The purpose of a general survey assessment is to provide an overall review of the patient's wellness. The general survey assessment begins with the first encounter with the patient and continues throughout the assessment process. Nonverbal cues enable you to use more targeted questions to obtain additional relevant information. The general survey assessment typically includes the patient's general appearance, apparent state of health, demeanor, facial expression or affect, grooming, posture, and gait. The depth and frequency of a more detailed assessment depends on several factors, including the patient's needs and the care, treatment, and services the patient received. Information you obtain at the patient's first contact may indicate a need for more data or a more intensive assessment . Documentation Document significant normal and abnormal findings in an objective, organized manner and according to the order of information you collected. Record the date, time, name of the practitioner you notified of any abnormal results, prescribed interventions, and the patient's response to those interventions (as indicated). Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching . R181 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation (AFib), History of Gastric Bypass, Ventral Hernia, Hydronephrosis, Hyponatremia, Saddle Pulmonary Embolism (PE), Sepsis, Obesity, Diabetes Mellitus 2 (DM2), Anemia, Diverticulosis, Covid Pneumonia with Hypoxia and Respiratory Failure. Surveyor reviewed R181's MDS (Minimum Data Set) admission Assessment with an assessment reference date of [DATE]. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. Prior to admission, R181 had been hospitalized from [DATE] to [DATE]. Discharge Summary from hospital documented: .Subacute care follow up - monitor bowel regimen . Hospital Course: [AGE] year old female with [past medical PM] including polymyalgia rheumatica, T2DM, hypertension, atrial fibrillation, PE on Eliquis who presents today from [subacute rehab (SAR)] with [complaints of (c/o)] increasing abdominal pain and [nausea and vomiting (N/V)]. The patient was recently discharged from this facility on [DATE] for AFib with VR and findings of saddle PE with heart strain. She was taken urgently for thrombectomy. Post procedure she developed hemoptysis and increased [oxygen (02)] requirements. Her 02 requirements gradually improved. She then developed anemia while on heparin [drip (gtt)] for PE. She was noted to have melena stools and required 1 [unit (U)] [packed red blood cells (PRBC)] with stabilization of [hemoglobin (hgb)]. She was eventually transitioned to [oral (po)] Eliquis at discharge. She was also hospitalized on [DATE] for acute hypoxic respiratory failure covid-19 pneumonia, atrial fibrillation with VR, and subsegmental pulmonary embolism treated initially with heparin infusion and transitioned to PO Eliquis. During that hospital stay she did develop left flank pain and worsening hydronephrosis for which she underwent retrograde pyelogram and stent placement. Patient was planning on ureteral stent removal just prior to her hospitalization last month and therefore had been off Eliquis when she developed saddle embolus. Patient stated she has been off Eliquis for about 2 weeks in anticipation of procedure. Patient has since had stent removed by urology on [DATE] with recommended [follow up (f/u)] in 6 weeks. This admission patient with finding of incarcerated hernia. [CT scan] was obtained showing bowel perforation in area of the incarceration. Gen surgery was consulted and patient taken to OR from ED. She had small section of colon removed in the area of the incarceration and [abdominal (abd)] wash out. Blood and urine cultures are growing klebsiella [pneumoniae (PNA)], [extended spectrum beta-lactamase [ESBL)] infection. She was treated with vancomycin and meropenem. Eliquis restarted . Significant Diagnostic Studies/Procedures: XXX[DATE] SODIUM 140 . Latest reference range and units: 136 - 145 mmol/L . POTASSIUM (K+) 4.2 . Latest reference range and units: 3.5 - 5.1 mmol/L . [blood urea nitrogen (BUN)] 11 Latest reference range and units: 7 - 26 mg/dL . [CREATININE (Cr)] 0.84 Latest reference range and units: 0.55 - 1.11 mg/dL . Surveyor reviewed facility's report sheet for incoming admission for R181. Documented was .Hernia Repair, [abdominal (Abd)] pads over incision then abd binder . [Jackson Pratt (JP)] drain on right side, empty [every (Q)] shift, Abd incision . Surveyor reviewed admission Data Collection assessment with a date of [DATE]. There was no assessment documented of the abdominal incision. There was no assessment documented of the JP drain. Surveyor reviewed Baseline and Comprehensive Care Plan for R181. There was no care plan in place for the abdominal incision or JP drain care, management or monitoring. Surveyor reviewed admission MD Orders for R181. There were no MD orders in place for the abdominal incision or JP drain care, management or monitoring per report sheet by taken by facility. On [DATE] Nurse Practitioner (NP)-CC visited R181. Visit note documented .Physical Exam: abdomen with surgical staples, protrusion of abdomen, tender to palpation . ASSESSMENT/PLAN: 1. Sepsis, stable monitoring labs. 2. ESBL, stable on antibiotics, follows infectious disease. 3. Hernia, stable general surgery follow up. 4. Perforation of intestine, stable post surgical repair, bed rails for mobility . There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. On [DATE] NP-CC wrote an order in for [complete blood count (CBC)] and [comprehensive metabolic panel (CMP)] . Surveyor reviewed R181's labs. These labs were not completed for R181. There were no orders written to address the abdominal incision or JP drain care, management or monitoring per report sheet taken by facility. Surveyor reviewed R181's Electronic Medical Record (EMR). There was no documentation of the abdominal incision or JP drain care, management or monitoring on [DATE]. Surveyor reviewed Skin - Weekly Non-Pressure Condition Record assessment with a date of [DATE]. Documented was .Site: 14) Abdomen; Type: Surgical Incision; Length: 9 cm; Width: 0.1 cm; Depth: [blank]; Stage: N/A; Description of the site: area scabbed over. No drainage noted . There is no comprehensive assessment of the abdominal incision or JP drain. On [DATE] NP-CC visited R181 again. Visit note documented .Physical Exam: abdomen with surgical staples, protrusion of abdomen, tender to palpation . ASSESSMENT/PLAN: 1. Sepsis, stable monitoring labs. 2. ESBL, stable on antibiotics, follows infectious disease. 3. Hernia, stable general surgery follow up. 4. Perforation of intestine, stable post surgical repair, bed rails for mobility-awaiting installation . There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. Surveyor reviewed R181's Electronic Medical Record (EMR). There was no documentation of the abdominal incision or JP drain care, management or monitoring on [DATE] and [DATE]. Surveyor reviewed Physical Therapy note from [DATE]. Documented was per [nursing (nsg)] reports [patient (pt)] not eating well and updated and discussed. [With (w/)] improved intake and fluids to improve task participation and healing to improve quicker, pt agreeable though reports of they need to wake me up to eat. Pt approached this date at lunch and stated I'm done w/ 2 bites only consumed off of plate. pt reports [symptoms (sx's)] in abdomen. pt reports of spinning w/ [weight bearing] trial and seated. BP 85/? diff to hear assessment and advised pt to cont to drink fluids. updated to nsg regarding concerns W/ BP's. Surveyor reviewed R181's Progress Notes from [DATE], [DATE] and [DATE]. There was no documentation of decreased appetite. There was no documentation of concern with low BP's. There was no documentation of the abdominal incision or JP drain care, management or monitoring. On [DATE] at 12:03 PM, a dose of Loperamide HCl Capsule 2 MG: Give 1 capsule by mouth as needed for diarrhea, up to twice daily was administered. There was no other documentation of loose stools or assessment of R181. On [DATE] orders were entered for R181 documenting Stool sample for [Clostridioides difficile (c diff)] and Stool sample for diarrhea. Surveyor reviewed R181's labs. There was no stool sample collected for R181. On [DATE] NP-CC visited R181 again. Visit note documented .[History of Present Illness (HPI)]: [AGE] year old female seen today for nausea and loose stool. Patient reports symptoms 3 days in duration. Patient is stable in no acute distress . Physical Exam: abdomen with surgical staples, protrusion of abdomen, tender to palpation . ASSESSMENT/PLAN: 1. Nausea - stable Zofran and bland diet encouraged. 2. Loose stools - stable stool sample ordered. There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. The stool sample was yet to be collected. Surveyor reviewed R181's Skin - Head to Toe Skin Checks with an assessment date of [DATE]. Documented was .JP drain to right pelvic area . There was no comprehensive assessment of the abdominal incision and no other charting of care, management or monitoring of either. Surveyor reviewed R181's labs. There was a CMP and CBC drawn on [DATE] at 8:37 PM. Lab results were faxed to the facility at 10:41 PM on [DATE]. The labs were not reviewed by NP-CC until [DATE]. Results included: SODIUM 135 (L) Range: 136 - 145 mmol/L . POTASSIUM 3.1 (L) Range: 3.4 - 5.1 mmol/L . BUN 29 (H) Range: 7 - 26 mg/dL . CREATININE 1.30 (H) Range: 0.50 - 1.10 mg/dL . NP-CC signed and dated the top of the CMP and CBC and wrote repeat in 1 week on the CBC lab. On [DATE] NP-CC visited R181 again. Visit note documented .HPI: [AGE] year old female seen today for nausea and loose stool. Recent labs reviewed. Patient is in no acute distress . Physical Exam: abdomen with surgical staples, protrusion of abdomen, tender to palpation, poor skin turgor, 24 gauge IV in left forearm placed, blood return noted . ASSESSMENT/PLAN: 1. Nausea - stable Zofran changed to scheduled q 8 hours and bland diet encouraged. 2. Loose stools - stable awaiting stool sample results. 3. Anemia - stable repeat CBC in one week. 4. Dehydration - stable BUN 29, creat 1.30, potassium 3.1, creatinine 1.30, albumin 2.3, calcium 7.9, repeat labs in 2 days. 5% dextrose 50 ml/hr X 3 days ordered. Peripheral IV 24 gauge placed in left forearm by writer using sterile technique, clear dressing applied, blood return noted, IV fluids running. There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. The stool sample was yet to be collected. NP-CC did not address the low Potassium level of 3.1. NP-CC did address the low Sodium, high BUN and high Creatinine with fluids for dehydration. Surveyor reviewed R181's Progress Notes. Documented under Administration Note on [DATE] at 11:22 AM was Dextrose Solution 5% Use 50 ml/hr intravenously every 24 hours for dehydration for 3 Days: on order. The IV fluids for dehydration were not administered. Surveyor reviewed Skin - Weekly Non-Pressure Condition Record assessments with a date of [DATE]. There is no assessment of the abdominal incision or JP drain. Surveyor reviewed R181's Progress Notes. Documented under Administration Note on [DATE] at 12:36 PM was Dextrose Solution 5% Use 50 ml/hr intravenously every 24 hours for dehydration for 3 Days: Medication not available. Pharmacy has been called and medication has been ordered STAT. [NP-CC] notified, [NP-CC] said to hang [normal saline (NS)] until dextrose arrives. This order was not put into the EMR and no IV fluids for dehydration were administered. Surveyor reviewed Occupational Therapy note from [DATE]. Documented was Pt feeling sick, vomiting and diarrhea. On [DATE] NP-CC visited R181 again. Visit note documented .HPI: [AGE] year old female seen today for follow up for nausea, loose stool, anemia, and dehydration. Patient reports slight improvement to symptoms. Patient is in no acute distress . Physical Exam: abdomen with surgical staples, protrusion of abdomen, decreased tender to palpation . ASSESSMENT/PLAN: 1. Nausea - stable Zofran changed to scheduled q 8 hours and bland diet encouraged. 2. Loose stools - stable awaiting stool sample results. 3. Anemia - stable repeat CBC in one week. 4. Dehydration - stable BUN 29, creat 1.30, potassium 3.1, creatinine 1.30, albumin 2.3, calcium 7.9, repeat labs in 2 days. 5% dextrose 50 ml/hr X 3 days, may substitute lactated ringers or normal saline if no dextrose available. There was no comprehensive assessment of the abdominal incision and no mention of the JP drain. NP-CC did not address the low Potassium level of 3.1. NP-CC did address the low Sodium, high BUN and high Creatinine with fluids for dehydration, but the IV fluids were not administered. Surveyor reviewed R181's Progress Notes. Documented on [DATE] at 6:04 AM was pt had blood in brief during the noc. will leave report for dayshift nurse to follow up. Documented on [DATE] at 10:30 AM was Resident has had two episodes of bloody stool. She is stating she is having pain near her rectum, and is nauseous. BP 95/55 but is in the normal range for resident. NP has been notified as of 3-17-22 0800. R181 was sent to the hospital and admitted from [DATE] through [DATE]. Hospital admission note documented: Assessment and Plan: Gl bleed C/o loose dark maroon stools × 3 days Just hospitalized in Jan w/ Gl bleed; received 1 unit PRBC, had NM bleeding scan Recent colon resection [DATE]; this could be [secondary] to surgery Hgb 9.1 (prior 8-9 range); BUN 21 Type and screen done Started on protonix 40mg [twice daily (BID)] IV; Held home Eliquis PO, IV fluids 100cc/hr Gen surgery already on for pneumoperitoneum; await further advice [hemoglobin and hemtocrit (H&H)] q6 hrs; monitor [Telemetry] . Pneumoperitoneum Confirmed on CT imaging Recent surgery at Ascension for incarcerated hernia and bowel perforation, had colon resection [DATE]- still has surgical drain in place ED provider contacted [Surgeon-AA] at Ascension; no beds available [MD of general surgery] consulted; no urgent need for surgery at this time; await further advice [nothing by mouth (NPO)] C diff infx C/o diarrhea x 3 days Tested + 2 days ago; wasn't on [treatment (tx)]; per ED provider [facility] couldn't get hold of a doc to get tx Was started in ED on oral vancomycin; will continue . Mild acute kidney injury Creatinine 1.06 (typically under 1) Given 600ml IV fluids in ED; continue at 100 cc/hr Likely [secondary] to dehydration and/or meds Avoid nephrotoxins today Am labs ordered, monitor Hypokalemia K+ 2.8 Supplemented 20 meq in ED; will order another 40 meq Likely [secondary] to home medication/diarrhea AM labs ordered; monitor . Patient Discharge Summary with a date of [DATE] documented: .Admitting Diagnosis: Gl bleed Discharge Diagnosis: C. difficile colitis Secondary Diagnoses: Pneumoperitoneum likely due to JP drain, chronic anemia, chronic hypocalcemia, diabetes mellitus type 2, hypertension, atrial fibrillation no longer on Eliquis due to recurrent Gl bleeding, history of PE status post IVC filter placement . Hospital Course: [R181] is a(n) 75 Y female who presents with bloody diarrhea for 3 days prior to admission. Patient also complained of 10 out of 10 generalized abdominal pain with associated nausea and vomiting. Patient was noted to have recently been hospitalized in [DATE] with Gl bleed receiving 1 unit packed red blood cells. She also has a history of saddle PE with right heart strain status post embolectomy and IC filter placement. She was found to have strangulated ventral hernia with bowel perforation and required Cohn's resection with colostomy placement and this was performed at Ascension on [DATE]. Patient still had a JP drain in place at the time of her presentation to our facility. CT imaging showed concern for pneumoperitoneum however after review by [MD] and clinical evaluation he suspected the pneumoperitoneum was secondary to the JP drain so this was removed. She was also seen in consultation by Gl who determined the patient's hematochezia and diarrhea was from C. difficile infection. For this the patient was started on oral vancomycin for 14 days total. Patient's stools were formed and infrequent prior to her discharge. Additionally patient had no further Gl blood loss prior to her discharge. She was seen by [cardiology] who indicated patient did not need to continue her Eliquis given her recurrent GI bleeding and the presence of an IVC filter placed. Patient has been advised to follow- up with [Cardiologist-BB] to discuss continued use of her Eliquis. Around the time of discharge it was noted the patient had some superficial necrosis of the incision area therefore the top of 8 staples were removed by [MD] and the other staples are to be left in place for at least another week. Patient has been advised to follow-up with [Surgeon-AA] who performed the surgery at Ascension for further instruction. Patient has been cleared by all consultants for discharge today and follow-up as indicated. Patient is agreeable and eager anticipating her discharge today . Lab values: POTASSIUM 4.0 Range: 3.4 - 5.1 mmol/L . BUN 8 Range: 7 - 26 mg/dL . CREATININE 0.79 Range: 0.50 - 1.10 mg/dL . After Visit Summary with a date of [DATE] documented: What's Next: -Schedule an appointment with [Primary MD] as soon as possible for a visit in 1 week(s) -Schedule an appointment with [Cardiologist-BB] as soon as possible for a visit in 1 week(s) -Schedule an appointment with Ascension physicians' general surgery [Surgeon-AA] as soon as possible for a visit in 1 week(s) . Surveyor reviewed R181's stool sample and Urine Culture collected [DATE] at the facility. Surveyor noted labs were sent to the facility [DATE] and [DATE] but not reviewed or followed up on until [DATE] when resident had already been hospitalized for 4 days. Surveyor reviewed admission Data Collection and Skin - Head to Toe Skin Checks assessment with a date of [DATE]. Documented was .Site: 14) Abdomen; Type: Surgical Incision . There was no comprehensive assessment documented of the abdominal incision. Surveyor reviewed readmission MD Orders for R181. There were no MD orders in place for the abdominal incision treatment, management or monitoring. Surveyor reviewed Comprehensive Care Plan for R181. There was no care plan added for the abdominal incision care, management or monitoring. Surveyor reviewed R181's EMR. There was no documentation that follow up appointments were made with Surgeon-AA or Cardiologist-BB. Surveyor reviewed Comprehensive Care Plan for R181. There was no care plan in place for the abdominal incision or GI assessments, management or monitoring. Surveyor reviewed R181's vital signs. On [DATE] the resident's blood pressure was 152/66, pulse 77. This was the last set of vital signs taken until [DATE]. On [DATE] NP-CC visited R181 again. Visit note documented .HPI: [AGE] year old female seen today for re H&P for C-diff, perforation of intestine, saddle embolus. Patient and writer discuss plan of care. Patient is in no acute distress . Physical Exam: abdomen with surgical staples, protrusion of abdomen decreased tender to palpation . ASSESSMENT/PLAN: 1. C-diff, stable on vanco. 2. Perforation of intestine, stable follow up with surgeon encouraged. 3. Saddle embolus- stable blood thinner stopped in hospital, IV filter in place. There was no comprehensive assessment of the abdominal incision. There is no instruction or orders for monitoring of R181's GI system, BP or documentation of nursing to schedule follow up appointment. Surveyor reviewed MD Orders for R181 placed by NP-CC on [DATE]. Documented was: Furosemide Tablet 20 MG: Give 1 tablet by mouth one time a day for diuretic. Ondansetron HCl Tablet 4 MG: Give 1 tablet by mouth with meals for nausea. admission Labs. Surveyor noted there was no order for a potassium supplement with the diuretic order per standard practice. According to American Family Physician, Hypokalemia and hyperkalemia are common electrolyte disorders caused by changes in potassium intake, altered excretion, or transcellular shifts. Diuretic use and gastrointestinal losses are common causes of hypokalemia, whereas kidney disease, hyperglycemia, and medication use are common causes of hyperkalemia. When severe, potassium disorders can lead to life-threatening cardiac conduction disturbances and neuromuscular dysfunction. Therefore, a first priority is determining the need for urgent treatment through a combination of history, physical examination, laboratory, and electrocardiography findings. Indications for urgent treatment include severe or symptomatic hypokalemia or hyperkalemia; abrupt changes in potassium levels; electrocardiography changes; or the presence of certain comorbid conditions. Hypokalemia is treated with oral or intravenous potassium. To prevent cardiac conduction disturbances, intravenous calcium is administered to patients with hyperkalemic electrocardiography changes . Causes: GI losses are another common cause of hypokalemia, particularly among hospitalized patients.9 The mechanism by which upper GI losses induce hypokalemia is indirect and stems from the kidney's response to the associated alkalosis. As a portion of daily potassium is excreted in the colon, lower GI losses in the form of persistent diarrhea can also result in hypokalemia and may be accompanied by hyperchloremic acidosis. https://www.aafp.org/afp/2015/0915/p487.html#:~:text=Hypokalemia%20is%20treated%20with%20oral,patients%20with%20hyperkalemic%20electrocardiography%20changes Surveyor reviewed R181's labs faxed to the facility at 4:09 PM on [DATE]. Results included: POTASSIUM 3.0 (L) Range: 3.4 - 5.1 mmol/L . Noted on the top was sent to NP-CC. NP-CC did not address the low potassium or schedule a potassium supplement that should have been added to counteract the loss of the potassium from the diuretic. NP-CC increased the Ondansetron from as needed to scheduled and as needed with no other instructions or reasoning. Surveyor reviewed MD orders. Documented on [DATE] with a start date of [DATE] was Klor-Con 10 Tablet Extended Release 10 MEQ (Potassium Chloride ER), Give 1 tablet by mouth one time a day for low potassium. There were no repeat labs ordered to check the level of the low potassium from [DATE]. From [DATE] through [DATE] there were no assessments, no treatments, no vital signs, and no gastrointestinal assessments. Surveyor reviewed Administration Note for R181 from [DATE] at 10:11 AM which documented wrap lower extremities in kerlix then ace wrap. everyday shift for edema; no edema this shift. There was no assessments of the edema