Every finding on record at Accolade Paxton Senior Living

Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to ensure resident's call lights were answered in a reasonable time frame for seven of 17 residents (R50, R60, R81, R82, R74, R83, R43) reviewed for resident rights on a sample list of 43.B. Based on interview and record review the facility failed to ensure residents were treated with dignity and respect for three of 17 residents (R18, R74, R82) reviewed for resident rights in the sample list of 43. a.1) The facility policy Call Lights: Answering dated 8/2/17 documents call lights are to be answered in a reasonable time frame and all call lights should be answered courteously. Record review of Resident Council meeting minutes dated January, February, and March 2026 document ongoing concerns related to call lights not being answered timely. On 4/6/2026 at 12:15PM, V4 (R81's Power of Attorney) stated R81 had to wait an hour to get a Certified Nursing Assistant (CNA) to answer the call light to go to the bathroom. On 4/08/26 at 10:01 AM, V25 (Certified Nursing Assistant) stated it is difficult to see the call light alerts located at the end of the hallway, especially as they wear glasses. V25 further stated there is no audible alarm and expressed that a light system above resident room doors would improve visibility of alerts. a.2) On 4/07/26 at 10:32 AM R50 and R60 stated that at times they have to wait over an hour for someone to answer the call light. More at night but is a constant problem. Resident Council Minutes dated 2/18/26 document call light times are a problem. On 4/7/26 at 1:00PM the call light banner indicated R82 needed assistance. There was no audible alert and no light on above R82's door. R82 asked V27 Speech Therapist for help and V27 stated that she is not there to help her with that, she would have to wait for other staff. No call light banner was noted in 100 hallway. On 4/7/26 at 1:15PM V1 Administrator verified there is no sound or light above resident room doors indicating the call light has been activated. V1 stated the only alert is the scroll above the hall end doors. On 4/7/26 at 1:45 PM, V11 Nurse Manager, indicated where the call light panel was located at the nursing station. The panel is a computer screen showing a map of the facility and resident room call lights. The room on the map illuminates when the call light is pushed. A text alert also scrolls on the screen indicating which resident is alerting for help. V2 verified no sound is made when a call light is triggered. On 4/8/26 at 9:45AM the call light banner indicated assistance was needed and no staff member was at the desk monitoring the call light panel. On 4/8/26 at 10:38AM the call light banner indicated assistance was needed in resident rooms for R74, R82 and R83. No staff were observed monitoring the call light panel. On 4/8/26 at 10:46AM the call light banner continued to indicate assistance needed for R74, R82 and R83. On 4/8/26 at 11:25 AM V19 Maintenance Staff stated there is no sound component to the call light system. a.3) On 04/06/2026 at 10:00 AM R43 stated the facility does not have enough staff, it takes an hour at times for call lights to be answered often while waiting to use the bathroom. R43's Minimum Data Set (MDS) dated [DATE] documents R43 as cognitively intact and dependent on staff assistance for toileting hygiene and toilet transfers. a.4) On 4/6/26 at 11:47 AM R18 was in a wheelchair in his room. R18 stated R18 often calls for staff assistance to use the urinal around 4:00-5:00 AM, often waiting over an hour, causing R18 to wet his bed requiring a linen change. R18's MDS dated [DATE] documents R18 as cognitively intact, that R18 needs substantial/maximal staff assistance for toileting hygiene and R18 is always continent of bladder. The facility's Resident/Family Concern/Grievance Form dated 3/19/26 documents a reported concern from the resident council meeting that residents don't feel like they get enough support on nights. b.1) The facility policy Call Lights: Answering dated 8/2/17 documents be courteous when answering call lights. The facility's Resident Privacy and Dignity policy dated January 2026 documents All residents will be addressed and spoken to with dignity and respect at all times. On 4/6/26 at 11:47 AM R18 stated R18 calls for staff assistance during the night to use the urinal and has to wait for over an hour causing R18 to wet his bed, this often happens when the Certified Nursing Assistant (CNA) V13 is working R18's hallway. R18 stated a few weeks ago he turned his call light on around 4:00 - 5:00 AM and no staff answered it until 6:00 AM when R18 required bed linen change. R18 stated R18 complained to management about V13 and V13 wasn't supposed to take care of R18 anymore after that but V13 took care of him again recently. R18 questioned V13 who got smart with R18 and told R18 he should be going to the bathroom on his own. R18 stated he feels like V13 was being vindictive after R18 told V13 that R18 was going to report V13. R18 stated R18 has arthritis in his hands making it difficult to hold the urinal, requiring staff assistance so it doesn't spill. R18's Minimum Data Set (MDS) dated [DATE] documents R18 as cognitively intact and R18 needs substantial/maximal staff assistance for toileting hygiene. The facility's Daily CNA Schedule dated 3/26/26 documents V13 was assigned to R18's hallway. The Resident/Family Concern/Grievance Form dated 11/12/25 documents concern reported from resident council regarding V13's tone of voice as coming off as rude. Action taken is listed as discussed tone and interaction with residents during care with V13 on 11/14/26. The Resident/Family Concern Grievance Form dated 3/27/26 documents R18 complained of V13 and waiting for help with his urinal requiring bed linen change. Action taken is listed as R18 was in agreement with having a different CNA provide care as R18 feels like V13 and R18 personalities just don't get along. This is documented as reviewed with the V7 CNA Supervisor regarding scheduling and education was given to V13. On 4/6/26 at 12:29 PM V7 stated a couple weeks ago R18 voiced concerns regarding V13 CNA and having personality conflict, which was reported to V1 Administrator. At 12:37 PM V1 stated about a week ago V7 reported R18's concern with personality conflict with V13. V1 and V2 Director of Nursing stated they followed up with R18 and R18 stated he just didn't care for V13. V1 and V2 stated V13 was instructed not to provide any further care for R18. On 4/6/26 at 3:08 PM V13 CNA stated V13 assisted R18 with using the urinal and R18 said that R18 wanted to talk to someone further and V13 told R18 that he could talk with V13's supervisor. V13 confirmed she received training on professionalism and tone on 3/28/26 regarding R18's concern. V13 stated V13 took care of R18 again sometime between 4/1/26-4/3/26. b.2) On 4/6/26 at 9:37 AM R82 stated one night a CNA was rude to R82, argued with R82, and R82 didn't like the way the CNA spoke to R82. On 4/06/2026 at 11:30 AM R74, R82's roommate, stated a night shift agency Certified Nursing Assistant (CNA) (identified as V17 based on R74's description) was really rude to R82 and talked down to R82 on the Saturday after R74 admitted to the facility (3/28/26). R74 stated R74 has not seen the CNA since that day. R74 stated the CNA rudely told R82 that R82 was going to have to wait for assistance since the CNA was there to answer R74's call light which caused R82 to get snippy with the CNA. R82's MDS dated [DATE] documents R82 as cognitively intact. The facility's Resident Council Minutes dated 2/18/26 document concerns with agency nursing staff, having attitudes and being mouthy. The Resident/Family Concern/Grievance Form dated 2/18/26 documents residents complained of agency staff not always identifying themselves and having mouthy attitudes. The action taken is listed as agency staff will be monitored related to expectations, reported concerns will be addressed and reported to the agency and with the staff member no longer being allowed to work in the facility. The facility's Daily Assignment Log dated 3/28/26 documents V17 CNA was assigned to R74's/R82's hallway on night shift. On 4/7/26 at 3:53 PM V17 CNA confirmed she last worked in the facility on night shift 3/28/26 and provided cares for R74/R82. V17 stated that night R74 kept turning on the call light for R82 saying R82 needed the bathroom or to be changed. V17 stated R82 denied needing to use the bathroom but then later called to report R82 had wet the bed.

Based on observation, interview, and record review the facility failed to appropriately label eye drops and inhalers with the date opened for three (R18, R42, R48) of eight residents reviewed for medication administration on a sample list of 43.Findings:On 4/8/26 at 10:53 a.m., the facility's Main Skilled Medication Cart was inspected in the presence of V20, Registered Nurse (RN). During the inspection, two open bottles of Latanoprost labeled for R18 were found without documented dates of opening. R42's Incruse Ellipta inhaler also lacked a documented date of opening and R48's Latanoprost and Timolol did not contain documented dates of opening.Review of R18's Medication Administration Record (MAR) dated April 2026 documents R18 has an active physician's order and is currently receiving Latanoprost 0.005 % Solution every evening.Review of R42's MAR dated April 2026 documents R42 has an active physician's order and is currently receiving Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 micrograms daily.Review of R48's MAR dated April 2026 documents R48 has an active physician's order and is currently receiving Latanoprost Ophthalmic Solution 0.005 % and Timolol Maleate Ophthalmic Solution 0.5 % daily.The Food and Drug Administration (FDA) approved package insert for Latanoprost Ophthalmic Solution states that once the bottle is opened, it may be stored at room temperature (up to 77 degrees Fahrenheit) for a maximum of six weeks before it must be discarded. The FDA approved package insert for Incruse Ellipta instructs staff to write the 'Tray opened' date on the inhaler's label at the time the tray is opened, and to write the 'Discard' date, which is 6 weeks after the tray opened date. On 4/8/26 at 10:53 a.m., V20, RN, stated that multi-dose containers must be labeled with the date of opening, and that the nurse who initially opens the container is responsible for documenting this information on the container. The facility's Labeling of Medications Policy dated August 2017 with a revision date of September 2023 documents that the facility will ensure that medications are properly labeled in accordance with current state and federal requirements. This policy also documents that it is the responsibility of the Charge Nurse to ensure that all medications are properly labeled.

Based on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for two (R8 and R51) of 17 residents reviewed for advanced directives in the sample of 43. Findings Include: 1. R51's admission Record documents an admission date of [DATE]. R51's Order Detail Report printed [DATE] documents on [DATE] an Advance Directive order for Full Code. R51's Resident Information Sheet printed on [DATE] documents R51's Advance Directive as FULL CODE. R51's IDPH (Illinois Department of Public Health) Uniform Practitioner Order For Life-Sustaining Treatment (POLST) Form documented an X marked on the box for Do Not Attempt Resuscitation. This form was signed by R51 and dated [DATE] and signed by the Authorized Practitioner. R51's Care Plan revised on [DATE] documents R51 chooses to have death with dignity, advanced directive established. Individual wishes include: DNR refer to POLST. On [DATE] at 12:02 PM V8 (Registered Nurse) verified she would refer to a resident's order listed on the Resident's Information Sheet in the facility's Electronic Healthcare Record (EHR) for their code status. 2. Review of R8's Electronic Health Record (EHR) shows a banner alert that documents Do Not Resuscitate (DNR): refer to POLST. The referenced POLST, dated [DATE], identified R8 as DNR but did not contain R8's signature or the resident representative's signature. This POLST form documents that it was signed only by an unknown hospital nurse indicating that verbal consent was received, however, the form did not identify who provided that consent. R8's Care Plan dated [DATE] documents R8 as a Full Code and documents R8 chooses to have death with dignity, with advance directives established. R8's EHR contains a progress note dated [DATE] at 5:37 p.m. by V18, Social Services Director (SSD) documenting that V18 made multiple unsuccessful attempts to clarify R8's preferences using R8's preferred communication method (white board). This note documents R8 had difficulty understanding Cardiopulmonary Resuscitation (CPR) despite explanation and was noted to have severe cognitive impairment during this interaction. On [DATE] at 9:56 a.m., V18, SSD stated R8's Care Plan should have been updated after R8 returned from the hospital with a reported change in code status to DNR. V18, SSD stated he was delaying the update until the next review and stated that when he contacted R8's POA, the POA did not recall agreeing to a DNR when R8 was hospitalized . On [DATE] at 3:10 p.m., V2, Director of Nursing (DON) stated that either R8 or his POA had given verbal consent at the hospital for R8 to be designated as DNR. V2 stated the POLST form returned from the hospital did not identify who provided the verbal consent. V2 stated the hospital had been returning POLST forms signed only by nursing staff indicating verbal consent, without identifying the consenting party, and the facility did not follow up with R8 or his POA to verify. V2 stated R8's code status change should have been addressed in the Care Plan at readmission. The facility's Advance Directive(s)/Care Planning policy with a revision date of [DATE] documents that it is the policy of the facility to establish, implement and maintain written policies and procedures for advance directive. The resident has the right, and the facility will assist the resident to formulate an advance directive at their option. The facility will inform and provide resident with a written description of the facility's policy to implement advance directives and comply with all applicable Illinois laws, including the Illinois Power of Attorney Act, the Health Care Surrogate Act and the Department of Public Health's Uniform POLST form. This includes the resident's right to formulate an advance directive, the facility's obligation to honor valid DNR/POLST orders, the process for revocation or modification of such directives, and the procedure followed in the event the facility or practitioner cannot comply with an advance directive due to reasons of conscience. Residents have the right to accept request refuse and/or discontinue medical or surgical treatment and to participate in or refuse to participate in experimental research. This Policy documents that the facility procedure is as follows: C. facility staff will provide the resident and/or resident representative with a written description of the facility's policies to implement an advance directive. The facility will identify the primary decision-maker (e.g. assess the resident's decision-making capacity and identify or arrange for an appropriate legal representative for the resident assessed as unable to make relevant health care decisions.) i. if an individual is incapacitated at the time of admission and is unable to receive information or articulate whether he or she has executed an advance directive, the facility will give advance directive information to the individual's resident representative in accordance with State law. E. resident wishes will be communicated to the staff via the care plan/progress note documentation and to the resident physician. This policy documents the interdisciplinary team will identify, clarify, and review, as part of the comprehensive care planning process, the existing care instructions along with the resident's goals wishes as the resident's medical condition changes.

Based on interview and record review, the facility failed to submit a discharge Minimum Data Sheet (MDS) resident assessment for two of 17 residents (R20, R54) reviewed for resident assessment on a sample list of 43.Findings Include: R20's census list documents an admission date of 11/12/25 and a discharge date of 12/27/25. R20's MDS list documents no discharge MDS completed. R54's census list documents an admission date of 11/06/25 and a discharge date of 12/11/25. R54's MDS list documents no discharge MDS completed. On 04/08/2026 at 11:22 AM V23 Minimum Data Set Registered Nurse stated she did in fact miss doing the discharge MDS for R20 and R54. V23 stated she usually completes the discharge MDS immediately.

Based on observation, interview, and record review the facility failed to revise a care plan with falls and post fall interventions for one of three residents (R82) reviewed for falls in the sample list of 43. Findings include:On 4/6/26 at 9:37 AM R82 was lying in bed, bed was low to the floor, and a fall mat was beside the bed. R82 stated R82 recently admitted to the facility following shoulder surgery. R82 stated R82 slid out of her wheelchair two days ago. R82 stated R82 is using a different wheelchair than the one she was using that day. R82 stated R82 had a prior fall from her wheelchair while trying to stand up. R82 stated R82 was unsure what follow up actions the facility took to prevent further falls. R82's wheelchair contained an anti-tip device. The facility's Fall report dated 3/29/26 documents R82 fell at 10:30 PM after attempting to stand from her wheelchair to look for clothing in her closet. The interdisciplinary note dated 3/30/26 documents: R82's wheelchair brakes weren't locked at the time of the fall, and the root cause of the fall was R82 standing by herself in combination with unlocked wheelchair brakes. An anti-rollback device was implemented on the wheelchair to reduce movement in the event that R82 attempts to self-transfer without locking the brakes. A fall mat at the bedside was also initiated. The care plan was updated to reflect these changes. The facility's Fall report dated 4/4/26 documents R82 fell at 11:50 PM after attempting to self-transfer from the wheelchair. V26 Certified Nursing Assistant found R82 on the floor of her room. The interdisciplinary team note dated 4/5/26 documents interventions for frequent rounding and room move closer to nurse's station. The interdisciplinary note dated 4/7/26 documents therapy adjusted the wheelchair to lower the chair for better mobility and removed the anti-rollback device. This note documents a wheelchair anti-tip device was in place. R82's Care Plan dated 3/27/26 documents R82 is at risk for falls, R82 admitted to the facility on [DATE], and R82 has a right humerus fracture. This care plan has not been revised to include R82's falls after admission or post fall interventions after 3/27/26. On 4/6/26 at 2:34 PM V3 Assistant Director of Nursing stated V23 Care Plan/Minimum Data Set Coordinator is responsible for updating the care plans with post fall interventions. V3 reviewed R82's care plan and confirmed it had not been updated with R82's falls and post fall interventions. On 4/7/26 at 3:05 PM V1 Administrator stated R82's fall on 3/29/26 was unwitnessed, root cause was R82's attempt to self-transfer and post fall intervention was bed low to floor with fall mat and anti-rollback device added to wheelchair. V1 stated R82 had an unwitnessed fall on 4/4/26, root cause was R82's attempt to self-transfer from wheelchair and post fall interventions included room move closer to nurse's station, which R82 declined, and therapy lowered the wheelchair seat height which then discontinued the anti-rollback device. V1 confirmed these interventions had not been added to R82's care plan. V1 stated V1 will add the interventions today.

Based on interview and record review the facility failed to accurately transcribe an order for pain medication for one of three residents (R18) reviewed for hospitalization in the sample list of 43. Findings include: On 04/06/2026 at 11:47 AM R18 stated he admitted to the facility from the hospital after being treated for severe pain in his left shoulder. R18 stated R18's pain returned and R18 was sent back to the hospital five days after R18 admitted to the facility. On 4/7/26 at 11:58 AM R18 showed a paper copy of R18's hospital discharge orders dated 3/9/26 which included Methocarbamol (muscle relaxant) 500 milligrams (mg) by mouth every six hours for 15 doses. R18 stated he did not recall taking this medication or requesting this order to be changed to as needed (PRN) instead of scheduled. R18's March 2026 Medication Administration Record (MAR) documents to administer Methocarbamol 500 mg by mouth every six hours as needed from 3/9/26-3/16/26, with only one dose administered. This MAR does not include the order to give Methocarbamol 500 mg every six hours for 15 doses. This MAR documents R18's pain was rated 3 on 3/11/26, 8 on 3/12/26 and 5 on 3/13/26. R18's medical record does not contain documentation as to why R18's Methocarbamol order was changed. R18's active care plan documents R18 has potential/actual pain with an intervention to give medication as ordered and document the effectiveness.On 4/8/26 at 11:10 AM V8 Registered Nurse stated V8 is the admissions nurse and reviews the orders with the Nurse Practitioner or Physician upon admission. V8 stated if there are ordered changes made then this is documented in a nursing note. V8 reviewed R18's 3/9/26 hospital discharge orders and confirmed the order for Methocarbamol 500 mg every six hours and V8 entered the order as PRN not scheduled. V8 stated V8 was unsure why. On 4/8/26 at 11: 50 AM V2 Director of Nursing stated R18's Methocarbamol order was a transcription error.

Based on observation, interview, and record review, the facility failed to monitor the dishwasher rinse temperatures to ensure sanitation of service wares and utensils utilized to serve meals to the residents. This failure affects nearly all (62 of 63) residents residing in the facility. Findings include: On 3/5/24 at 8:57 AM, V3, Dietary Manager, stated the commercial dishwasher utilized to wash the resident dishes, wares, and utensils, was a hot water sanitizing dishwasher. At this time, while the facility commercial dishwasher was in operation, the final rinse temperature was not displaying as designed on the digital display on the front of the dishwasher. When asked how the kitchen staff are monitoring the final rinse temperature to ensure the wares are being properly sanitized, V3 replied, I will have to look for test strips. V3 could not locate the temperature sensitive test strips. V3 questioned a Dietary Aid (V4) who likewise could not identify the location of the test strips. V4 also stated, I don't know how long the display has not been showing the final rinse temperature. V3 then stated, I will get maintenance in here to look at it. On 3/5/24 at 09:25 AM, V9, Maintenance Assistant, stated, I'm not sure but I think something like a knife or spoon may be stuck in the drain outlet because the drain is releasing water while the wash cycle is going. On 3/5/24 at 9:35 AM, V5, Dietary Aid, stated, The final rinse temperature display has not been working since they came and repaired the dishwasher about 2 weeks ago. V3 confirmed (the dishwasher repair company) had worked on the dishwasher about 2 weeks prior. On 3/6/24 at 8:25 AM, V9, Maintenance Assistant, stated, I think it may be the rinse thermostat not working but I will need to get with my boss because I don't want to start tearing this dishwasher apart. On 3/6/24 at 8:32 AM, V3, Dietary Manager, provided the dishwasher temperature recording log for January 2024, which was the log in place on the clipboard in the dishwashing room. This temperature log documented 3 columns for recording the final dishwashing rinse temperature once for each of the three daily mealtimes, breakfast, noon, and evening. This temperature log documented the final dishwashing rinse temperature had not been recorded for 1/25/24 all three meals, 1/26/24 for breakfast and noon, 1/27/24 through 1/30/24 all three meals each day, and 1/31/24 breakfast and evening. On 3/6/24 at 10:12 AM, V3 provided the dishwasher temperature recording log for February 2024. This log documented the dishwasher final temperature was not being monitored from 2/24/24 though 2/29/24 all three meals each day. V3 confirmed, The temperature has not been monitored for about the past 2 weeks since the repair company worked on the dishwasher. The facility's Form 671 Long Term Care Facility Application for Medicare and Medicaid dated 3/5/24 documents 63 residents reside in the facility, all of whom, with one exception (R31 who receives nothing by mouth), consume food prepared by the facility kitchen.

Based on observation, interview and record review the facility failed to provide dignity while obtaining a respiratory assessment for one (R46) resident out of one resident reviewed for dignity in a sample list of 33 residents. Findings include: R46's undated Medical Diagnosis List documents medical diagnoses of Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Protein Calorie Malnutrition, Shortness of Breath and Disorders of Electrolyte and Fluid Imbalance. R46's Minimum Data Set (MDS) dated [DATE] documents R46 as cognitively intact. R46's Care Plan intervention dated 11/20/2023 documents R46 transfers with the assist of one person and a walker. On 3/6/24 at 12:00 PM R46 was sitting at a dining room table eating the lunch meal. V14 Registered Respiratory Therapist (RRT) walked up to R46 while R46 was eating lunch meal and stated 'Put your finger out so I can get your Oxygen saturation (O2 sat)'. V14 RRT obtained R46's O2 sat, Pulse, Respirations and Blood Pressure at dining room table in front of table mates. V14 stated to R46 Lean forward so I can listen to your lungs. V14 removed V14's stethoscope from around V14's neck and placed it on the front and back of R46's lung fields while R46 was sitting at dining room table. V14 instructed R46 to take a deep breath and cough three times. R46 produced three separate deep coughs without covering her mouth while sitting at dining room table with table mates. On 3/6/24 at 12:20 PM V14 Registered Respiratory Therapy (RRT) stated I was scheduled to see (R46) today. If I don't see (R46) when I can then I will have to leave without seeing her. (R46) is being weaned off of her Oxygen. I should have asked (R46) to cover her mouth too. (R46) just coughed so hard over those other residents. Next time I will be sure to complete the respiratory assessments in the residents' room and be sure to tell them to cover their mouths when they cough. On 3/6/24 at 1:15 PM R46 stated I really didn't care for that nurse (V14) Registered Respiratory Therapist (RRT) interrupting my lunch. We had tacos today and mine got cold while waiting for (V14) to get done. I don't see why (V14) couldn't have just done that in my room. On 3/6/24 at 12:50 PM V2 Director of Nurses (DON) stated V14 Registered Respiratory Therapist (RRT) should have completed (R46's) respiratory assessment in a private area. V2 DON stated the dignity of R46 was compromised by V14's actions. The facility policy titled 'Resident Privacy and Dignity' dated 8/2/2017 documents it is the responsibility of all staff to ensure that all residents have privacy and dignity. Medically necessary procedures will be conducted in the resident's room or private setting.

Based on interview and record review the facility failed to complete a Baseline Care Plan timely for one (R266) resident out of one resident reviewed for Baseline Care Plans in a sample list of 33 residents. Findings include: The facility policy titled '24 Hour Interim Care Plan' revised 2/2021 documents the purpose is to provide guidelines for completion of a 24 hour (Interim) Plan of Care for newly admitted residents. The policy states a 24 Hour Care Plan guides provision of care from the time of the resident transfer/admission until the Interdisciplinary Care Plan is completed and to provide a Kardex with the Electronic Medical Record (EMR) for resident care direction. R266's undated Face Sheet documents R266 admitted to facility on 3/1/24. R266's undated medical diagnosis list documents R266's medical diagnoses of Local Infection of the Skin and Subcutaneous Tissue, Cellulitis Unspecified, Diabetes Mellitus Type II, Chronic Venous Hypertension with Ulcer and Inflammation of Bilateral Lower Extremities, Atrial Fibrillation, Chronic Congestive Heart Failure, Acute Kidney Failure, Peripheral Venous Insufficiency and Hypertension. R266's Electronic Medical Record (EMR) documents R266's Baseline Care Plan was initiated on 3/5/24. On 3/6/24 at 2:00 PM V17 Care Plan Coordinator (CPC) stated every resident should have a baseline care plan completed within 48 hours of admission. V17 CPC stated the admission nurse is supposed to start a baseline admission care plan when the resident admits. V17 CPC stated (R266) was admitted on [DATE] and his baseline care plan was not initiated until 3/5/24.

Based on observation, interview, and record review the facility failed to prevent cross contamination of pressure ulcers during pressure ulcer wound care and failed to complete wound treatments for two (R45, R266) residents out of four residents reviewed for Pressure Ulcers in a sample list of 33 residents. Findings include: 1.) R45's undated Face Sheet documents R45 admitted to the facility on [DATE]. This same Face Sheet documents R45's medical diagnoses of Right Hip Pressure Ulcer Stage IV, Morbid Obesity, Acute Respiratory Failure with Hypoxia, Sepsis, Diabetes Mellitus Type II, Cognitive Communication Deficit, and Embolism and Thrombosis of Deep Veins of Right Lower Extremity. R45's Physician Order Sheet (POS) dated March 2024 documents a physician order to cleanse Right Lateral Hip wound with gauze and 1/4 strength bleach solution, apply Gentamicin Sulfate 0.1% topical ointment to periwound and in wound tunnel. Soak roll gauze in 1/4 strength bleach solution and pack into wound after Gentamicin placed into wound. DO NOT USE GAUZE-IT MUST BE CONTINUOUS ROLL GAUZE. Once hole is packed, cut roll gauze leaving tail on the outside to cover the peri wound. Apply two absorbent pads and retention tape to secure. change twice daily and every two hours as needed for wound management. R45's Minimum Data Set (MDS) dated [DATE] documents R45 as cognitively intact. This same MDS documents R45 requires maximum assistance for bed mobility and is dependent on staff for assistance with bathing and dressing. R45's Treatment Administration Record (TAR) dated March 2024 documents R45's Right Hip Stage IV Pressure Ulcer dressing change was not completed as ordered by the Physician on 3/1/24 night shift and 3/5/24 night shift. On 3/6/24 at 3:00 PM V12 Licensed Practical Nurse (LPN) completed wound care for R45's Stage IV Right Hip Pressure Ulcer. As R45 turned to his Left side, the fitted sheet underneath where R45's dressing was touching was smeared in multiple areas with a brown substance, food particles and unknown debris. V12 LPN removed the undated bandage from R45's Right Hip. The bandage was overly saturated with brown, foul smelling drainage that was dripping from the bandage onto R45's open wound, Right Hip area and flat sheet. R45's Right Hip Stage IV Pressure Ulcer was a half dollar sized hole with reddened edges. V12 LPN inserted a long cotton tipped applicator into R45's Right Hip wound to approximately half the length of the cotton tipped applicator. V12 stated Wow. This wound is really tunneled at the 5-6 o'clock area. I can stick half this stick in there. R45 moved the contaminated sheet back over R45's Stage IV Pressure Ulcer after V12 LPN had cleansed the wound causing the contaminated sheet to directly touch the open area of the wound. V12 LPN did not re-cleanse R45's open wound after the contaminated sheet touched it. V12 LPN used her contaminated Right hand to push R45's flat sheet off of the open wound and did not perform hand hygiene after moving contaminated sheet before continuing wound care. On 3/6/24 at 3:40 PM V12 Licensed Practical Nurse (LPN) stated R45's Stage IV Pressure Ulcer to Right Hip should not be laying on soiled sheets. V12 LPN stated R45's wound had a copious amount of drainage. V12 LPN stated I can't be sure when (R45's) Right Hip Pressure Ulcer dressing was changed because there was no date, time or initials on the old bandage. (R45's) bed is a mess. That brown substance was probably the chocolate ice cream (R45) had for lunch and I am not sure what the rest of that debris was. V12 LPN stated V12 cross contaminated R45's Pressure Ulcer by not cleansing his wound again after R45 put the sheet directly on it and by not performing hand hygiene after V12 used her Right hand to move the sheets. V12 LPN stated Cross contaminating an open wound could cause bacteria to get into wound and cause an infection or make an infection worse. On 3/6/24 at 4:00 PM R45 stated They (facility) change my dressing to my Right Hip sometimes. They have missed a few times too. They did not change it last night. I don't know why. 2.) R266's undated Face Sheet documents R266 admitted to facility on 3/1/24. R266's undated medical diagnosis list documents R266's medical diagnoses of Local Infection of the Skin and Subcutaneous Tissue, Cellulitis Unspecified, Diabetes Mellitus Type II, Chronic Venous Hypertension with Ulcer and Inflammation of Bilateral Lower Extremities, Atrial Fibrillation, Chronic Congestive Heart Failure, Acute Kidney Failure, Peripheral Venous Insufficiency and Hypertension. R266's Physician Order Sheet (POS) dated March 2024 documents a physician order to cleanse Left Leg (Knees to Toes) with (antiseptic soap) 4.0 % and gauze, then allow to dry. Paint with (povidone-iodine), cover with abdominal pads, wrap with roll gauze, wrap with elastic gauze wrap from toes up. DO NOT PULL ELASTIC GAUZE WRAP OR ROLL GAUZE TIGHT change daily and as needed (PRN) for soilage. This same POS does not document a specific order for R266's Stage II Left Heel Pressure Ulcer. R266's Pressure Ulcer Risk assessment dated [DATE] documents R266 is at risk for Pressure Areas. R266's Facility Wound Rounds report dated 3/4/24 documents R266's Left Heel wound as a Stage II Pressure Ulcer. R266's Care Plan intervention dated 3/5/24 documents R266 requires assistance with bathing, dressing, bed mobility and full mechanical lift for transfers and to follow facility protocols for treatment of injury. This same careplan does not include any pressure relief interventions prior to 3/5/24. On 3/6/24 at 3:55 PM V12 Licensed Practical Nurse (LPN) and V13 Registered Nurse (RN)/Wound Care Certified (WCC) completed wound care for R266's Stage II Left Heel Pressure Ulcer. V12 LPN removed a partially filled urinal from R266's bedside table. R266's bedside table had several areas where unknown liquid had been spilled. V13 RN/WCC observed V12 remove the urinal, then V13 placed bottles of wound supplies (wound cleanser, (antiseptic soap) and (providone-iodine)) directly on the contaminated bedside table. V12 LPN and V13 RN/WCC positioned R266 with a pillow under R266's knees for the dressing change. On R266's Left Heel was a nickel sized open area with red drainage. R266 rested the Left Heel Pressure Ulcer directly on the contaminated fitted sheet three separate times during wound care after V12 cleansed wound. A dime sized red area of drainage was observed on fitted sheet directly under where R266's Left Heel was laying. V12 LPN continued to dress R266's Left Heel contaminated Pressure Ulcer without re-cleansing the wound. On 3/6/24 at 5:45 PM V12 Licensed Practical Nurse (LPN) stated V12 cross contaminated R266's Stage II Left Heel Pressure Ulcer by not cleansing it after R266 had laid his Left Heel directly on the contaminated sheet. V12 LPN stated a clean field should have been provided prior to starting wound care for R266. V12 LPN stated I usually make sure I have a clean area to start with but (R266) just didn't have any room for all the supplies. I saw (R266) lay his Left Heel on the sheet but didn't think to reclean it. I should have. I have never met (R266) before this wound change so I didn't know what to expect. On 3/7/24 at 11:00 AM V10 Infection Preventionist (IP)/Registered Nurse (RN) stated cross contaminating a wound during wound care could introduce bacteria to the resident's wound and possibly cause an infection. V10 IP stated We (facility) have a few policies on Pressure Ulcers but I don't think we (facility) have a policy on this but it should be considered a standard of care to not cross contaminate open wounds. The facility policy titled 'Preventative Skin Care' revised April 2023 documents the facility should maintain wrinkle free, clean, dry bed linen.

Based on observation, interview, and record review, the facility failed to provide a safe environment for use of oxygen in the presence of electrical heating devices and flammable materials in the facility beauty shop. This failure affects two residents (R11 and R48) out of nine reviewed for accidents and safety on a sample list of 33. Findings include: On 3/5/24 at 10:40 AM, R11 was in the beauty shop wearing oxygen tubing on her face and nose and actively receiving oxygen therapy from a portable liquid oxygen tank flowing at 2 liters per minute through a nasal cannula (tube connecting the oxygen tank to the resident's nose). V7, Beauty Shop Operator, was in the process of drying R11's hair with a hand-held electric blow dryer (glowing orange electrical coils and an electric fan motor which produces sparks, ignition source) approximately one foot from R11's head. R48 was seated in a wheelchair inside the beauty shop approximately 6 feet away from R11 and the hair dryer being used by V7. R48 was also wearing oxygen tubing on her face and nose and actively receiving oxygen therapy from a portable liquid oxygen tank through a nasal cannula flowing at 2 liters per minute. In the beauty shop there were flammable products present such as aerosol hair spray. On 3/5/24 at 10:41 AM, V1, Administrator, removed R48 from the beauty shop, and instructed V7 to remove the oxygen tubing from R11's face and turn R11's portable liquid oxygen tank to the off position. V7 stated, I have only been told not to use the large commercial hair dryers that the residents sit under when a resident is wearing oxygen. V7 stated, I have not been told about not using hand-held hair dryers when residents are wearing oxygen. On 3/5/24 at 11:05 AM, the door of the beauty shop was closed and R11 remained inside the beauty shop. R11 was then again wearing oxygen tubing on her face and nose and actively receiving oxygen therapy from the portable liquid oxygen tank flowing at 2 liters per minute through the nasal cannula. V7 again stated, I have not been informed about not using a curling iron (internal glowing orange electrical coils, ignition source) when a resident is wearing oxygen, only not to use the large hair dryers. On 3/5/24 at 11:10 AM, V1 stated, I would need to look up the facility policy and go over that policy with (V7). The current (3/5/24) American Lung Association guidelines for safe use of oxygen document, Do not use any electrical appliances such as hair dryers, curling irons, heating pads, and electric razors while wearing oxygen. The facility policy Oxygen Safety dated 2/2000 documents, spark producing devices shall be prohibited in oxygen storage. Refer to manufacturer recommendations as needed. The facility provided a piece of copy paper (untitled and undated) which was a manipulated copy of pages labeled 2, 3, 14, and 15. The provided page 2 was a picture of liquid oxygen portable tanks. Page 3 was a list of hazards and safety measures related to the use of oxygen concentrators (room air concentrators) and not related to the liquid oxygen portable tanks. Page 14 was related to care of the tubing associated with oxygen administration (cannulas). Page 15 was blank except for a handwritten manufacture (sic, manufacturer) reccommendations (sic, recommendations) for safety. The safety measures for room air concentrators listed on the page 3 did include statements such as, Keep all flammable materials away from your oxygen. Do not use your oxygen around space heaters (glowing orange electrical coils). It takes 15 minutes for oxygen to leave your clothing, hair, and skin once you take off your oxygen. Be careful around anything that produces a spark such as a hair dryer or electric razor. On 3/6/24 at 11:05 AM, V11, Life Safety Architect, confirmed, Oxygen in a beauty shop is a no-no. First you have pure oxygen along with flammable materials like hair spray, then a blow dryer is an ignition source. Upon request, V1, Administrator, provided the (Oxygen Supply Company) complete manufacturer education pamphlet dated 2/2021. This education pamphlet included additional cautionary statements such as, Keep the liquid oxygen tank at least 5 feet away from electrical appliances. Keep the liquid oxygen away from any flammable material.

Based on observation, interview, and record review, the facility failed to provide complete perineal care for one resident (R8) of one resident reviewed for perineal care in the sample list of 33. Findings include: R8's undated Face Sheet documents R8's diagnosis as: Chronic Kidney Disease, Stage 2. R8's Care Plan dated 2/15/24, documents R8 is incontinent of bowel and bladder, clean perineal area with each incontinent episode. On 3/7/24 at 11:00 AM, V18 Certified Nursing Assistant (CNA) provided perineal care to R8. During this care, V18 wiped R8's outer labia and failed to spread the labia to wipe the inner labia. At this same time, V18 cleansed R8 buttocks but failed to clean R8's anal area. On 3/7/24 at 11:20 AM, V2 Director of Nursing (DON) stated V18 should be following the perineal care policy. The facility's Perineal Care policy dated Revised 12/22, documents cleanse the outer skin folds, open all skin folds, cleanse from front to back, cleanse the anal area.

Based on observation, interview, and record review, the facility failed to obtain and implement physician orders for Continuous Positive Airway Pressure (CPAP) machine settings and cleaning schedules and failed to properly store Nebulizer tubing. These failures have the potential to affect three residents (R12, R17, R21) out of three reviewed for respiratory care on a sample list of 33. Findings include: 1. On 3/5/24 at 10:06 AM, there was a CPAP machine in R12's room next to R12's bed. On 3/5/24 at 10:20 AM, R12's Care plan focus area initiated 7/15/22 documents (R12) has OSA (Obstructive Sleep Apnea) and utilizes a CPAP machine. This Care Plan focus area documents nursing interventions for the CPAP machine include, Clean CPAP per orders. R12's medical record including R12's Physician Order Sheet, Treatment Administration Record, and Care Plan, did not contain any specific orders for pressure settings to be utilized for the CPAP machine during use, nor a cleaning schedule for R12's CPAP. On 3/5/24 at 12:54 PM, R12's Physician Order Sheet was revised to include a physician order for CPAP- use during sleep hours, place CPAP at HS (hour of sleep), remove in the morning. There was not a physician order for CPAP cleaning schedule, nor for pressure settings to be utilized during the CPAP operation. On 3/5/24 at 1:14 PM, R12's Physician Order Sheet was revised to include a physician order for CPAP- use during sleep hours, place CPAP at HS, remove in the morning and in the morning for remove. There was not a physician order for CPAP cleaning schedule, nor for pressure settings to be utilized during CPAP operation. On 3/6/24 at 11:58 AM, R12's Physician Orders were revised to include a physician order for Dream Station CPAP set to a pressure of 14- use during sleep hours, place CPAP at HS, remove in the morning and in the morning for remove. There was not a physician order for CPAP cleaning schedule, nor for the low end of the pressure settings to be utilized for CPAP operation. On 3/6/24 at 12:03 PM, R12's Physician Order Sheet was revised to include a physician order for Dream Station CPAP set to a pressure of 8 - 14- use during sleep hours, place CPAP at HS, remove in the morning and in the morning for remove. There was not a physician order for CPAP cleaning schedule. On 3/6/24 at 1:29 PM, R12's Physician Order Sheet was revised to include a physician order for CPAP cleaning to be conducted every Sunday night and as needed. On 3/7/24 at 1:09 PM, R12's CPAP tubing was stretched out across the floor beside R12's bed. The tubing on the floor was the portion of tubing that was designed to connect to R12's face mask. At that time, R12's face mask was stored in a plastic bag on the window sill. V20, Registered Nurse, stated, The tubing should not be on the floor. V20 further stated, (R12) can not take care of her own CPAP and tubing. 35380 2. R17's undated Face Sheet, documents R17's diagnoses as Shortness of Breath, Insomnia due to medical condition, Chronic Obstructive Pulmonary Disease (COPD), moderate, persistent Asthma, and Snoring. R17's Medication Administration Record (MAR) dated 3-1-24 - 3-31-24, documents Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (mg)/3 Milliliters (ml) (Ipratropium-Albuterol) 3 ml inhale orally every 6 hours related to COPD. R17's Treatment Administration Record (TAR) dated 3-1-24 - 3-31-24, documents Continuous Positive Airway Pressure (CPAP) Pressure: 4-20 pressure centimeters (cm) water autosense 11 or 10 pap with oxygen bled into CPAP if needed in the evening related to COPD, place CPAP at night, remove in the morning. R17's Care Plan dated 1/11/24, documents utilize a CPAP machine secondary to COPD, Asthma, Alveolar / Parieto-Alveolar Conditions. On 03/05/24 at 10:06 AM, R17's nebulizer tubing was observed on the floor. R17's Continuous Positive Airway Pressure (CPAP) was observed on the dresser by the bed, not in plastic bag. On 3/5/24 at 3:45 PM, R17 stated R17 has used a nebulizer and CPAP for about a year and a half. On 03/06/24 at 10:29 AM, R17's nebulizer face mask and tubing observed not in a bag, out in the open on the nebulizer machine. 41970 3. R21's undated Face Sheet documents an admitted [DATE]. R21's undated medical diagnoses list documents medical diagnoses of Alveolar and Parieto-Alveolar Conditions, Morbid Obesity, Portal Hypertension, Cardiomegaly, Obstructive Sleep Apnea, Lack of Coordination, Carpal Tunnel Syndrome, Essential Tremor and Weakness. R21's Minimum Data Set (MDS) dated [DATE] documents R21 as cognitively intact. R21's Physician Order Sheet (POS) dated March 2024 documents a physician order starting 3/5/24 for R21 to wear Continuous Positive Airway Pressure (CPAP) every night and remove every morning. This same POS does not document any orders for R21's use of the CPAP prior to 3/5/24. This same POS does not document Physician orders to clean R21's CPAP machine as per manufacturer guidelines. On 3/5/24 at 11:20 AM R21's CPAP machine was setting on top of the bedside dresser with tubing extending down the front of the dresser and CPAP mask attached to end of the tubing was placed in the top drawer of R21's bedside dresser with other personal items. R21's CPAP machine water reservoir contained water and had visible debris on the inside wall of the water reservoir. R21's CPAP tubing was not contained in a plastic bag. On 3/5/24 at 11:22 AM R21 stated I admitted here (facility) over a year and a half ago with the CPAP. I have used it every night since I admitted . The mask has been cleaned two times since I admitted . The machine has never been cleaned. The staff here do a pretty good job. I don't want to complain but that air from the CPAP goes directly into my lungs. On 3/6/24 at 8:35 AM V10 Infection Preventionist (IP) stated all of the devices that residents use should be cleaned regularly. V10 IP stated R21's Continuous Positive Airway Pressure (CPAP) machine should be cleaned by the manufacturer guidelines. V10 stated R21's orders for administering the CPAP were entered on 3/5/24. V10 IP stated (R21) admitted to the facility with his own CPAP machine a year or so ago. (R21) should have had orders entered as soon as he admitted . The CPAP machines have reservoirs that hold the water and that can be a source for bacterial growth. If (R21's) CPAP machine has not been cleaned that that could definitely present a health risk for (R21). On 3/6/24 at 10:00 AM V2 Director of Nurses (DON) stated every resident that utilizes Oxygen or Continuous Positive Airway Pressure (CPAP) should have orders in place to instruct nursing staff on the resident usage. V2 DON stated the orders should include the specific settings for each resident and the cleaning of the mask and the CPAP machines. V2 DON stated resident orders for their CPAP's were not entered for the use of the CPAP nor for the cleaning of the machine. V2 DON stated I am working on cleaning up all the Oxygen and CPAP orders today. All residents receiving Oxygen or use a CPAP will have their orders reviewed and adjusted for accuracy today. The facility provided Continuous Positive Airway Pressure (CPAP) machine undated manufacturer guidelines documents Cleaning: Daily-Empty the humidifier tub and wipe it thoroughly with a clean disposable cloth. Allow it to dry out of direct sunlight. Refill the standard humidifier with distilled water only or the cleanable water tub with potable drinking quality water. Weekly-Wash the components as described: air tubing-in warm water using a mild dishwashing liquid. humidifier tub-in warm water using a mild dishwashing liquid OR in a solution with a ration of one part vinegar and nine parts water at room temperature. Outlet connector-in warm water using a mild dishwashing liquid OR in a solution with a ration of one part vinegar and nine parts water at room temperature. Components should not be washed in temperatures higher than 131 degrees Fahrenheit (F). Rinse each component thoroughly in water. Allow to dry out of direct sunlight or heat. Wipe the exterior of the device with a dry cloth. The facility policy titled 'Oxygen Administration Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure (BIPAP)' revised 8/2018 documents all orders for CPAP and/or BIPAP must be ordered by the Physician. All orders include the following: Type of unit (CPAP or BIPAP), Pressure settings, Oxygen order (if applicable), deliver device and size (mask, nasal prongs), frequency of therapy (continuous, at bedtime) and need for humidifier. When using a mask, advice resident not to eat two to three hours prior to using unit. The facility's Nebulizer Therapy policy dated Revised 9/2018, documents store in plastic bag when not in use.

Based on observation, interview, and record review, the facility failed to ensure safety of a resident by failing to ensure R1 was assessed for independent safe handling of extremely hot liquids. This resulted in R1 sustaining 2nd degree burns to R1's left thigh. The facility also failed to implement an intervention for an adaptive cup for one (R1) of three residents reviewed for accidents in the sample list of three. Findings include: R1's Minimum Data Set, dated dated dated [DATE] documents R1 has Dementia with moderate cognitive impairment and requires setup and supervision assistance for eating. R1's Care Plan dated 8/14/23 documents (R1) has a skin burn of the left lateral thigh/groin r/t (related to) burn from hot coffee spilled at dinner. This care plan includes an intervention to use a spill proof cup for hot liquids during meals. R1's Skin Report dated 8/13/23 at 4:30 PM recorded by V11 (Licensed Practical Nurse/LPN) documents a Certified Nursing Assistant (CNA) alerted V11 that R1 had a skin concern to the left outer thigh and R1 stated R1 had spilled coffee on R1's self during dinner. This report documents the area was assessed and describes the wound as a burn on the left hip, but there is no description of the wound or measurements of this burn until 8/14/23. The interdisciplinary team (IDT) note dated 8/14/23 documents the root cause of R1's burn was determined to be R1 spilled hot coffee on R1's lap during dinner and the new intervention was for R1 to use a spill proof container for hot liquids during meals. R1's Skin assessment dated [DATE] at 5:00 PM documents a 6 (centimeter) by 6 by 0.1 new open area to the left hip. V18 (Certified Nursing Assistant/CNA) written statement dated 8/14/23 documents at 4:30 PM (on 8/13/23) a dietary staff member reported that R1 had spilled coffee and R1's pants may be wet. V18's statement documents V18 went to the dining room and did not notice R1's pants to be soiled. There is no documentation that R1's pants were changed or that R1's skin was immediately assessed for injury. V13 (Certified Nursing Assistant/CNA) written statement dated 8/13/23 documents at 10:30 PM V13 was assisting R1 with toileting and noticed what appeared to be a burn to R1's left thigh. V13 reported this to the nurse. V8 (LPN) written statement dated 8/13/23 documents at 10:30 PM V8 was notified that R1 had a wound to R1's left upper thigh/groin, and R1's wound appeared to be a scald burn. R1 reported that R1 had spilled coffee on herself. V11's Written Statement, dated 8/13/23, documents at 11:03 PM V8 reported that R1 had blistered, red areas to R1's left upper thigh and groin area. R1's medical record does not document R1 was assessed to determine R1's ability to safely handle hot liquids prior to R1's incident. The 8/13/23 Evening Meal Food Temperature Log documents the coffee temperature was 170 degrees Fahrenheit. On 8/15/23 at 9:25 AM, V21 (Certified Nursing Assistant/CNA) written transferred R1 onto the toilet and there was a large, reddened area with peeling skin to R1's left upper thigh. V21 stated V21 was told by V2 (Director of Nursing/DON) that R1 burned herself with coffee. V21 stated R1 usually feeds herself and requires only setup assistance. V21 stated R1 has spilled drinks when R1 is really tired. On 8/15/23 at 10:53 AM, V7 (Registered Nurse/RN) administered R1's left thigh wound treatment. There was a large reddened, raised area from R1's outer thigh that extended across the thigh and down to R1's groin. The center of the wound contained a large, circular, open, moist, shallow wound that contained white, red, and pink tissue. R1 asked V7 what did I (R1) do there. V7 (RN) told R1 that R1 had spilled coffee there. On 8/15/23 at 11:11 AM, R1 was sitting in the dining room. V21 (CNA) poured R1 coffee that was served in a ceramic coffee mug that did not contain a lid. There was no staff sitting with R1 providing assistance. At 11:15 AM, V23 (Dietary Aide) poured R1's coffee out of the mug and into an adaptive cup with a sipper lid. At 11:24 AM, V21 stated staff were given education following R1's coffee burn, but it did not say anything specific other than dietary is supposed to check the coffee temperature prior to serving. V21 stated R1 does not use any specialized or adaptive cups and V21 was unsure what interventions were implemented to prevent R1's burn injury from reoccurring. V21 stated V21 had added ice to R1's coffee today prior to serving. On 8/15/23 at 11:36 AM, V18 (CNA) stated on 8/13/23 around 4:30 PM, V22 (Dietary Aide) told V18 that R1 spilled coffee on R1's pants. V18 stated V18 went to the dining room and R1 was sitting at the table eating, V18 didn't think anything of it at the time, because V18 thought R1's coffee spilled onto the table and then onto R1's pants. V18 did not think about the coffee burning R1. V18 did not physically check R1's pants nor report the coffee spill to a nurse. V18 stated V18 did not provide any care for R1 that evening. V18 stated R1 does not need assistance with eating, staff just need to keep an eye on R1. On 8/15/23 at 11:42 AM, V9 (Certified Nursing Assistant/CNA) written stated R1 feeds herself, requires cues, and sometimes R1 places R1's coffee mug between her legs while wandering the facility in R1's wheelchair. V9 stated sometimes R1 would spill coffee while wandering. On 8/15/23 at 12:18 PM, V3 RN stated R1 feeds herself, but occasionally spills food onto her clothes. On 8/15/23 at 1:22 PM V10 CNA stated R1 spills liquids all the time and R1 does not use any type of special cups. On 8/15/23 at 12:39 PM, V22 (Dietary Aide) stated on 8/13/23 around 4:30 PM/5:00 PM V22 saw that R1 had spilled coffee on R1's lap and V22 reported this to a CNA. V22 stated R1's coffee is always served in a standard coffee mug and R1 does not use any type of specialized cups. V22 stated V22 did not realize the coffee was hot enough to burn R1 and was unsure what the temperature of the coffee was that evening and that they generally start serving coffee around 4:00 PM. V22 stated we now have to check the temperature of the coffee when the first cup is poured and record it on the log. V22 was unsure of any other interventions implemented after R1's incident. On 8/15/23 at 2:27 PM, V8 (LPN) stated V8 came on duty at 6:00 PM on 8/13/23 and around 10:30 PM V9 (CNA) reported R1's wound. V8 stated R1 had what appeared to be a splash burn on R1's left thigh that extended to R1's groin, and the top part had broken skin where the initial contact was made. V8 stated the burn appeared to be a 2nd degree, that was red and blistered. V8 confirmed R1 has spilled liquids previously and stated it was related to R1's age and shaky hands. V8 stated we should either monitor residents while they are drinking coffee or add ice cubes to the coffee. On 8/15/23 at 12:31 PM, V11 (LPN) stated V11 worked 6:00 PM to 6:00 AM on 8/13/23 and at 11:00 PM V8 (LPN) reported that R1 had an apparent burn with blisters to R1's left upper thigh. V11 stated R1 reported that R1 had spilled coffee at breakfast, but R1's time perception is not always accurate. V11 stated R1's left thigh wound was red with small, raised blisters and one open circular wound. V11 stated none of the staff on evening shift were aware that R1 had spilled coffee on herself earlier that day until the wound was identified. On 8/15/23 at 12:24 PM, V19 (Social Services Director/Former Dietary Manager) stated V19 was the Dietary Manager for 4 years up until a few weeks ago. V19 stated prior to R1's incident the facility had been checking the coffee temperatures when dispensed from the machine and from the carafe when taken to the dining room, and now we are checking the temperature when the first cup is poured from the carafe. The coffee temperature dispensed from the machine was 180 degrees Fahrenheit (F) and the temperature from the carafe was between 160-170 degrees F. V19 stated on 8/14/23 R1 was provided a spill proof cup to use during meals. V19 stated V19 was not aware if the facility has a policy regarding assessing residents for safe handling of hot liquids. V19 stated if residents are noted to have safety concerns it is brought up in the interdisciplinary team meetings, the resident is then assessed to determine if safety interventions are needed. V19 denied that R1 had a history of spilling food/liquids prior to R1's incident. On 8/15/23 at 12:00 PM, V2 (DON) stated V2 is unsure if the facility has a policy regarding the provision of hot liquids and assessing residents for safe handling of hot liquids. V2 stated nursing does not conduct any kind of assessment for that, but maybe dietary does. At 1:35 PM, V2 stated V11 (LPN) reported on the evening of 8/13/23 that R1 had what appeared to be a burn wound to the left thigh/groin area, and R1's incident happened at supper. V2 stated V2 was informed that staff had witnessed R1 spill coffee at dinner, and confirmed this was the cause of R2's burn. V2 stated the incident was reviewed with IDT and we implemented for R1's hot liquids to be in a spill resistant cup. On 8/15/23 at 1:05 PM, V1 (Administrator) stated we prefer the coffee from the dispensary machine to temp between 180-190 F. V1 stated there is no routine assessment done to assess residents for ability to safely handle hot liquids, it is just done on an as needed basis when concerns have brought them to IDT. V1 stated there had been no prior reported concerns that R1 has spilled hot liquids and R1 has not had any burns previously. On 8/16/23 at 2:37 PM, V6 (Physician) stated V6 was notified that R1 had a burn on 8/13/23 caused from a coffee spill. V6 stated a burn like that could happen instantly and the damage would have happened within the first few seconds to minutes of the spill. V6 stated V6 thought the facility did ongoing assessments of resident's spill risk. V6 stated it hadn't been reported to V6 that R1 had a history of spilling food/liquids, and if R1 had repeated spilling V6 may have recommended the use of lids or keeping the coffee temperature below a certain range. The facility's Food Safety: Preventing Burns policy dated 2017 documents the following: Hot food and beverages will be served at a safe temperature that prevents burns. Hot beverages will be served at 160 (degrees Fahrenheit) F to 185 (degrees) F, the optimum temperature for patient satisfaction. Hot beverages will be handled carefully during food delivery and meal set-up in an attempt to avoid spills that could cause burns. Appropriate supervision to obtain hot beverages and/or reheat foods in a microwave will be provided to any individual demonstrating decreased safety awareness and/or anyone who is at risk for burns or scalds based on clinical assessments. Lap trays, slip guards, or cup holders on wheelchairs may be used to help hot liquids remain upright. This policy includes a chart that documents the following estimated time to receive a 2nd degree and 3rd degree burns based on water temperature: less than 1 second for 2nd degree and 1 second for 3rd degree for 150 degrees, 3 seconds for 2nd degree and 5 seconds for 3rd degree at 140 degrees, 17 seconds for 2nd degree and 30 seconds for 3rd degree at 131 degrees, 2 minutes for 2nd degree and 4.2 minutes for 3rd degree at 124 degrees, and 8 minutes for 2nd degree and 10 minutes for 3rd degree at 120 degrees.

Based on observation, interview, and record review, the facility failed to timely assess a resident for injury following a coffee spill, document an initial wound assessment, and ensure a wound was covered with a protective dressing for one resident (R1) of three residents reviewed for accidents in the sample list of three. Findings include: R1's Minimum Data Set, dated dated dated [DATE] documents R1 has Dementia with moderate cognitive impairment. R1's Care Plan dated with an initiated date of 8/14/23 documents (R1) has a skin burn of the left lateral thigh/groin r/t (related to) burn from hot coffee spilled at dinner. V18 (Certified Nursing Assistant/CNA) written Statement dated 8/14/23 documents at 4:30 PM (on 8/13/23) a dietary staff member reported that R1 had spilled coffee and R1's pants may be wet. V18's statement documents V18 went to the dining room and did not notice R1's pants to be soiled. There is no documentation that R1's pants were changed or that R1's skin was immediately assessed for injury or that V18 reported this incident to a nurse. V13 (Certified Nursing Assistant/CNA) Written Statement dated 8/13/23 documents at 10:30 PM V13 was assisting R1 with toileting and noticed what appeared to be a burn to R1's left thigh. V13 reported this to the nurse. V8 LPN Written Statement dated 8/13/23 documents at 10:30 PM V8 was notified that R1 had a wound to R1's left upper thigh/groin, and R1's wound appeared to be a scald burn. R1 reported that R1 had spilled coffee on herself. V11's Written Statement dated 8/13/23 documents at 11:03 PM V8 reported that R1 had blistered, red areas to R1's left upper thigh and groin area. The 8/13/23 Evening Meal Food Temperature Log documents the coffee temperature was 170 degrees Fahrenheit. R1's Skin Report dated 8/13/23 at 4:30 PM recorded by V11 (Licensed Practical Nurse/LPN) documents a CNA alerted V11 that R1 had a skin concern to the left outer thigh and R1 stated that R1 had spilled coffee on R1's self during dinner. This report documents the area was assessed and describes the wound as a burn on the left hip, but there is no description of the wound or measurements of this burn until 8/14/23. There is no documentation in R1's medical record that R1 spilled coffee on R1's self during the evening meal on 8/13/23, that R1's clothes were changed, or that R1 was immediately assessed for injury following the incident. The interdisciplinary team (IDT) note dated 8/14/23 documents the root cause of R1's burn was determined to be that R1 spilled hot coffee on R1's lap during dinner. R1's Skin assessment dated [DATE] at 5:00 PM documents a 6 (centimeter) by 6 by 0.1 new open area to the left hip. R1's August 2023 Treatment Administration Record documents a treatment to apply a petroleum-based gauze and cover with an abdominal pad secured with tape, changed daily, to R1's left upper thigh/groin wound initiated on 8/14/23. On 8/15/23 at 9:25 AM, V21 (Certified Nursing Assistant/CNA) transferred R1 onto the toilet and there was a large, reddened area with peeling skin to R1's left upper thigh/groin. R1's wound was partially covered with a petroleum-based gauze but was not covered with a protective outer dressing. V21 stated R1's wound dressing has been like that since earlier this morning, and V21 had reported it to the nurse who said it would be changed after breakfast. On 8/15/23 at 10:53 AM, V7 (Registered Nurse/RN) administered R1's left thigh wound treatment. There was a large, reddened area from R1's outer thigh that extended across the thigh and down to R1's groin. The center of the wound contained an open, moist, shallow, circular wound that contained white, red, and pink tissue. There was a petroleum-based gauze on the wound, but it was not covered with an abdominal pad. V7 cleansed the wound, applied petroleum-based gauze, covered with an abdominal pad, and secured with tape. V7 confirmed R1's wound should be covered with an abdominal pad. At 11:05 AM, V7 stated no one had reported that R1's dressing was dislodged. On 8/15/23 at 11:36 AM, V18 (CNA) stated on 8/13/23 around 4:30 PM, V22 (Dietary Aide) told V18 that R1 spilled coffee on R1's pants. V18 stated V18 went to the dining room and R1 was sitting at the table eating, V18 didn't think anything of it at the time because V18 thought R1's coffee spilled onto the table and then onto R1's pants. V18 did not think about the coffee burning R1. V18 stated R1 did not appear to be in any pain/discomfort, and V18 did not physically check R1's pants nor report the coffee spill to a nurse. V18 stated V18 did not provide any care for R1 that evening and looking back, V18 should have reported the coffee spill to a nurse. On 8/15/23 at 12:38 PM, V3 (RN) stated V3 worked on 8/13/23 from 6:00 AM until 6:00 PM and was R1's nurse. V3 stated nothing was reported during V3's shift that R1 had spilled coffee or that R1 had any sign of injury to R1's thigh. On 8/15/23 at 12:39 PM, V22 (Dietary Aide) stated on 8/13/23 around 4:30 PM/5:00 PM, V22 saw that R1 had spilled coffee on R1's lap/groin and V22 reported this to a CNA. V22 stated V22 did not realize the coffee was hot enough to burn R1 and was unsure what the temperature of the coffee was that evening. On 8/15/23 at 2:27 PM, V8 (LPN) stated V8 came on duty at 6:00 PM on 8/13/23 and around 10:30 PM V9 (CNA) reported R1's wound. V8 stated R1 had what appeared to be a splash burn on R1's left thigh that extended to R1's groin, and the top part had broken skin where the initial contact was made. V8 stated the burn appeared to be a 2nd degree, that was red and blistered. V8 stated R1's coffee spill was not reported prior to that night. On 8/15/23 at 12:31 PM, V11 (LPN) stated V11 worked 6:00 PM to 6:00 AM on 8/13/23 and at 11:00 PM V8 LPN reported that R1 had an apparent burn with blisters to R1's left upper thigh. V11 stated R1 reported that R1 had spilled coffee at breakfast, but R1's time perception is not always accurate. V11 stated R1's left thigh wound was red with small, raised blisters and one open circular wound. V11 stated V11 did not document V11's assessment of R1's burn/wound. V11 stated none of the staff on evening shift were aware that R1 had spilled coffee on herself earlier that day until the wound was identified. On 8/15/23 at 1:22 PM, V10 (CNA) stated V10 was assigned to R1's care on 2nd shift on 8/13/23. V10 stated no one had reported that R1 had spilled coffee that evening and V10 was not aware that R1 had a skin injury to the left thigh. V10 stated V10 had toileted R1 prior to supper and did not provide any care for her until R1 was checked for incontinence around 9:00 PM/9:30 PM and R1 was dry. V10 stated V10 rolled R1 over in bed to check the back of R1's incontinence brief. V10 confirmed V10 did not observe R1's groin or thighs when V10 checked R1 for incontinence. On 8/15/23 at 1:35 PM, V2 (Director of Nursing/DON) stated V11 (LPN) reported on the evening of 8/13/23 that R1 had what appeared to be a burn wound to the left thigh/groin area, and R1's incident happened at supper. V2 stated V2 was informed that staff had witnessed R1 spill coffee at dinner, and confirmed this was the cause of R2's burn. V2 stated the facility is currently educated staff that when a coffee spill occurs, they should notify a nurse or CNA so that the clothing can promptly be removed, and the area assessed for injury. V2 stated an investigation should be initiated and the physician and family notified of the incident. V2 confirmed that staff should have assessed R1's skin at the time of the coffee spill. V2 confirmed that when hot liquids are left in contact with skin it can potentially worsen the burn. V2 stated staff should notify the nurse when a dressing is dislodged so that the dressing can be replaced. At 2:50 PM, V2 confirmed there is no documented assessment of R1's burn until 8/14/23. V2 stated V2 had instructed the nurses to do a general assessment of the wound, and that should had been documented in an assessment or progress note. The facility's Treatment Administration policy dated April 2023 documents to administer treatments as ordered, record treatments on the Treatment Administration Record, and record significant observations in the electronic medical record. The facility's Accidents & Incidents policy dated as revised March 2021 documents employees who witness an incident or accident must report the incident to their supervisor as soon as practical. This policy documents to notify the charge nurse, examine the resident, provide medical attention, report the incident/accident to the resident's physician, and document follow up assessments on the accident/incident form. The facility's Food Safety: Preventing Burns policy dated 2017 documents hot liquids will be served between 160 and 185 degrees Fahrenheit and will be served at safe temperatures in order to prevent burns. This policy includes a chart that documents the following estimated time to receive a 2nd degree and 3rd degree burns based on water temperature: less than 1 second for 2nd degree and 1 second for 3rd degree for 150 degrees, 3 seconds for 2nd degree and 5 seconds for 3rd degree at 140 degrees, 17 seconds for 2nd degree and 30 seconds for 3rd degree at 131 degrees, 2 minutes for 2nd degree and 4.2 minutes for 3rd degree at 124 degrees, and 8 minutes for 2nd degree and 10 minutes for 3rd degree at 120 degrees. The facility's Burns Clinical Guidelines dated 4/2023 documents all burns and scalds are investigated to prevent reoccurrence and treated to provide comfort and prevent infection. Further documents nursing staff should do the following: Remove resident from danger if it is present and remove or cut away clothing that has been soaked in a chemical or boiling fluid. If clothing is stuck, do not force. Assess resident and induration of burn. a. Extreme pain at the site of injury (deep burns may be less painful due to damage of the nerve endings) b. Swelling that develops rapidly in the burned area c. Redness around the burn d. small fluid filled blisters under the top layer of skin. If possible, hold the burned part under cold running water for 10 - 20 minutes. Protect the area with a sterile dressing large enough to cover burned area completely. Never use wool or an adhesive dressing. Notify the physician or nurse practitioner for treatment orders or transfer to the hospital if necessary. Notify the resident representative. Document in the progress notes and complete an incident report in Risk Management Notify the DON and Wound Care Nurse of the incident.

Based on observation, interview, and record review, the facility failed to implement a post fall intervention for one of three residents (R1) reviewed for falls on the sample list of three. Findings Include: R1's Fall Report dated 6/11/23 documents R1 was being pushed into R1's room to be laid down by V6 (Registered Nurse/RN) when R1 started to fall forward and fell from R1's wheelchair. The root cause of this fall was R1 is noted to have weakness and fatigue while sitting in the wheelchair while at the nurses' station, and during transportation, fell forward out of the chair. New intervention: hospice was contacted and a request for a high back, adjustable wheelchair was placed with the hospice nurse. On 6/20/23 at 11:22 am, V4 (RN/Nurse Manager) stated hospice is supposed to be getting R1 a reclining/high back wheelchair but that hasn't happened yet. V4 explained the hospice warehouse burnt down and they are having problems getting supplies. V4 stated R1 is currently in the same wheelchair that R1 has been in. On 6/20/23 at 11:27 am and 12:50 pm, R1 was observed sitting up in a regular wheelchair, not a high back/adjustable wheelchair. On 6/20/23 at 1:10 pm, V1 (Administrator) stated that R1 had been right outside of R1's room and was leaning forward, so V6 (RN) properly positioned R1 in R1's wheelchair and was taking R1 inside R1's room to lay R1 down when R1 quickly put R1's feet down and then fell forward. On 6/20/23 at 1:26 pm, V1 confirmed R1's post fall intervention for the 6/11/23 fall was a high back/adjustable wheelchair but explained the new wheelchair just got delivered today {9 days later} and stated, R1 should be in it now. On 6/20/23 at 1:29 pm, R1 was sitting up in a regular wheelchair in R1's room. The facility Accidents and Incidents Policy dated March 2021 documents after a fall, the charge nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions.

Based on observation, interview and record review, the facility failed to: maintain residents respiratory equipment in clean and sanitary condition, follow the facility oxygen policy to obtain physician orders for oxygen administration, monitor blood oxygen saturation (SATS) level as ordered by the physician, provide physician ordered oxygen tubing bags to keep excess tubing off the floor, fill and/or replace oxygen humidifiers and nasal cannula, record the date and initial the oxygen tubing and humidifier bottles, and failed to obtain a physician order for care of a resident's positive airway pressure device (CPAP). These failures affected seven of seven residents (R3, R4, R12, R21, R39, R60, R67) reviewed for respiratory treatment on the sample list of 33. Findings include: 1. R3's Medical Diagnosis sheet updated 3/29/23 documents the following diagnoses: CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED, SHORTNESS OF BREATH, History ATELECTASIS (collapsed lung). R3's Minimum Data Set (MDS) documents dated 4/03/23 documents R3's Brief Interview of Mental Status (BIMS) score of nine out of a possible 15, indicating moderate cognitive impairment at the time of the assessment. R3's Physician Order Sheet (POS) 4/12/23 documents: O2 (oxygen) AT 2-5L/MIN (liters per minute) PER N/C (nasal cannula), TO KEEP SATS (>) greater 90% (percent), as needed for Shortness of Breath. Oxygen per NC 2-5L as needed to keep o2 Sat>90%. AND every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED Active 4/4/2023. R3's same POS documents the following: Change 02 humidifier 500cc and 02 tubing every Sunday, no directions specified for order. and O2 TUBING/NEB EQUIPMENT CHANGE, no directions specified for order. On 4/12/23 at 10:24 am, R3 was seated in R3's wheelchair bedside. On the opposite side of the bed, R3's oxygen tubing was coiled under R3's oxygen concentrator. The refillable oxygen humidifier bottle and tubing were undated. R3 stated, It is always on the floor like that, and I do not know if anybody ever changes it. On 4/12/23 at 10:28 am, V10 (Registered Nurse/RN) observed R3's oxygen equipment and stated There is no date on anything, and the tubing (oxygen) should not be on the floor. I will be getting plastic bags for storing them, like they are supposed to be. R3's 4/1/23- 4/30/23 Medication Administration and Treatment Administration record does not document R3's blood oxygen saturation level or oxygen equipment changes. 2. R4's Physician Order Sheet (POS) dated 4/1/23- 4/30/23 documents the following: Contact Isolation form Metapneumovirus (Upper Respiratory infection) through 4/14/23. The same POS does not document an order for oxygen administration. R4's Diagnoses Sheet updated 4/11/23 documents the following: Acute Upper Respiratory Infection, Unspecified, and Other Alveolar and Parieto-Alveolar Conditions. R4's Medication Administration Record and Treatment Administration Record dated 4/1/23- 4/30/23 does not document O2 administration or equipment change. On 04/12/23 at 10:52 am, R4 was lying in bed. R4 had oxygen administration through a nasal cannula at two liters. R4's oxygen tubing and oxygen pre-filled humidifier bottle were dated of 4/3/23. V10 (RN) confirmed observation and stated R4's oxygen tubing and humidifier bottle were not changed either. I see there is a theme here. I will get these (oxygen issues) taken care of. 3. R12's Medical Diagnoses sheet updated 2/27/23 documents the following diagnoses: Covid-19 Pulmonary 2/27/2023, Shortness of Breath, and Other Alveolar and Parieto-Alveolar Conditions. R12's Physician Order Sheet dated 4/1/23-4/30/23 documents the following: O2 tubing equipment change: Date and initial tubing. Place tubing in plastic bag at bedside when not in use. On 04/12/23 at 10:32 am, R12 was seated in her wheelchair. R12's oxygen/nasal cannula tubing was attached to a portable oxygen tank. R12's oxygen/nasal cannula tubing was dated 4/3/23. V10 (RN) confirmed the observation and stated R12's tubing (oxygen/nasal cannula) should have been changed on 4/10/23. 4. R21's Medical Diagnoses Sheet updated 7/27/22 documents the following diagnoses: Other Alveolar and Parieto-Alveolar Conditions. R21's Physician Order Sheet 4/12/23 does not document an order for oxygen administration until after observation documented below. R21's Minimum Data Set, dated dated dated [DATE] document R21's Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment. On 04/12/23 at 10:50 am, R21 was lying in bed. Oxygen was being administration per nasal cannula at two liters per minute. There were no date or initials on refillable humidifier bottle or oxygen tubing. R21 stated I am not sure of the date the last time it was changed, maybe a week ago. V10 (RN) confirmed the observation that R21's oxygen tubing and humidifier bottle were not dated. V10 stated, R21's oxygen tubing and humidifier bottle should have been changed and dated Sunday. 5. R39's Diagnoses Sheet dated 12/29/22 documents the following diagnoses: Centrilobular Emphysema, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Respiratory Failure with Hypoxia, Personal History of Other Diseases of the Respiratory System, Pleural Effusion, Not Elsewhere Classified, Abnormal Pulmonary Function Studies, Shortness of Breath, Other Nonspecific Abnormal Findings in Lung Field, and Dyspnea. R39's Physician Order Sheet (POS) dated 3/17/23 documents the following: Hospice provider RN (Registered Nurse) or HHA (Home Health Aide) visit per hospice schedule. The same POS documents the following: Oxygen: May use two to four liters (per minute) to maintain blood oxygen saturation above 93 percent. If more than three liters needed, notify physician. Oxygen (administer) at three liters per nasal cannula continuous. The same POS documents: Change 02 humidifier 500 cc (cubic centimeter capacity) and 02 tubing every Sunday. No directions specified for order. The same POS documents: O2 tubing /neb (nebulizer) equipment change tubing and neb weekly, and prn (as needed). R39's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 4/1/23- 4/12/23 does not document that R39's O2 tubing or refillable humidifier have been changed this month. The same MAR and TAR do not document R39's blood oxygen level was measured in April 2023. On 4/11/23 at 10:30 am, R39 was lying in bed. Oxygen concentrator running at three liters per minute via nasal cannula. Tubing was appropriately labeled as changed 4/10/23 (not documented on MAR or TAR). R39's oxygen concentrator humidifier bottle was completely empty and undated. R39's oxygen tubing was coiled on the floor between R39's bed and oxygen concentrator. R39 stated, I asked them (unidentified) to fill the humidifier bottle this morning. They are aware it is dry. On 04/12/23 10:10 am R39 was lying in bed. R39's oxygen concentrator refillable humidifier bottle remained completely empty and undated. R39's oxygen tubing continued coiled between the bed and the bedside oxygen concentrator. R39 stated, I still haven't gotten the new bottle of water on my oxygen. I asked yesterday, they did nothing. My nose is very dry and irritated. On 04/12/23 at 10:15 am, V10 (RN) stated, R39's humidifier bottle should have been changed and dated. He is on 3-4 litters and requires his humidifier bottle to be filled more frequently than most. The O2 (oxygen) tubing should never be on the floor. 6. R60's Physician Order Sheet dated 4/12/23 does not document an order to administer oxygen. R60's Medical Diagnoses Sheet dated 2/27/23 documents the following diagnoses: Other Alveolar and Parieto-Alveolar Condition and COVID-19 Pulmonary. R60's Minimum Data Set, dated dated dated [DATE] documents R60's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment. On 4/12/23 at 10:47 am, R60 was lying in bed with oxygen concentrator administering oxygen at two liters per minute via a nasal cannula. R60's oxygen tubing and empty refillable humidifier bottle were both dated 4/3/23. V10 (RN) confirmed R60's oxygen tubing and empty humidifier bottle were both dated 4/3/23. V10 stated, R60's tubing should have been changed 4/10/23. R60's humidifier bottle should be changed at the same time, or more frequently. It should never run completely dry. R60 then pulled her nasal cannula out of her nares and directing the oxygen tubing towards her eyes. R60 stated, My nose tube (nasal cannula) has not been putting out the air like it is supposed to. I can usually test it like this, but the air isn't coming out like it should. That bottle of water has been emptying since yesterday. On 4/12/23 at 1:30 pm, R60 stated, A nurse (unidentified) put oxygen (no physician order) on me (R60) about a month ago, because I had some shortness of breath. I thought it was because of my allergies. I guess I need it. V10 (RN) confirmed R60 does not have an order for oxygen. V10 stated, I will have to call V11 (Nurse Practitioner/NP) and get an order. That could be why the tubing and humidifier bottle had not been changed. It wouldn't be on the MAR without an order. The facility policy Oxygen Administration updated 02/2021 documents the following: PURPOSE: The purpose of this procedure is to provide guidelines for oxygen administration. To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. POLICY: Oxygen therapy will be administered to the resident only upon the written order of a licensed physician. It will be administered by way of an oxygen mask, nasal cannula and/or a nasal catheter. RESPONSIBILITY: It is the responsibility of the Charge Nurse to ensure that residents who have an order for oxygen are receiving the proper amount via the proper way, per physician order. EQUIPMENT: A. Portable oxygen tank/O2 tank. Concentrator B. Nasal cannula, nasal catheter, mask (as ordered) C. Humidifier bottle PROCEDURE: 14. CARE AND USE OF PREFILLED DISPOSABLE HUMIDIFIERS: A. PREFILLED disposable humidifiers will be changed when necessary. G. Set the flow meter to the rate ordered by the physician. I. Label humidifier with date opened. Tubing will be changed as needed. 15. CARE AND USE OF REUSABLE HUMIDIFIERS: A. Remove humidifier from sterile wrapper. B. Fill with sterile distilled or sterile deionized water to fill line. C. Attach humidifiers to flow meter by screwing nut onto the flow meter. This fit must be tight to ensure accurate flow of oxygen to the resident. D. Attach mask or cannula tubing to humidifier. E. Set the flow meter to the rate ordered by the physician. F. Place mask or cannula on resident as indicated above. G. Label humidifier with date opened. Tubing will be changed as needed. 15. CARE AND USE OF REUSABLE HUMIDIFIERS; A. Remove humidifier from sterile wrapper. B. Fill with sterile distilled or sterile deionized water to fill line. C. Attach humidifiers to flow meter by screwing nut onto the flow meter. This fit must be tight to ensure accurate flow of oxygen to the resident. D. Attach mask or cannula tubing to humidifier. E. Set the flow meter to the rate ordered by the physician. F. Place mask or cannula on resident as indicated above. G. Label humidifier with date opened. Tubing will be changed as needed. 18. PRECAUTION: CONSTANT FLOW OF OXYGEN CAN CAUSE DRYING AND THICKENING OF NORMAL SECRETIONS RESULTING IN LARYNGEAL ULCERATION. 41002 7. V67's Facilities Census documents R67 was admitted to the facility on [DATE] with the following medical diagnoses, Obstructive Sleep Apnea, and Insomnia. R67's Physician's Order Sheet (POS) has no order for R67's CPAP mask and tubing to be cleaned weekly. R67's Care Plan updated on 3/21/23 does not document R67's CPAP (Continuous Positive Airway Pressure) device to be cleaned weekly. On 4/11/23 at 9:46 am, R67 was lying in bed wearing a positive airway pressure device (CPAP). R67 said, no one cleans the mask or tubing, and it should be cleaned weekly. R67 said R67 is not able to clean the mask or tubing. On 4/14/23 at 9:15am, V2 (Director of Nursing/DON) said the nurses should clean the CPAP masks and tubing weekly. V2 said that R67 uses a CPAP, and there should be orders for the cleaning of the CPAP mask and tubing. V2 said it should be documented in R67's Treatment Administration Record (TAR) that the tubing and mask are cleaned weekly. V2 said, I'm not sure why R67 doesn't have an order for R67's CPAP mask and tubing to be cleaned weekly. The (Positive Airway Pressure Device) manufacturer's instructions for use dated November 2017 documents: Wash the CPAP nasal mask or nasal pillows with a mild detergent soap and warm water in the sink weekly. Wash the CPAP tubing weekly in the same manner. Wash the humidifier chamber in soap and water weekly. Disinfect the humidifier chamber with one part vinegar and up to five-parts water. The humidifier chamber should be disinfected to prevent buildup of bacteria. Replace disposable filters once a month and non-disposable filters once a year.

Based on interview and record review, the facility failed to provide a notice of bed-hold to a resident nor the resident's representative upon transfer of the resident to the hospital. This failure affects one(R16) of three residents reviewed for hospitalization /discharge on the sample list of 33. Findings include: R16's Census List printed 4/13/23 documents R16 was hospitalized [DATE], and 11/10/22. R16's Electronic Medical Record does not have documentation that bed hold notification was provided to R16 nor V17 (R16, Family Representative) on 2/2/23 or 11/10/22. On 4/13/23 at 1:20 pm, V1 (Administrator) acknowledged that there is no documentation found in R16's electronic medical records to indicate that a bed hold notice was sent with R16 to the hospital or that V17 was provided written bed hold notices. V1 stated V1 had the medical records department check through documents that had not been scanned to R16's chart. V1 also stated the medical records department was not able to find any documentation to support that the facility provided bed hold/written notices. The facility undated, blank policy form Statement of Resident Rights Regarding Bed Hold documents the following: 1. When a resident of the nursing home is transferred to a hospital (,) when the resident leaves on therapeutic leave, the resident has the right to request that his or her bed be held (,) continuously available for the residents return to the nursing home. Such request is called bed hold. The same Statement of Resident Rights Regarding Bed Hold from documents 10. The undersigned (no evidence of this documentation for R16) state that this notice was provided to the resident or handed to or mailed to a member of the resident's family or legal representative on the dates (form is a blank copy) indicated below. On 4/14/23 at 8:05 am, V6 (Social Service Director/SSD) confirmed V6 is responsible for sending the resident family representatives a copy of the bed hold. V6 also stated the family are notified by the nurses by phone, and a hard copy of the form is supposed to be sent with the resident. V6 also stated V6 has been busy and cannot remember if the bed hold forms were mailed 2/2/23 or 11/10/22 to R16's family. V6 also stated V6 recognizes that if V6 does not document, there is no way to confirm if the bed hold forms were sent to a residents' family representative. I know I am supposed to chart that I sent the resident families (representative) a copy of the bed hold. I just don't always have time to.

Based on observation, interview and record review, the facility failed to transcribe and implement R32's physician ordered pressure ulcer treatment. R32 is one of five residents reviewed for pressure ulcers on the sample list of 33. Findings include: On 4/12/23 3:00 pm - 4:30 pm, V12 (Wound Physician) was in the facility completing wound assessments on numerous residents. V12 updated R32's physician's order for pressure ulcer treatment while in the facility. V12 (Wound Physician) completed R32's Specialty Physician Wound Evaluation and Management Summary dated 4/12/23, which documents the following assessment and order: Left lateral calf, full thickness, Stage IV pressure ulcer measurements: Wound Size (L x W x D) (Length by width by depth): 0.6 x 0.3 x 0.3 cm (centimeters) Surface Area: 0.18 cm Undermining (depth under the wound surface): 0.5 cm. at 12 o'clock Exudate: Moderate Serous Slough: 30. R32's same Specialty Physician Wound Evaluation and Management Summary note documents R32's Stage IV, pressure ulcer wound treatment plan order as follows: DRESSING TREATMENT PLAN, PRIMARY DRESSING FREQUENCY LENGTH OF TX (treatment) (DAYS) NOTE, Add (wound treatment order) Pack wound cavity with collagen powder (enzymatic debridement agent used inside wound), once daily 30 (days). Discontinue (wound treatment order) Pack wound cavity and tunnel with collagen powder mixed with TAO (triple antibiotic ointment). SECONDARY DRESSING FREQUENCY LENGTH OF TX (DAYS), NOTE, Continue Tape (Retention) once daily 30 (days), ABD (large absorbent cotton pad), once daily 30 (days) PERIWOUND DRESSING FREQUENCY LENGTH OF TX (DAYS) NOTE, Continue Skin Prep (protective liquid film dressing to protect the healthy surrounding tissue), Once Daily 16 (days). R32's Physician Order dated 4/13/23, new treatment order was transcribed incorrectly as follows: Left lateral calf-remove old dressing, remove old collagen (powder), clean with wound cleaner, pack wound cavity and tunnel with collagen powder, cover with abd, secure with tape daily. (R32's transcribed treatment order did not include the peri wound for skin prep ordered by V12 as noted above). On 4/13/23 at 2:00 pm, R32 was lying in bed on an air mattress with feet elevated to float heels. V8 (Registered Nurse/ Wound Nurse) and V14 (Certified Nursing Assistant/CNA) entered R32's room, provided privacy, completed hand hygiene, and donned a protective gown and clean gloves, for enhanced precaution during wound treatment. V8 set-up a clean field and opened treatment dressing packages. There was not a skin prep package present with the treatment supplies. V8 and V14 repositioned R32 on R32's back, with R32's left leg positioned slightly inward. V8, washed hands and donned new gloves to remove a soiled. There was a moderate amount of serous drainage noted. R32's Stage IV pressure ulcer wound bed was moist and red. V8 disposed of the soiled wound dressing and again completed hand hygiene and donned new gloves. V8 cleansed the Stage IV pressure ulcer with wound cleaner and a four-by-four-inch gauze pad. V8 applied collagen powder by rolling a cotton tip applicator one time, across the surface of R32's wound and surrounding healthy skin. A scant amount of collagen powder adhered to the surface. V8 did not pack R32's wound cavity with collagen powder. V8 did not apply skin prep to the surrounding healthy peri wound area, as V12 (Wound Physician) ordered. V8 (RN/ Wound Nurse) stated, I didn't do (apply collagen powder) the undermining (tissue) that V12 said R32 had. (V12, documented in the above evaluation note. 'Undermining (depth under the wound surface: 0.5 cm. at 12 o'clock'). I did not probe (check with a cotton tip swab) to find it though. I thought rolling the collagen powder over the top was enough. I did forget the skin prep. I guess I didn't follow V12's order exactly, as I should have. The facility policy Treatment Administration dated 4/2023 documents the following: Procedure: 1. Administration of Treatment: a. Review the physician orders in the EHR (electronic health record) and place all necessary supplies in treatment cart. Treatments may require supplies such as, dressing, solutions, ointment, eye drops, enemas, suppositories, catheters, oxygen, IV (intravenous, sterile, occlusive dressing) tube feeding equipment, etc. c. Complete treatment as ordered (physician order) utilizing stringent infection prevention and control measures.

Based on interview and record review, the facility failed to maintain equipment in safe working order and failed to develop and implement fall interventions for two of four residents (R34, R68) reviewed for falls on the sample list of 33. Findings include: The facility's Fall Prevention Program dated [DATE] documents staff are to initiate and provide ongoing risk reducing interventions. 1. R34's Medical Diagnoses list dated [DATE], documents R34 is diagnosed with Dementia, Muscle Wasting and Atrophy, Muscle Weakness, Unsteadiness on Feet, and Abnormal Posture. R34's Minimum Data Set, dated dated [DATE], documents R34 is totally dependent on at least two staff members for transfers. R34's Fall Risk Assessment, dated [DATE], documents R34 is at High Risk for falls related to Intermittent Confusion, Three or More Falls in the Past Three Months, Chair Bound, Decreased Muscular Coordination, and Requires Assistive Devices. R34's Care Plan, dated [DATE], documents R34 has a Self-care Performance Deficit due to Activity Intolerance, Fatigue, Impaired Balance, and Stroke. R34 has a Limited Physical Mobility related to Trans-Metatarsal Amputation of Right Foot. R34 is at High Risk for Falls related to Actual Falls, Weakness, Drowsiness, Decreased Safety Awareness, and Impaired Balance. R34's Post Fall Evaluation dated [DATE] documents R34 had an unwitnessed fall out of bed at approximately 3:00 AM. The same Evaluation documents the reason for the fall was that R34's air mattress was only partially inflated. R34 sustained a bloody nose and complained of pain to her right arm. The same evaluation documents a contributing factor to the fall was a Bed Malfunction. R34's Fall Incident Investigation dated [DATE] documents the Root Cause of R34's [DATE] fall was that R34's Air Mattress malfunctioned. On [DATE] at 9:42 AM, V2 (Director of Nursing/DON) confirmed the root cause for R34's fall out of bed on [DATE] was determined to be because R34's air mattress's Cardio-Pulmonary Resuscitation (CPR) cord was pulled and the mattress was only partially inflated, leaving it unstable. V2 confirmed staff should be familiar with the air mattress' functions and recognize when a CPR cord is pulled unnecessarily. Staff should have made sure R34's air mattress was properly inflated in order to ensure R34's safety. 20892 2. The facility care plan dated [DATE] for R68 documents R68 was admitted to the facility on [DATE]. The care plan documents the following diagnoses for R68: History of Falling, Difficulty in walking and Repeated falls. The Minimum Data Set (MDS) dated [DATE] documents R68 requires two plus persons assist for all activities of daily living to include toileting, transfers, and personal hygiene. The MDS documents R68 functional abilities for mobility requires two plus person physical assist. for bed mobility, transfers and for locomotion. R68 uses a wheelchair to help her move within the facility. The facility fall report dated [DATE], document R68 had a fall at 8:20 PM. The fall report documents R68 was observed lying face down. Right leg bent at the knee drawn up towards abdomen. Left leg was straight. Wearing no socks. No call light on at this time. Only light on was above the sink. R68 states, I was trying to walk home. I fell and hit my head and need to go to the hospital R68 had a Hematoma on the top of her scalp. The fall report lists the predisposing environmental factors as: Poor lighting, Confused, Incontinent, Weakness, Gait imbalance and impaired memory. R68 was also wearing improper footwear and was ambulating without assistance. Progress note dated [DATE] at 2:29 AM for R68 documents R68 being admitted to the hospital for acute encephalopathy and a closed head injury. Nurse from hospital reported R68 continues to be hypertensive and due to her being on blood thinners, MD wants to monitor closely for intracranial bleeding. R68's undated baseline care plan does not document where the facility develops and implement fall interventions for R68 to help prevent falls. V2 (DON) stated on [DATE] at 1:11 PM, The baseline care plan did not have any interventions for falls. R68 was transferred to another facility when R68 was discharged from the hospital.

Failures at this level required more than one deficient practice statement: 1) Based on observation, interview and record review the facility failed to supervise R1, a resident with a known history of wandering and diagnoses of Dementia and Alzheimer's Disease with moderate cognitive impairment, which resulted in R1 leaving the facility alone and unsupervised. R1 was found by a member of the community, blocks away from the facility, unattended, seated in her wheelchair. R1 was self-propelling the wheelchair in the street of a residential neighborhood. R1 is one of three residents reviewed for wandering in the sample list of seven residents. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 8/15/22, the facility remains out of compliance at severity level two. The facility is in the process of training and educating staff on resident supervision and elopement policies and procedures, and is conducting drills to ensure the policies and procedures are followed. Findings include: The facility's investigation dated 8/2/22 documents the following: On 7/28/22 at 6:26 PM V1 Administrator was notified that R1 was assisted to the facility by a community member at 6:25 PM. It was identified that R1 had left the facility through the front door at 6:00 PM. V3 Receptionist told V1 that V3 had opened the door for R1. V3's employment was terminated. V3's Notice of Termination of Employment dated 8/1/22 documents the following: (V3) pushed a resident (R1) in a wheelchair outside and left her unattended. The resident (R1) was found blocks away by a community member who returned R1 to the facility. V3 admitted that V3 took R1 outside and left R1. The facility's video surveillance footage confirmed this as well. A local web based weather application documents on 7/28/22 at the time R1 eloped from the facility the temperature ranged from 78 and 79 degrees Fahrenheit with humidity ranging from 68-69%. R1's Minimum Data Set, dated dated dated [DATE] documents R1 has moderate cognitive impairment, requires setup and supervision of one staff person for locomotion on the unit and limited assistance for locomotion off the unit. R1's Care Plan revised 10/30/20 documents (R1) is at risk for elopement and is a high risk for wandering related to impaired cognition secondary to diagnosis Alzheimer's disease, Dementia. The goal for this problem area documents (R1) will not leave the facility unattended through the review date. Interventions include: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Observe location at regular and frequent intervals. Document wandering behavior and attempted diversion interventions. Orient (R1) to environment. Redirect (R1) away from the door and explain to her the reason she can't leave. R1's Behavior Tracking documents wandering on 7/17/22 at 10:33 AM and on 7/28/22 at 10:57 AM. R1's Nurse Practitioner (V9) Note dated 7/27/22 at 3:25 PM documents: Staff reported that R1's family was concerned about R1 being more tired than usual. R1 is a poor historian and has cognitive deficits. R1 was started on antibiotic treatment for a Urinary Tract Infection ([CONDITION(S)]). On 8/10/22 at 3:35 PM R1 was interviewed. R1 could state R1's name and the town R1 was in. R1 could not recall the name of the facility, room number, or month/day/time. R1 was unable to recall any details of the incident that occurred on 7/28/22, or that R1 had left the facility unattended. R1 was asked questions to determine safety awareness while outside of the facility, but verbalized incoherently, and fell asleep. On 8/10/22 at 8:42 AM V4 Registered Nurse (RN) stated: V4 received a phone call from a community member (V7) between 5:15 PM and 5:30 PM on 7/28/22. V7 told V4 that V7 thought R1 was one of the residents of the facility. V4 was not aware that any residents were missing, and asked V7 to elaborate. V7 reported R1's name was labeled on the back of R1's wheelchair. V7 was driving by and saw R1 self propelling R1's wheelchair in the street that is East of the facility (Washington Street) and North about a block or two, which caused V7 to stop and assist R1. V8 CNA returned R1 to the facility at approximately 5:30 PM. R1 could not tell V4 how R1 got out of the facility, and R1 was not aware that R1 had left the facility. On 8/10/22 at 11:50 AM V4 stated: R1 is more confused in the evening. R1 had a [CONDITION(S)] when R1 eloped, which caused increased confusion. It is hard to say what R1's safety awareness was at that time that R1 was outside of the facility. V4 was not sure that at that time R1 would be able to safely navigate traffic while attempting to cross the street. On 8/10/22 at 10:04 AM V5 Certified Nursing Assistant (CNA) stated: V5 worked until 5:00 PM on 7/28/22. As V5 was leaving the facility through the front entrance, R1 was sitting near the double doors leading to the receptionist area at the front entrance of the facility. R1 caused the door alarm to sound. V5 reset the alarm, and the door alarm sounded again as V5 left the facility. V3 Receptionist responded to the door alarm. On 8/10/22 at 10:12 AM V8 CNA stated: R1 has a history of wandering in the facility and into other resident rooms. R1 gets more anxious after R1's Family (V11) leaves, and V11 visited R1 the day R1 eloped from the facility. V7 notified the facility that V7 found R1 a couple blocks away from the facility between 4:30 PM and 5:30 PM on 7/28/22. V8 assisted R1 back to the facility at approximately 5:30 PM. On 8/10/22 at 10:30 AM V1 Administrator stated: V2 Director of Nursing (DON) notified V1 on 7/28/22 at 6:26 PM that V7 Community Member called the facility to report R1 was outside of the facility on Washington Street. V1 interviewed V3 Receptionist. V3 reported that prior to the incident, R1 was trying to go through the double doors at the front entrance of the facility, and set off the door alarms. V3 reported R1 wanted to go outside, so V3 let R1 go outside and left R1 outside unsupervised. V3's employment was terminated based on this incident. Following the incident, a binder was placed at the receptionist desk that includes a list of residents who wander. Prior to the incident this binder/list was only kept at the nurse's station. On 8/10/22 at 12:11 PM V6 Administrator of (Sister Facility) stated: V6 reviewed the video surveillance footage for the time frame identified for R1's incident as part of the investigation. V6 saw R1 come through the double doors to the front receptionist area. There was no one else observed with R1. R1 pushed on the doors to the front entrance of the facility and sounded the door alarm. V3 redirected R1 and deactivated the alarm. V5 CNA waved at R1 and walked outside through the front door of the facility. R1 sounded the front door alarm, and V3 pushed R1 in a wheelchair outside through the front entrance of the facility. V3 came back into the facility without R1. R1 had to have turned right after leaving the facility, heading up the hill incline towards Washington Street. If R1 would have turned left, R1 would have rolled down the incline in R1's wheelchair. On 8/11/22 at 9:36 AM V10 (R1's Physician) stated: V10 was notified that R1 was found outside of the facility self propelling R1's wheelchair in the street. V10 was told by the facility that a staff member had let R1 outside of the facility when R1 had attempted to get out of the facility, and the employee left R1 unsupervised. R1 should not have been left outside of the facility unsupervised. In that setting R1 would have very little to no safety awareness. R1's Urinary Tract Infection certainly could have caused increased confusion. Potential consequences of the incident would include dehydration and risk for serious injury if R1 was struck by a car. Staff should not have let R1 out of the facility and the facility staff need to be educated. On 8/10/22 at 5:10 PM Washington Street was located to the East of the facility's main entrance, up an incline/hill. [NAME] Street (the street the facility's main entrance is located on) inclines East to Washington Street and declines West to Union Street. There were no sidewalks located on [NAME] Street in front of the facility. There were no sidewalks observed on the West side of Washington Street between Summer Street (the block South of the facility) and Ottawa Road (the block North of the facility). Vehicles were parked on the streets. The facility's Missing Residents policy dated as revised on May 2021 documents the following: 1. Should an employee observe a resident leaving the premises, he/she should: A. Attempt to prevent the departure; B. Obtain assistance from other staff m embers in the immediate vicinity, if necessary; C. Instruct another staff member to inform the charge nurse or director of nursing services that a resident has left the premises; and D. Be courteous in preventing the departure and in returning the resident to the facility. An Immediate Jeopardy situation was identified on 8/11/22. The Immediate Jeopardy began on 7/28/22 when R1's health and safety was put at risk when V3 Receptionist transported R1 in a wheelchair through the front doors of the facility, and left R1 outside unsupervised. R1 has moderate cognitive impairment and poor safety awareness. Based on the description of where R1 was found, R1 had propelled R1's wheelchair up an incline and onto a road where R1 was seen propelling R1's wheelchair in the roadway. On 8/11/22 at 5:51 PM V1 Administrator was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the immediate jeopardy: 1. On 8/10/22 at 8:42 AM V4 Registered Nurse stated R1 returned to the facility at approximately 5:30 PM on 7/28/22, and R1 did not have any injuries. On 8/15/22 at 1:00 PM V1 Administrator stated R1 was placed on visual monitoring, within sight of staff, for 24 hours following R1's incident on 7/28/22, and R1's room is located near the nurse's station. 2. On 8/15/22 at 1:00 PM V1 stated on 7/28/22 immediately following R1's incident the facility initiated an investigation and reviewed the facility's surveillance footage. V1 confirmed a Quality Assurance Performance Improvement (QAPI) meeting was held on 7/29/22 to review R1's incident. On 8/15/22 at 1:38 PM V1 confirmed the facility reported R1's incident to the Illinois Department of Public Health on 7/28/22 at 7:05 PM. 3. On 8/15/22 at 11:51 AM there was a binder at the front receptionist desk that contained a list of residents who wander and their pictures. On 8/15/22 at 1:00 PM V1 stated on 7/28/22 a binder containing a list of residents who wander was placed in the front reception desk. V1 confirmed V18 Social Services Director completed elopement risk assessments on all residents on 7/29/22, care plans were updated, and the binders at the nurses station and front desk that include the list of residents who wander were updated with a new list and correct pictures of the residents. On 8/15/22 at 4. On 8/15/22 at 1:53 PM V1 confirmed V1 provided education to staff on 7/28/22 and 7/29/22 regarding elopement/missing residents, how to identify residents at risk for elopement, exit seeking behaviors, and door alarms. V1 confirmed staff completed a post test to validate understanding of the training. 5. Door Alarm checks were completed by V20 Maintenance three times during the week of 7/31/22 and 8/7/22 to ensure door alarms are functioning properly. Elopement/missing resident drills were conducted on 8/1, 8/3, 8/4, 8/7, 8/9, and 8/12/22 by V20. On 8/15/22 at 1:38 PM V1 confirmed the door alarm audits and missing resident drills will continue to be conducted up to 3 times per week for 4 weeks, and the results will be reviewed during the facility's QAPI meetings. 6. On 8/15/22 V1 and V19 Human Resources confirmed education on elopement and door alarms was added to new employee training packets as of 8/8/22. 7. The facility's undated abatement plan documents on 8/12/22 V1 conducted additional in-services for all staff and agency staff regarding identification and supervision of residents that cannot be left outside unsupervised, and residents who are at risk for elopement must always be supervised when outside of the facility. This plan documents staff will complete the training prior to their next scheduled shift, and will be monitored by V2 Director of Nursing and V14 CNA Supervisor. The Daily Staffing Assignments document V21 Registered Nurse (RN) worked 6:00 PM - 6:00 AM on 8/12/22, and on 8/14/22; V4 RN worked on 8/14/22 from 6:00 AM-6:00 PM; V22 Agency RN was scheduled to work 6:00 AM-6:00 PM on 8/15/22; and V23 Certified Nursing Assistant (CNA) was scheduled to work from 8:00 AM-2:00 PM on 8/15/22. V21, V22, and V23 are not listed on the staff in-service for elopement and supervision of residents prior to 8/15/22. There is no documentation that V4 received the training prior to working on 8/14/22. On 8/15/22 at 11:26 AM V22 was administering medications to residents. V22 stated V22 has not received any recent training on residents at risk for elopement and supervision of residents while outside of the facility. V22 was asked how V22 identifies residents who are at risk for elopement, and V22 stated that is information that is just passed on in nurse report. On 8/15/22 at 11:57 AM V23 stated V23 was not aware of any list of residents who wander/are at risk for elopement, or where to locate the list. On 8/15/22 at 2:30 PM V1 and V2 confirmed there is no documentation that V4 received the elopement/supervision training initiated on 8/12/22, prior to working on 8/14/22. V1 and V2 confirmed V22 and V23 received the elopement/supervision training at approximately 12:00 PM on 8/15/22, and not prior to the start of their shift. V1 and V2 confirmed V21 is documented as receiving the training on 8/15/22. 2) Based on observation, interview, and record review the facility failed to transfer residents in accordance with the resident assessment and plan of care, and failed to thoroughly investigate a fall to accurately identify the root cause and implement appropriate post fall interventions for two (R4, R5) residents of 7 reviewed for transfer assistance. This failure resulted in R4 falling and sustaining an acute right femur fracture. Findings include: R4's Minimum Data Set (MDS) dated [DATE] documents: R4 requires extensive assistance of staff for transfers, and has severe cognitive impairment. R4 has impaired balance, and is only able to stabilize self with staff assistance for toileting transfers. R4's Care Plan documents interventions dated 2/21/21 R4 requires limited assistance for transfers and toileting. R4's Nursing Note dated 7/27/22 at 3:17 PM documents: R4's fall was witnessed by Certified Nursing Assistant (CNA) (V12), who was transferring R4 to the toilet in R4's bathroom. V12 stated that R4 suddenly started to fall, V12 attempted to break R4's fall, and R4 fell on to R4's right side. V12 thought R4 may have passed out. R4 was transferred back to bed by V12, who was then educated to leave the resident where the fall occurs until after a nurse completes an assessment. R4 screamed out in pain when R4 was turned, and passive range of motion was unable to be performed to the right leg due to pain. R4's Fall Investigation dated 7/27/22 at 1:15 PM documents the following: A CNA (V12) notified V4 Registered Nurse (RN) that R4 had fallen in the bathroom while transferring to the toilet. R4 was found lying in R4's bed with signs of right hip pain rated a 10 on a 1-10 scale. R4 was unable to perform right hip active range of motion. V12's Interview dated 7/27/22 documents V12 was transferring R4 to the toilet, V12 was unable to break R4's fall, and R4 fell on to R4's right side. The root cause of R4's fall was that R4 lost balance during the transfer. The post fall intervention was physical and occupational therapy evaluation and treatment when R4 returns from the hospital. There is no documentation that V12 used a gait belt during R4's transfer, or what V12 was doing at the time of R4's fall. There is no documentation that education on how to transfer residents was provided to V12 following R4's fall. R4's Hospital History & Physical dated 7/27/22 at 8:16 PM documents R4 was brought to the emergency room following a fall at the long term care facility with obvious right hip deformity. R4's Right Femur X-ray dated 7/27/22 documents: The indication for the x-ray is listed as a fall, and additional history lists hip deformity and pain. Findings: Comminuted displaced fracture involving the proximal right femur with fracture involvement of the right femoral neck and intertrochanteric region. Impression: 1. Acute fracture of the proximal right femur. 2. Osteopenia. On 8/10/22 at 1:52 PM R4 was lying in bed. R4 stated R4 had a recent fall and hurt R4's leg, but was unable to give details of the fall. On 8/10/22 at 12:48 PM V4 RN stated: V4 was on break at the time R4 fell . V4 was notified of the fall and went into R4's room to assess R4. At this time R4 was lying in bed, yelling out in pain. V12 told V4 that V12 had transferred R4 in the bathroom, and R4 went limp when V12 moved R4's wheelchair. V12 had transferred R4 from the floor to the bed before notifying anyone. That was a big error. Prior to R4's fall, R4 transferred with 1 assist and a gait belt. V4 was not sure if a gait belt was used during R4's transfer/fall. On 8/10/22 at 12:53 PM V12 stated the day R4 fell , V12 was transferring R4 to the toilet. V12 stated R4 used the grab bar in the bathroom to pull R4's self to a standing position from the wheelchair. V12 stated V12 attempted to move R4's wheelchair, which was difficult to move due to automatic locking brakes. V12 stated V12 had to use both hands to move the wheelchair, R4 lost R4's balance, and R4 fell to the floor. V12 stated V12 prevented R4 from hitting R4's head, but could not stop R4 from falling. V12 confirmed a gait belt was not used during R4's transfer. V12 stated V12 then transferred R4 off of the floor, into the wheelchair, and into bed by placing V12's arms underneath of R4's shoulders. V12 stated R4 yelled out in pain and was unable to bear weight. V12 confirmed V12 did not notify a nurse prior to transferring R4 off of the floor. On 8/10/22 at 1:49 PM V12 stated after R4's fall, V12 learned that the wheelchair seat can be folded to be easily moved, and this would have allowed V12 to move the wheelchair more quickly and be able to provide hands on support of R4. V12 was not sure what R4's post fall intervention was. On 8/10/22 at 3:46 PM V2 Director of Nursing (DON) stated CNAs can see the resident's transfer status through the electronic charting system that pulls information from the resident's care plan. V2 stated the standard practice in the facility is that staff are expected to use gait belts for 1 and 2 assist transfers. V2 stated R4's post fall intervention for the 7/27/22 fall was physical and occupational therapy, and V12 was educated to notify a nurse prior to moving a resident following a fall. On 8/11/22 at 11:00 AM stated V2 was not sure that a gait belt not being used during the transfer caused R4's fall. V2 stated V12 had to let go of R4 to fold up the wheelchair. V2 confirmed V12 was not provided education to maintain contact with the resident or use of a gait belt during transfers. b2.) R5's MDS dated [DATE] documents R5 requires extensive assistance of one staff person for transfers and toileting assistance. R5 has impaired balance that requires staff assistance to stabilize when moving on and off of the toilet. R5's Baseline Care Plan dated 7/30/22 documents R5 uses two or more staff for transfers and toileting assistance. On 8/10/22 at 2:25 PM V16 Physical Therapist was providing therapy services for R5 in R5's room. V16 stated R5's transfer status is moderate assistance of one person with the use of a gait belt. On 8/10/22 at 3:08 PM R5 grabbed the bathroom assist bar and stood from the wheelchair. V13 (CNA) grabbed the back of R5's pants during the transfer. R5 had difficulty pivoting to the toilet, and sat partially sideways onto the toilet. V13 transferred R5 back to a standing position while R5 held onto the assist bar. V13 cleansed R5's buttocks, and was not holding onto R5. R5's knees were bent, and V13 instructed R5 to stand up straight. R5 became shaky. V13 held onto the waistband of R5's pants with one hand, and used the other hand to grab R5's wheelchair that was sitting in the doorway of the bathroom. V13 transported R5 in the wheelchair to the bed. V13 instructed R5 to hold onto V13 and place R5's hands on V13's shoulders. R5 stood and pivoted to the bed. V13 did not use a gait belt for R5's transfers. The facility's Incident and Accident Prevention policy dated July 2022 documents: Following a fall, determine root cause of the fall. Put interventions in place to address root cause of fall. The facility's Transfers policy dated as revised January 2020 documents: To promote safe transfer for the residents, as well as the staff, gait belts, (full mechanical lifts), and/or sit to stand will be used, unless otherwise specified. Follow Plan of Care to ensure the use of proper transfer technique. The facility's Transfer Belts/Gait Belts policy dates as revised July 2020 documents: It is the responsibility of the Restorative staff/Nursing Staff to determine when the need for the use of Transfer Belts/Gait Belts for each resident. It is the responsibility of the CNA's/Restorative Aide to utilize the Gait Belt/(full mechanical lift) when transferring or ambulating resident. The resident is transferred by grasping the secured gait belt to provide stability and balance during movement. Grasp belt from behind if one person transfer, bringing hand from bottom up. Do not attempt to transfer/lift/ambulate a resident who requires assist, without a gait belt.

Based on observation, interview and record review the facility failed to complete a transfer for a resident according to the resident's plan of care for one of three residents (R2) reviewed for accidents in the sample list of three. This failure resulted in R2 sustaining a Right Humerus Fracture (an injury to the bone of the upper arm that connects the shoulder to the elbow).and R2 was admitted to the hospital. Findings include: The facility's Transfers policy with a revised date of 1/2020 documents, Purpose: To provide guidelines to nursing assistant/nurse for proper technique for transferring residents. Policy: To promote safe transfer for the residents, as well as the staff, gait belts, (mechanical lift), and/or sit to stand will be used, unless otherwise specified. Responsibility: It is the responsibility of all nursing staff to ensure the use of safe transfer techniques when transferring a resident. It is the responsibility of the D.O.N. (Director of Nursing)/Designee to ensure that adequate training is provided to all nursing staff on the proper use of gait belts, (mechanical lifts) and sit to stand. Procedure: 3. A minimum of two staff members is recommended when transferring with a (mechanical lift). 4. When using a (mechanical lift) pay close attention to be sure that the (mechanical lift) sling is properly positioned. 7. Follow Plan of Care to ensure the use of proper transfer technique. The facility's Resident Handling Policy dated 8/2017 documents, Purpose: To provide guidance to staff in the proper handling/lifting of residents. It is the responsibility of the CNAs (Certified Nursing Assistants)/Restorative Aide to transfer/ambulate according to assessed needs. R2's Order Summary Report dated 8/2/22 documents diagnoses including Spondylolisthesis, Lumbosacral Region, Unspecified [CONDITION(S)], Presence of Left Artificial Knee Joint, Other Malaise, Other Specified Disorders of Bone Density, Unsteadiness on Feet, Contracture Left Knee, Contracture Right Knee, Cognitive Communication Deficit, Hereditary and Idiopathic [CONDITION(S)], Other Lack of Coordination, Contracture Left Hip and Contracture Right Hip. This Order Summary documents an order for [MEDICATION(S)] patch 72-hour 25 mcg (microgram)/hr (hour), apply one patch transdermally every 72 hours for pain management and remove per schedule with a start date of 7/30/22. This Order Summary also documents an order for [MEDICATION(S)] (Concentrate) Solution 20 mg (milligrams)/ml (milliliter), give 0.25 ml by mouth every four hours as needed for pain or air hunger with a start date of 7/28/22. Also, [MEDICATION(S)] tablet 5-325 mg, give one tablet by mouth every six hours as needed for breakthrough pain with a start date of 7/28/22. R2's Care Plan dated 2/26/21 documents R2 was at risk for falls related to Confusion, Deconditioning, (Mechanical Lift) transfers, staff assist with ADL's (Activities of Daily Living). R2's Care Plan dated 2/26/21 documents R2 has an ADL self-care performance deficit related to Activity Intolerance, BLE (Bilateral Lower Extremities) Contracture's, Presence of Left Artificial Knee Joint, Pain, Secondary to diagnosis HF (Heart Failure), [CONDITION(S)] [CONDITION(S)], Depression, Right and Left Hip Contractures, [CONDITION(S)] and [CONDITION(S)]. Interventions documented for this problem are for transfers, R2 requires Full Mechanical Lift x (times) 2 staff assistance for transfers dated 3/13/2020. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has severely impaired cognition and is totally dependent on two or more staff for transfers and for bathing. R2's Kardex Report dated 8/2/22 provided by V3 Director of Nursing documents R2 requires a mechanical lift with two staff assistance for transfers. On 8/2/22 at 4:30 PM, V10 Care Plan Coordinator confirmed the CNAs (Certified Nursing Assistants) get the resident's information from the Kardex. V10 stated it is the Care Plan for the residents. R2's Original Incident Report documents, On 7/22/22 at 1:55 PM (V1) Administrator was notified that (R2) was complaining of shoulder pain during (R2's) shower. (R2's) right shoulder appeared swollen. (R2) was laid down in bed and a full body assessment was completed. All 3 C.N.A.'s that assisted in (R2's) shower were suspended pending investigation. (V12) Nurse Practitioner notified and ordered stat (immediate) X-rays to right shoulder, POA (Power of Attorney), and (hospice company) also notified. Initial report emailed to (reporting agency). X-ray results showed a Right Humerus Fx. (fracture). Doctor, POA, and Hospice notified; (R2) was then sent to (the hospital) for tx (treatment). On 8/2/22 at 7:30 AM, V5 Registered Nurse stated regarding R2 that all three CNAs got fired (employment terminated) because they were supposed to use a mechanical lift for transfers for R2 but did not. On 8/2/22 at 11:49 AM, V4 Licensed Practical Nurse (LPN)/Nurse Manager stated on 7/22/22 V4 was working in V4's office and the floor nurse, V6 LPN came into V4's office and asked V4 to look at R2's shoulder in the shower room. V4 stated R2's shoulder appeared swollen and V4 stated V4 instructed the CNAs to lay R2 down in bed. V4 stated V4 contacted V12 Nurse Practitioner and x-rays were ordered. V4 stated V7 and V8 CNAs stated R2 started complaining of pain during the shower. V4 stated V9 CNA told V4 that V9 lifted R2 up out of the geriatric reclining chair while V7 and V8 removed R2's clothing and then V9 sat R2 on the shower chair. V4 stated all three CNAs were terminated for not following R2's plan of care for transfers. V4 stated R2 was supposed to be transferred using a mechanical lift. On 8/2/22 at 1:07 PM, V1 Administrator stated on 7/22/22 V1 was not in the building and was notified by V4 regarding R2's pain and swelling and improper transfer in the shower room by V7, V8 and V9. V1 stated V7, V8 and V9 were all suspended immediately pending an investigation. V1 stated V7 and V8 told V1 that they were going to give R2 a shower but the mechanical lift sling that was underneath R2 did not have a cut out on the bottom to be able to wash R2's perineal area. V7 and V8 requested help from V9. V1 stated V9 went into the shower room and lifted R2 up off the geriatric reclining chair while V7 and V8 removed R2's clothing and then V9 sat R2 down on the shower chair. V1 stated R2 should have been transferred using a mechanical lift. V1 stated V7, V8 and V9 were all terminated on 7/28/22 for not following R2's plan of care. On 8/2/22 at 1:35 PM, V3 Director of Nursing stated V3 was notified regarding R2's incident by V4. V3 stated V4 explained what had happened. V3 stated the CNAs are supposed to get resident care information from the Kardex. V3 stated they just completed an inservice with the staff regarding how to find all of the resident's information. V3 confirmed R2 was only supposed to be transferred using a mechanical lift. V3 stated R2 was and still is in a lot of pain. They had R2 on a five day course of [MEDICATION(S)] and now have transitioned to a [MEDICATION(S)] patch to help manage the pain. V3 stated R2 used to be able to feed R2's self but now R2 cannot due to the fracture. On 8/2/22 at 2:57 PM, V7 stated V7 and V8 were going to give R2 a shower but the mechanical lift sling that was underneath R2 did not have a cut out to clean the perineal area. V7 stated that they got V9 to assist. V7 stated V9 told V7 that V9 has done this before. V7 stated V9 wrapped V9's arms underneath R2's arm pits and gave R2 a bear hug and picked R2 up like that from the geriatric reclining chair. V7 stated R2 started yelling when V9 picked R2 up. V7 stated that during R2's shower R2 was moaning and started to look pale and greyish in color. V7 stated they went to get the nurse at that point. On 8/2/22 at 3:06 PM, V8 stated that V8 was the shower aide that day and R2 was on the list for a shower. V8 stated that V8 asked V7 to assist with the shower. V8 stated the mechanical lift sling underneath R2 did not have the cut out on the bottom to be able to wash R2's perineal area. V8 stated that V8 and V7 did not feel comfortable transferring R2 by themselves so they got help. V9 came to help transfer R2. V8 stated that V9 lifted R2 up from the geriatric reclining chair and V7 and V8 removed R2's clothing and then V9 sat R2 down on the shower chair. V8 stated that during the shower when V8 lifted R2's arms up R2 started screaming. V8 stated they went to get the nurse. V8 stated that V8 knew R2 was a mechanical lift transfer but other staff had told V8 that they have transferred R2 with 2 people before instead of a mechanical lift so V8 stated V8 thought it was ok to do so. On 8/2/22 at 3:15 PM, V6 LPN stated one of the CNAs came to get V6 and took V6 to the shower room. V6 stated that when V6 touched R2's right shoulder R2 moaned and flinched. V6 stated that V6 went to get V4 Nurse Manager. V6 stated that V4 took over from there. V6 stated that V6 did not witness the transfer or anything else. On 8/3/22 at 7:27 AM, V11 R1's Physician stated V11 was aware of R2's Humerus fracture and the improper transfer. V11 confirmed the improper transfer could have caused the fracture of R2's right Humerus. On 8/3/22 at 7:44 AM, R2 stated R2 does not remember how R2's arm got broke. R2 stated that R2 still has a lot of pain and is tired. R2 was laying in bed with a pillow underneath the right arm and right arm was in a sling. Hospital documentation dated 7/22/22 documents expected stay at least two days. Hospital Radiology report dated 7/22/22 documents Findings of R2's x-ray as Oblique fracture of the proximal humerus abdomen just below the surgical neck, with medial apex angulation and impaction. Impression: Oblique impacted fracture of the proximal humerus. V7, V8 and V9's Notice of Termination of Employment form documents V7, V8 and V9 were all terminated on 7/28/22 with the reason of failure to follow patient's plan of care resulting in injury. All three termination notices are signed by V1 and V3.

Based on interview and record review the facility failed to protect residents from significant medication errors for two of three residents (R2, R6) reviewed for intravenous antibiotic administration in the sample list of 15. This failure resulted in recurrence of pain, swelling/[MEDICAL CONDITION], and additional surgical procedures and hospitalization to treat exacerbation of an infection for R2. Findings include: The facility's Medication Errors policy dated August 2017 documents Medication/Treatment Errors shall be documented on the Nursing Home Incident Reporting Form. An error shall be defined as any variation in administration of medication from the physician's orders [REDACTED]. 1.) R2's Face Sheet dated 8/18/20 documents R2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's Care Plan dated 3/4/19 documents R2 has an infection of the right internal knee with an intervention to administer antibiotics per physician orders. R2's Progress Note dated 4/11/2019 at 3:07 PM, V2 Nurse Practitioner documents R2 had a right total knee replacement in December 2018 and had complications with an infected total knee that had to be removed. R2 has an antibiotic cement spacer in R2's right knee, and is being followed by R2's orthopedic surgeon (V12). This note documents R2 was recently sent back to the hospital after increased pain and swelling and was admitted to the hospital on [DATE]. This note documents R2 had a repeat irrigation and debridement of R2's right knee and an antibiotic cement spacer was inserted. This note documents on 4/8 and 4/9 there was concern that there may be an infection migrating into the soft tissues of R2's thigh. R2 was discharged from the hospital and back to the facility on [DATE] on intravenous antibiotics. R2's Hospital Progress Note dated 4/7/19 at 9:37 AM, V12 Orthopedic Surgeon documents, (R2) is doing some better. We did talk about (R2's) knee and the infection. It certainly appeared as if the infection was still there. We talked about the fact that we have to cure this. We even mentioned the possibility of an amputation as an end result if we cannot cure it. This note also documents R2's [MEDICAL CONDITION] Arthritis affects R2's immune system. R2's Hospital Discharge Orders dated 4/11/19 documents orders for [MEDICATION NAME] (Antibiotic) 2 grams intravenously every 8 hours and [MEDICATION NAME] (Antibiotic) 1500 mg (milligrams) intravenously every 12 hours. R2's Aerobic Culture of the right knee dated 4/10/19 documents the presence of one colony of Coagulase negative Staphylococcus (bacteria.) R2's April 2019 Medication Administration Record [REDACTED]. This MAR indicated [REDACTED]. R2's Progress Note dated 4/11/19 at 8:41 PM, V4 LPN (Licensed Practical Nurse) documents intravenous [MEDICATION NAME] 2 grams was not on hand. R2's Progress Note dated 4/12/2019 at 5:12 AM by V4 documents intravenous [MEDICATION NAME] 2 grams Meds (medications) not on hand, not an rn (Registered Nurse.) R2's Progress Note dated 4/15/2019 at 1:51 PM, V2 Nurse Practitioner documents R2 has had increased leg pain and swelling, and R2 was concerned that did not receive all of R2's scheduled doses of antibiotics. R2's Progress Note dated 4/18/2019 at 12:28 PM, V2 documents R2 reported having a fever of 101.1 degrees Fahrenheit last night. R2 had returned from the hospital a week ago after having a second antibiotic knee spacer placed and R2's knee irrigated. This note documents R2 reported missing antibiotics to V2 on 4/15/19. R2 is to be seen today in V12's office. This note documents an addendum that V2 spoke with V6 (Physician's Assistant at V12's office) regarding R2's missed doses of intravenous antibiotics. This note documents Discussed with (V6) that upon chart review it appeared pt (R2) did not have 2 doses of the [MEDICATION NAME], one the night of return and one the morning after. Also, discussed with (V6) that (R2) arrived at facility at 2:45 PM so this provider not sure if (R2) received the 2pm dose at the hospital and may have missed that dose as well. (R2) also did not have her vanc ([MEDICATION NAME]) the night of (R2's) return. This provider was notified by the pt (R2) on 4/15 that (R2) missed doses of (R2's) antibiotic. This was discussed with the facility at that time. (V6) is discussing readmitting (R2) to the hospital and may need more surgery vs (versus) aspiration, ID (Infectious Disease) consult, and stressed this is a limb threatening situation. R2's Hospital Progress note dated 4/16/19 at 4:33 PM, V6 Physician Assistant documents R2 had an irrigation and debridement of R2's right knee, deep cultures, and placement of an antibiotic cement spacer on 4/5/19. This note documents R2 was discharged six days ago to an extended care facility to receive regular Intravenous antibiotics. This note documents, Apparently there were two and a half to three days where (R2) was getting either no antibiotics or not the complete intended ordered antibiotics. This note documents Plan: Obviously an interruption and (in) antibiotics like this is not at all acceptable. It sounds like (R2's) antibiotics have resumed appropriately, but I am very concerned about the interruption. R2's Hospital Procedure Summary Note dated 4/21/19 at 12:47 PM, V12 Orthopedic Surgeon documents Preoperative Diagnosis: [REDACTED]. Indication for surgery: Missed antibiotic doses with recurrence of pain, swelling and [MEDICAL CONDITION]. On 8/18/20 11:44 AM V2 Director of Nursing/Nurse Practitioner confirmed R2 had missed doses of intravenous [MEDICATION NAME] and [MEDICATION NAME] on 4/11 and 4/12/19. V2 stated V2 had spoken with V6 and R2 was admitted to the hospital for surgical intervention for R2's right knee infection. V2 stated it is hard to determine if the missed doses of antibiotics contributed to R2's infection since R2 had a history of [REDACTED]. V2 stated if a medication is unavailable then the nurses should check the facility's emergency medication supply, or notify the after hours pharmacy which can deliver the medication in 4 hours. V2 stated at the time R2's antibiotics were due, the nurses should have contacted V13 to obtain orders on how to proceed. On 8/21/20 at 4:04 PM, V6 Physician Assistant stated There were problems when (R2) returned to the facility in April where (R2) did not receive (R2's) IV antibiotics. It was a big deal because we were trying to eradicate (R2's) infection. It is possible that missing the doses of the IV antibiotics made (R2) more vulnerable to requiring additional surgery. 2.) The undated Nursing Home Incident Reporting Form documents R2 received two doses of intravenous (IV) [MEDICATION NAME] (antibiotic) administered intravenously through a CADD (Continuous Ambulatory Delivery Device). This report documents V11 Physician was notified, labs were ordered, and R2's [MEDICATION NAME] was held. R2's Physician order [REDACTED]. R2's Progress Note dated 5/7/2019 10:35 PM by V5 RN (Registered Nurse) documents Medication Error happened. This RN (V5) hung the bag of [MEDICATION NAME] 5/6 at 2300 (11:00 PM) and ran the whole bag of fluid. The bag was suppose to be for two doses using a cad (CADD) pump. The AM nurse also hung an entire bag of [MEDICATION NAME] (2 doses). This RN (V5) called Pharmacy on 5/6 x 2 asking how the CAD (CADD) pump worked and it was never explained that there was two doses in one bag. MD (V11) called and notified of the med (medication) error and MD (medical doctor) (V11) said to hold the dose tonight and tomorrow am (morning) and draw the Vanco ([MEDICATION NAME]) lab (laboratory test) in the am. Resident (R2) has had increased stool and is slightly nauseated. VS (Vital Signs) WNL (Within Normal Limits.) Will continue to monitor. R2's [MEDICATION NAME] Trough (laboratory test) dated 5/8/19 documents an elevated level of 23.8, with the reference range of 15.0 - 20.0 micrograms/milliliter. On 8/18/20 10:21 AM V5 stated the pharmacy had sent the [MEDICATION NAME] premixed in a bag to administer intravenously to R2 through a CADD pump. V5 stated V5 was not aware that each bag of [MEDICATION NAME] was meant to be used for two doses of the medication. V5 stated that on 5/6/19 at 11:00 PM V5 administered the entire bag of [MEDICATION NAME] (2 doses) and the following morning another nurse administered an additional bag of [MEDICATION NAME] (2 doses). V5 stated V5 had not received any training from the facility on the use of the CADD pump prior to administering R2's [MEDICATION NAME]. On 8/18/20 11:39 AM, V9 Pharmacist stated administering double doses of the ordered [MEDICATION NAME] could cause a person to develop Redman's Syndrome, including a rash and itching. V9 stated [MEDICATION NAME] is dosed renally and could also have an affect on kidney function. V9 stated V9 would consider R2 receiving double the ordered dose of [MEDICATION NAME] would be considered a significant medication error. 3.) R6's Face Sheet dated July 19, 2020 documents R6 has [DIAGNOSES REDACTED]. R6's Discharge Hospital Orders dated July 29, 2020 document orders for Ertapenem (Antibiotic) one gram intravenous, every 24 hours for five days. R6's Medication Administration Record [REDACTED]. On 8/18/20 at 3:20 PM, V2 Director of Nursing confirmed that the Ertapenem one gram was not given on July 30, 2020 or July 31, 2020 and should have been given on July 30, 2020 and July 31, 2020. The facility's Administration of Medications policy revised on 11/21/18 documents Residents shall receive their medications on a timely basis in accordance with state and federal guidelines, and within established facility policies. The facility's Drug Orders from Pharmacy policy revised on September 2018 documents The purpose of this policy is to provide necessary to the pharmacy to assure accurate dispensing and prompt delivery of medications. The facility will provide information to the pharmacy when new medication or a change in medication order is received. This policy documents D. If possible new drug orders should be ordered before the pharmacy makes late afternoon delivery. E. If new drug orders have been received after the usual late delivery, the pharmacists are available for 24 hour emergency call.

Based on observation, interview, and record review the facility failed to respond to R5's repeated requests for toileting assistance using the emergency nurse call system. R5 was permitted to remain unassisted , and on the bed pan in excess of two hours, inconsistent with R5's needs and preferences. This failure resulted in extreme distress and psychosocial harm to R5. R5 is one of six residents reviewed for dignity in a sample of six residents. Findings include: R5's Electronic Medical [DIAGNOSES REDACTED]. R5's Brief Inventory of Mental Status (BIMS) dated 6/13/19 documents R5 is cognitively intact. R5's Minimum (MDS) data set [DATE] documents R5 requires extensive assistance of one staff member for transfer and toileting. R5's Care Plan entry dated 6/13/19 documents The resident is an extensive assist x1 (times one) for toilet use. On 6/18/19 at 3:50PM R5 was seated in a wheelchair in R5's room. R5 stated I can't remember if it was Saturday morning or Sunday morning this week, but I had to (urinate) and I put on my call light at 4:00AM. The aide came in and wouldn't help me to the bathroom but put me on the bed pan. The aide said they were too busy to get me up. I kept pushing and pushing my call light. You can find out which morning it was because they handed out bells because they were having trouble with the call lights. I didn't know the aide, but she was short and dark. I pushed the call light and rang the bell over and over. R5 looked away and was visibly upset and shaky. Nobody came to help me until after day shift came in. When the day shift took me off that bed pan it was like they were tearing me apart. It was stuck to me. I think my skin came off! Nobody came. I was scared! I can't explain how bad it was. R5 sighed deeply and looked away. R5's lower lip quivered. On 6/19/19 at 9:15AM V2, Director of Nursing and V3, Registered Nurse (RN) assisted R5 to stand and with R5's verbal consent lowered R5's pants. There was a visible red raised area surrounding R5's buttocks. There was a purple to yellow bruise approximately four inches in diameter to R5's right buttocks. V2 and V3 verbalized neither were aware of this injury until now. V2 stated this is the first I have been aware of this. The Alarm Response Report provided by V1, Administrator dated 6/15/19 (Saturday) documents a call light was activated from R5's room at 4:09AM and canceled in 18 minutes and 52 seconds. R5's call light was activated at 6:23AM and canceled in 13 minutes and 44 seconds. There were six additional activations of R5's call light between 4:09AM and 6:23 AM, but these were canceled within seconds, which would support R5's claim that I kept pushing and pushing my call light. On 6/19/19 at 2:08PM V18, Certified Nurse's Aide (CNA) stated I remember coming in on day shift Saturday (6/15/19) (V22, Certified Nurse's Aide) (CNA) told me that (R5) was on the bed pan and (V22) was too busy to take (R5) off the bed pan. By that time (R5) had pressed her call light and I went in and took (R5) off the bed pan. It was between 6:00AM and 6:30AM. I don't know how long (R5) had been on the bed pan. The facility policy Call Lights Answering issued 8/2/17 states Responsibility: 1. It is the responsibility of the CNA and or Nurses to answer the call light/pagers to see what requests or needs the resident may have. 2. It is the responsibility of the Charge Nurse to ensure the CNA answers the call light/pager so that the needs and requests of the resident have been met. 3. It is the responsibility of the Director of Nurses or designee to ensure the call lights/pagers are answered in a reasonable time frame.

Based on observation, interview and record review the facility failed to provide services to promote the healing of pressure ulcers for three of four residents (R18, R16, R14) reviewed with pressure ulcers, on the sample of 12. The facility failed to reposition, monitor, evaluate the effectiveness of treatment of [REDACTED]. These failures resulted in R18 developing multiple avoidable pressure ulcers and the deterioration of the ulcers without timely treatment. Findings include: The facility Wound and Ulcer Policy and Procedure dated 2/27/17 documents the following: High Risk Protocol: Residents with existing ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment Score Specialty mattress (low air loss, alternating pressure, etc.) with enhanced pressure reducing/relieving properties may be placed on the resident's bed as indicated The resident may be placed on a turn and position schedule if clinically indicated Approaches will be placed in the resident's care plan .Assessment of progress toward healing is completed at least weekly and the physician is notified at least monthly of progress toward healing. If there is regression, the physician is notified of the condition change . 1. R18's MDS (Minimum Data Set) dated 12/29/16 documents [DIAGNOSES REDACTED]. The Skin Risk assessment dated [DATE] documents that R18 is at moderate risk for skin breakdown. The Wound Documentation Report dated 12/31/16, 1/25/17, 2/1/17 and 2/21/17 documents a unstageable pressure ulcer on the left heel which was acquired in the facility on 7/7/16. On 3/8/17 at 12:15pm the skin on R18's left heel was intact with no open areas. On 3/8/17 at 12:15pm E4, RN (Registered Nurse) verified that R18's left heel is healed. On 3/8/17 at 12:10pm E2, DON (Director of Nursing) stated that a air mattress was put on R18's bed yesterday (3/7/17) and prior to yesterday there was a regular mattress on R18's bed. E2 verified that for a high skin risk assessment a specialty mattress is to be used per protocol. The Care Plan dated as revised on 3/8/17 documents that R18 has pressure ulcers to the buttocks/coccyx area with the following interventions: 3/7/17- low air loss mattress on bed; 3/7/17-lay down after meals; 1/17/17-protective leg boots on when up; 3/7/16-turn and reposition and 7/7/16-float heels and apply protective boots when in bed. The undated Weight Log provided by the facility on 1/7/17 documents R18's weight as follows: October 2016-162; November 2016-155.7; December 2016-156 and January 2017-145. The physician's orders [REDACTED]. Z5 RD recommended to increase the Medication Pass to 90cc twice daily. There is no weight available for March 2017. The Laboratory Report dated 1/27/17 documents R18's total protein as 7.2 and [MEDICATION NAME] as 3.8, which is in the normal range for both. The electronic Progress Note dated 1/28/17 documents that R18 returned from the hospital with a pressure ulcer on the Rt. (right) upper buttocks, also a line bruise noted on rt. upper buttocks, 1.5 inches long, dark in color The Wound Documentation Report dated 12/31/16 documents an initial assessment for the development of a in-house Stage 2 pressure ulcer on the right upper buttock (coccyx) measuring 0.6 cm (centimeter) by 0.5cm by a depth of 0.1cm with no drainage. The electronic Progress Note dated 12/31/16 documents Z2, Physician was notified of the pressure ulcer. The Physician order [REDACTED]. The electronic Progress Note dated 1/1/17 documents a Stage 2 pressure ulcer in the right ischial crease measuring 0.5cm by 0.5cm by 0.1cm depth. The note documents the wound was cleaned with wound cleanser and [MEDICATION NAME] dressing was applied. The Wound Documentation Report dated 1/8/17 documents the right ischial crease pressure ulcer is healed. The Wound Documentation Report dated 1/25/17 documents the Stage 2 pressure ulcer on the upper right buttock/coccyx as measuring 1.2cm by 1.2cm by 0.2cm depth with scant drainage, no odor and granulation tissue present. There is no documentation in the record found that Z2 was notified of the increasing size of the ulcer until 1/29/17. The physician's orders [REDACTED]. On 3/8/17 at 4:00pm E2, DON and E17, Regional RN verified R18's pressure ulcer on the right upper buttock/coccyx doubled in size and there was no notification of Z2. E1 Administrator and E17 stated they would expect documentation of notification to be on the Wound Documentation Report (wound assessment) or in the progress notes. The Wound Documentation Report dated 2/1/17 documents the Stage 2 pressure ulcer on the upper right buttock/coccyx as measuring 3.5 cm by 1.5cm by 0.3cm depth, with moderate drainage, no odor and no slough or necrosis present. The Wound Documentation Report dated 2/1/17 documents an initial assessment for a new Stage 2 pressure ulcer on the right lower buttock measuring 1.0cm by 1.0cm by 0.1cm depth. There is no documentation found in the record that Z2 was notified of the increasing size of the upper buttock/coccyx ulcer or the new ulcer on the lower right buttock. On 3/8/17 at 4:00pm E2 and E17 verified R18's ulcer deteriorated and Z2 was not notified. The Wound Documentation Report dated 2/21/17 documents the Stage 2 pressure ulcer on the upper right buttock/coccyx as measuring 3.0cm by 1.4cm and depth UTD (unable to determine), with slough present, scant drainage and no odor. The Wound Documentation Report dated 2/21/17 documents the Stage 2 pressure ulcer on the lower right buttock as measuring 0.5cm by 1.5cm with scant drainage. There is no documentation found that Z2 was notified of the deterioration (slough present) of the upper right buttock/coccyx pressure ulcer. There is no documentation in the record of any pressure ulcer measurements between 2/1-2/21/17. On 3/8/17 at 4:00pm E2 and E17 verified there was no assessment documented in R18's record of the pressure ulcers between 2/1-2/21/17. E2 and E17 verified there was deterioration of R18's ulcers during that period, with no notification to Z2 or treatment change. The physician's orders [REDACTED]. The Wound Documentation Report dated 3/3/17 documents the Unstageable upper right buttock/coccyx pressure ulcer as measuring 3.2cm by 2.0cm and depth UTD, with scant tan drainage with an odor. The report documents the ulcer as being necrotic with dark brown around the edges and tan in the middle. The Wound Documentation Report dated 3/3/17 documents the Unstageable lower right buttock pressure ulcer as measuring 1.0cm by 0.5cm with slough present. There is no documentation in the record that Z2 was notified of the deterioration of the pressure ulcers. On 3/8/17 at 4:00pm E2 and E17 verified the deterioration of R18's pressure ulcers and no notification of Z2 of the deterioration. E2 and E17 stated Z2 was notified on 3/8/17 of the deterioration of R18's pressure ulcers. On 3/7/17 at 2:20 and 3:40pm R18 was lying on her back in bed with her feet/heels resting on the bed. On 3/8/17 at 8:55, 9:03, 9:40, 9:50, 9:55, 10:19 and 10:23am R18 was sitting in the activity room sleeping in the wheelchair. R18's feet/heels were resting directly on the metal footrest of the wheelchair, with no protective leg boot in place. On 3/8/17 at 10:30am Z3 and Z4 , Agency CNA's (Certified Nurse Aides) transferred R18 to bed, positioning her on her back. R18's heels were resting directly on the mattress, with no protective boot on. At 11:05 and 11:30am R18 remained in bed, on her back with her heels resting directly on the mattress. At 11:40am E4, RN removed the dressing from R1's coccyx/buttock pressure ulcers. Tan brown drainage was on the dressing and there was a foul odor present. E4 cleaned the ulcers and applied skin prep to the peri wound (skin around ulcers). E4 then measured R18's upper buttock/coccyx ulcer at 4.6cm by 1.8cm and depth UTD. The wound bed of the ulcer was completely covered with necrotic tissue. E4 then measured R18's lower buttock ulcer at 1.0cm by 1.0cm with a small amount of slough present. E4 then applied Santyl to both wound beds and placed an [MEDICATION NAME] dressing on both ulcers. On 3/8/17 at 11:50am E4, RN verified that R18's air mattress was placed on the bed on 3/7/17. When asked how much drainage there was from the coccyx/buttock ulcers E4 stated, it's hard to tell how much drainage on the dressing, because of urine. E4 stated the dressing has been soaked with urine when she's changed it most of the time and E4 verified that she never notified Z2. On 3/8/17 at 12:25pm E4 stated she had been thinking about the drainage on R18's dressing and was wondering, if it wasn't urine on the dressing, but a large amount of drainage. E4 stated the drainage has increased since the use of Santyl on the ulcers. E4 stated the dressing was intact and didn't smell of urine. The Wound Documentation Report dated 3/8/17 documents the Unstageable upper right buttock/coccyx pressure ulcer measures 4.6cm by 1.8cm and depth UTD, with moderate drainage with an odor. The report documents the ulcer has necrosis which is mostly black with a little tan slimy tissue. The Progress Notes dated 2/16/17, 2/23/17 and 3/2/17, identified as the Medicare Meeting Note, documents that R18 .Being put in bed after meals for pressure relief to help heal ulcers . This intervention was not placed on the care plan until 3/8/17. On 3/8/17 at 4:00pm E2 and E17 verified the intervention identified in the Medicare Meeting Note, to put R18 to bed after meals for pressure relief should have been put on the careplan and implemented. E2 and E17 verified that R18's heels need to be floated with protective boots in bed and R18 needs protective leg boot on when up in the wheelchair. The Physician (Z2) Progress Note dated 3/8/17 documents Z2 recommended a Multivitamin daily, Vitamin C daily, an indwelling urinary catheter and consultation with the Wound Clinic. On 3/9/17 at 9:45am Z2, Physician stated if it's not documented that he was notified or made a response that he is unable to recall if they notified him about R18's pressure ulcers. Z2 stated normally if there is a deterioration (pressure ulcers), he will make a change in the treatment when notified. Z2 stated he doesn't expect any improvement of R18's ulcers. When told that staff didn't reposition, place an air mattress on the bed or monitor/measure R18's ulcers, Z2 was then asked if in his opinion the ulcers were avoidable, Z2 stated, I can't say for sure. Z2 stated it might have made a difference, do I feel that we should have followed the protocol, we should have tried. Z2 stated she's in the endstage (of life) they deteriorate. 2. R16's MDS dated [DATE] documents a [DIAGNOSES REDACTED]. The MDS documents severe cognitive impairment and extensive assistance with bed mobility. The Care Plan dated 2/5/17 documents a Stage 2 pressure ulcer to the coccyx. The Wound Documentation Report dated 2/22/17 documents a initial in-house Stage 2 pressure ulcer of the coccyx measuring 1.0cm by 0.8 by 0.1cm. The Wound Report dated 2/28/17 documents a Stage 4 pressure ulcer of the coccyx measuring 6.5 by 7.0cm by 0.3cm. The report documents wound has appearance of kennedy ulcer. Peri intact however purple discoloration noted. The report documents scant amount of blood, no odor, irregular wound shape and no tunneling or necrosis. On 3/6/17 at 4:15pm E5, LPN (Licensed Practical Nurse) verified that 2/22/17 was the initial assessment of R16's pressure ulcer to the coccyx and it was a very small Stage 2 ulcer. E5 stated the peri wound was red with discoloration. E5 stated then on 2/28/17 the pressure ulcer was a Stage 4. E5 stated when she measured the ulcer she measured the width and length of the purple area, but not the open ulcer which was surrounded by the purple discoloration. E5 stated she did measure the depth of the open area, which was 0.3cm. On 3/7/17 at 8:45am E19, RN removed the dressing from R16's coccyx. E19 then measured the coccyx pressure ulcer at 1.6cm by 1.5cm with slough in the center and serous drainage. The open area was surrounded by a discolored area measuring 5cm by 4.8cm and surrounded by pink which blanched. E19 cleansed the wound, applied skin prep to the peri wound and then place silver alginate on the wound bed and applied an [MEDICATION NAME] dressing. On 3/7/17 at 9:45am E19 stated when she saw the coccyx pressure ulcer on 3/2/17 there was no slough, no drainage and there was one open area, approximately 1.5 by 1cm (not measured) and there were no small open areas around it. E19 stated the ulcer looks much worse today and thinks they need Santyl to debride the slough from the ulcer. 3. According to the current physician's orders [REDACTED]., Cerebral Infarction and [MEDICAL CONDITIONS]. The Minimum Data Set ((MDS) dated [DATE] assesses R1 with severe cognitive impairment, a Stage I pressure ulcer with [MEDICATION NAME] tissue, and requires extensive to total assistance for all activities of daily living. The POS listed a treatment order dated 3/1/17 for the left hip to cleanse area with wound cleanser and apply [MEDICATION NAME] every five days until healed. On 3/6/17 at 10:00am, E2 (Director of Nursing) stated that R14 had a pressure ulcer to the left hip, acquired in the facility. R14 was not in bed at that time, and was up in the high-back specialty recliner chair in the activity room. At 12:15pm, R14 was in the dining room, up in the same recliner chair. No additional cushion was visible in recliner chair. R14 continued in the recliner chair in the dining room at 12:35 and 12:55pm. At 1:15pm, R14 was in the recliner chair in the same position in the activity room, and continued there at 1:30pm, 1:50pm, 2:15pm, 2:30pm, 2:50pm, 3:10pm, 3:30pm and 4:00pm. At 4:00pm, E15 (Registered Nurse/RN) stated, yes, he (R14) must have been up all afternoon. On 3/7/17, R14 was up in the recliner chair at 8:00am, and at 9:00am, 9:15am, 9:30am, 9:45am, 10:00am and 10:15am. At 10:15am, E16 (Certified Nurse Aide/CNA) stated she got R14 up in the chair at 5:30am that morning. At 10:25am, E16 and unnamed agency staff transferred R14 to bed per mechanical lift. R14 had a regular concave mattress with no specialty pressure-reducing mattress. R14's recliner chair also had no cushion in the seat that he had been sitting on since 5:30am. On 3/7/17 at 10:45am, E4 (RN) did the treatment for [REDACTED]. The existing dressing was dated 3/4/17, and had dark serous drainage visible through the dressing. E4 stated at that time the dressing had shadowing and should be changed. Upon removing the dressing, the area directly on the left trochanter was very red approximately two inches around, with a center crater approximately 1/4 inch covered with whitish/gray slough. E4 confirmed that the dressing had serous drainage on it. E4 cleansed the area with wound cleanser and applied the [MEDICATION NAME] dressing as per order. E4 stated at that time that the area was worse because before when she first documented on 2/28/17, there was a small scab or flake over the center, and now the center was open. On 3/8/17 at 11/30am, E4 stated that the original measurements on 2/28/17 were of the entire reddened area, because the center was not open, but now the center is open and covered with slough. E4 stated it would still be unstageable due to the slough. E4 confirmed that she did not measure or document on the area when she changed the dressing on 3/7/17. The electronic Progress Notes dated 2/28/17 states R14 noted to have a reddened area that blanches slowly on his lt (left) hip. It measures 3.5 x (by) 3.5cm (centimeters). Faint thin dry light tan scab present on 0.25% (percent) of wound. Wound cleansed.and [MEDICATION NAME] applied. The Wound Documentation sheet dated 2/28/17 notes the area on the left trochanter as pressure type, 3.5 x 3.5cm with depth undetermined, and Unstageable. The peri-wound skin is described as healthy and pink.round/oval crater like with regular firm edge. No other Progress Notes or Wound Documentation was in the record regarding condition and description of the wound. No evidence was in the record that the physician was notified of the change in condition of the wound noted on 3/7/17. On 3/8/17 at 11:40am, Z1 (Hospice RN) confirmed that R14 had no special pressure-relieving mattress on the bed or cushion in the recliner chair, and they were to be ordered 3/8/17. R14's careplan dated 2/21/17 notes under the skin impairment includes the following interventions: Skin care, preventative measures and/or impairment treatments as ordered/needed.Pressure-relief management and preventative skin measures/barriers and turning as needed to minimize risks. Provide turning/repositioning/pressure- relieving assist.as needed for proper position and comfort. Seek additional chair or bed padding if needed for comfort/pressure reduction. When applicable, provide weekly wound measurements as indicated. Report site decline to MD (medical doctor).

Failures at this citation resulted in four deficient practices. 1. Based on observation, interview, and record review, the facility failed to ensure the safety of a mechanical lift for one of six residents (R6) reviewed for falls in the sample of 13. R6 was dropped from a mechanical lift on two separate occasions as a result of the lift's mechanical failure. R6 is one of six residents reviewed for falls in the sample of 13. These failures have the potential to affect four other residents (R18, R27, R28, R29) who use the full mechanical lifts for transfers. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 05/03/13, the facility remains out of compliance at severity level two as the facility is in the process of evaluating the effectiveness of staff education and counseling regarding proper use of the lift, and monitoring maintenance compliance with thorough documentation of lift specific repairs. Findings include: R6's Physician order [REDACTED]. R6's Minimum Data Sets ((MDS) dated [DATE] documents that R6 requires extensive assistance with transfers, and that R6 has bilateral upper extremity impairment and impairment of one lower extremity. R6's MDS dated [DATE] documents that R6 is totally dependent on staff for transfers. R6's MDS dated [DATE] documents that R6 has bilateral impairment of her upper and lower extremities and is totally dependent on staff for bed mobility. R6's Fall Risk Assessments dated 10/02/12 and 12/23/12 document that R6 was at risk for injury from falls. R6's Care Plan was updated on 12/05/12 and documented that R6 transfers using a full mechanical lift. The Facility's Resident Accident Report dated 01/03/13 at 1:05pm documents that R6 fell again from the full mechanical lift as she was being lifted to her bed by E11, Registered Nurse (RN) and E12, Certified Nursing Assistant (CNA). R6 fell from the air when being raised by the full mechanical lift, landed on another resident's bed, and then fell on to the floor. R6 sustained no injury. The Report documents the cause of the event as "Lift malfunction, mechanical failure." The documented Corrective Actions Taken on 01/03/13 is "Maintenance department to assess the lift." Follow up, dated 01/04/13, was "(full mechanical lift) taken out of service, (checked) by maintenance, new parts ordered, checked weekly by maintenance." On 05/03/13 at 9:52am, E12, CNA, stated that she and E11, RN, transferred R6 on 01/03/13 at 1:05pm using the full mechanical lift. E12 stated that when R6's wheelchair was pulled back from under the resident and sling, the lift fell over on its side and "bolts came out of one leg of the (lift)." On 05/03/13 at 10:02am, E11, RN, stated that she and E12 had attempted to transfer R6 on 01/03/13 using the full mechanical lift. E11 stated that the lift collapsed as they began to move the lift forward (with R6 in the air), and that "a pin fell out of the (lift)." E11 stated that she immediately called maintenance and notified them of the lift's failure. The Facility's Resident Accident Report dated 02/28/13 at 12:45pm documents that R6 fell from the full mechanical lift to the floor while being transferred to her bed by E14, CNA, and E20, CNA. The report documents that the full mechanical lift tipped over onto its side during the transfer. R6 sustained no injury. The documented Cause of Event was "Possible lift malfunction--Res (resident) wt (weight)--lg (large) body mass." The Corrective Action taken was "Lift taken out of service. Staff in-serviced (reinserviced) on proper use of a lift." The Weekly Lift and Sling Check document that the full mechanical lift #2 was out of order on 03/03/13 (two days after the last fall). On 05/03/13 at 9:45am, E14, CNA, stated that the full mechanical lift appeared normal prior to using it to transfer R6 on 02/28/13. On 05/03/13 at 9:57am, E20, CNA, stated that on 02/28/12, she and E14 transferred R6 using the full mechanical lift. E20 stated that R6 was lifted into the air and as the lift was pushed forward toward R6's bed, it fell on to its side, causing R6 to fall onto the floor. E20 stated that the top piece of the lift (boom) appeared bent after the fall. On 05/03/13 at 9:15am, E8, Maintenance Director, stated that he does not remember the incident on 01/03/13 involving use of the full mechanical lift. E8 stated that he may have been notified of the incident and that he may have ordered parts for the lift. E8 stated that he often orders parts to repair each of the four lifts, but he does not document what repairs are made on which lift, when the lifts are taken out of service, or when the lifts are returned to service. E8 was unable to produce a purchase order or any documentation of which repairs were made to which lift. E8 stated that following R6's fall on 02/28/13, the full mechanical lift #2 appeared to have a bent boom, so lift #2 was taken out of service and a new lift was ordered to replace lift #2. On 05/03/13 at 1:20pm, E8 stated that after reviewing the Weekly Lift and Sling Check, he is certain that lift #1 was the lift used with R6's transfer on 01/03/13. The Weekly Lift and Sling Check document that the full mechanical lift #1 was out of order on 01/05/13 (two days after the fall) and 01/12/13, and that it was back in use on 01/20/13 during the weekly check. E8 was unable to identify when lift #1 was put back into use. E8 stated that he cannot remember what was wrong with the lift, what was replaced, or when it was repaired. E8 was unable to produce any record of repairs or servicing to lift #1. E8 stated that a purchase order was placed on 03/04/13 for a full mechanical lift. The new lift replaced lift #2. On 05/03/13 at 9:20am, E19, Maintenance Staff, stated that he did not remember any incidents involving the full mechanical lifts or any repairs completed on the lifts in January or February 2013. The Weekly Lift and Sling Check document that the facility maintains four lifts: two full mechanical lifts and two stand aid lifts. On 05/07/13 an Internet purchase order was retrieved by E1, Administrator, for an order placed on 01/03/13 for "a replacement handle mount; a lift part, spring compression; lift part, screw shoulder; and lift part, tie rod." A purchase order was also retrieved for an order placed on 03/04/13 for a "(Mechanical) Floor Lift, Powered Low-Height Base" (four days after the fall of 02/28/13). On 05/08/13 at 10:00am, E1 stated that no other documentation was available for what repairs were made to which lift, the final status of the lift prior to being put back into use by staff, or when the new lift was put into use. On 05/08/13 at 10:00am, E1 produced a typed statement signed by E19 on 05/08/13 which states that lift #1 was taken to the maintenance department on 01/03/13, with a bent left tie rod and loose bolt. The statement reported repairs being made on 01/14/13. E1 stated that she did not know why E19 was unable to report this information on 05/03/13 at 9:20am when asked by the surveyor. The Facility's undated (Full Mechanical Lift) Procedure does not direct staff to observe the lift for loose, missing, or bent parts prior to performing resident transfers using the full mechanical lift. On 5-3-13 E1, Administrator provided a list of four additional residents requiring the use of a full mechanical lift which included R18, R27, R28, and R29. On 05/03/13 an Immediate Jeopardy was identified to have begun on 01/03/13 when the full mechanical lift collapsed, and R6 fell on to the floor. On 05/03/13 at 2:15pm, E1, Administrator, was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 05/03/13. The surveyor confirmed through observation, interview, and record review on 05/03/13 that the facility took the following actions to remove the Immediate Jeopardy: 1. Lifts #1-#4 were immediately removed from service on 05/03/13 at 2:15pm. Completed by Administrator and Maintenance Director. 2. Lifts #1-#4 were inspected and deemed in good working order on 05/03/13 at 5:05pm. Completed by Administrator and Maintenance Director. 3. All staff were educated on the proper use of the lifts, the safety checklist, and the safety checklist for slings on 05/03/13 at 5:05pm. Completed by Administrator and Maintenance Director. 4. Return demonstration by staff performing transfers using Lifts #1 and #2 on 05/03/13 at 5:05pm. 2. Based on observation, record review and interview the facility failed to identify a lap tray table as a strangulation/entrapment risk, failed to initiate new interventions, and failed to identify medical symptoms for use of the lap tray table after a fall for one of three residents (R12) reviewed for restraints in the sample of 13. R12 slid underneath the lap tray table becoming entrapped. The facility continued to use the device after the entrapment without any new assessment or interventions to provide for the safety of R12. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 5/3/13, the facility remains out of compliance at severity level two. The facility is in the process of evaluating the effectiveness of staff education and counseling regarding proper use of restraints to treat medical symptoms, monitoring of the resident with a restraint and the risks that are involved when using a physical restraint. Findings include: The Physician order [REDACTED]. The POS reflects a telephone order dated 9/11/12 for the use of a table tray. The Minimum (MDS) data set [DATE] for R12 documents severe cognitive impairment. The facility's document titled "Pre-Restraining Assessment" and dated for 9/13/12 documents R12's balance as, leans forward, leans sideways to the left, and slides down. Under ambulation the document notes R12 as unsteady on feet, history of falls and is able to take short steps. R12's fall risk assessment dated for 3/6/13 documents R12 as high risk for falls. On 5/2/13 at 5:10 pm R12 was in the dining room sitting upright in her wheelchair with good trunk control. R12 had restless behaviors during the meal, attempting to get out of her wheelchair several times. On 5/3/13 at 9:00 am R12 was sitting upright in her wheelchair with good trunk control, the tray table was in place. R12 was self-propelling down the hall. The facility's policy titled "Physical Restraint Policy And Protocols for Reduction states: "A restraint is any device designed to limit movement to protect resident from injuring self and others. Restraints include lap cushions and lap trays, bed rails to keep resident from voluntarily getting out of bed, chairs that prevent rising (reclining geriatric chair, belts, and self-release devices). Any resident who a physician prescribes a physical restraint for, must have a Physical Restraint Reduction Assessment completed at the time the order is obtained by the attending physician." The facility policy does not direct staff to identify any medical symptoms warranting restraints used in their facility. The facility document titled "Resident Accident Report" and dated 3/10/13 documents the following fall with no injury for R12. R12 was discovered sitting on the floor in front of her wheelchair with her left arm up under the lap tray table with table attached to wheelchair. No new intervention was put in place and no reassessment of the physical restraint was done. The lap tray table was continued. On 5/2/13 at 5:25 pm E10, (CNA) stated that R12 was known to slide down under her lap tray table and stated "Oh yeah she can slide down and get out of the chair, she is a regular Houdini, even over the pummel cushion. She can get out of just about anything." On 5/3/13 at 1:20 pm E13, Licensed Practical Nurse (LPN) stated that he was very familiar with R12 and has cared for her numerous times. E13, LPN stated that R12 is checked on ..."I know at least every hour, and she has been found to have slid down in her wheelchair trying to get out, but we just pull her up." R12's Care Plan dated 3/6/13 documents R12 as being at an increased risk for falls due to her poor safety awareness and her history of falls. R12 is to have a Lap Tray when up in wheelchair to help with posture and positioning and R12's lack of safety awareness. There is no approach or direction to staff documented in the Care Plan for any type of monitoring for the risk of entrapment or strangulation in association to R12 and the lap tray table. The Care Plan does not address any new intervention following the 3/10/13 fall and R12's subsequent entrapment in her lap tray table. On 5/7/13 at 3:15 pm Z1 (R12's Healthcare Power of Attorney) stated that he was told by the facility that the restraints were used on R12 because of her falling all the time and they were to keep her from getting out of her wheelchair and falling. The Immediate Jeopardy was identified on 5/3/13 at 2 p.m. The Immediate Jeopardy was identified to have begun 3/10/13 when R12 was discovered by staff to be entrapped by her wheelchair tray table without subsequent assessment and new intervention. E1, Administrator was informed of the Immediate Jeopardy on 5/3/13 at 2:15 p.m. The Immediate Jeopardy was removed on 5/3/13. The surveyor confirmed through observation, interview and record review on 5/3/13 that the facility took the following actions to remove the Immediate Jeopardy: 1. Tray table and pommel cushion were removed from R12 and R12 was placed on one to one supervision while up in wheelchair to continue until not needed and based on R12's needs. Completed By E1, Administrator, and completed on 5/3/13. 2. Foot pedal with foot board to be used during transport of R12 to prevent injury related to propelling self out of wheelchair and injury to lower extremities. Completed by E1, Administrator and completed on 5/3/13. 3. All staff to be educated by E1, Administrator on R12's care, including no tray table restraint on wheelchair, one to one staff supervision while up in wheelchair and foot pedals with foot board while being transported. New employees to be educated upon hire. 4. Interdisciplinary team to review restraints and restraint policy consisting of: Quality Assurance team, Department Managers, Nursing Supervisors and Board of Directors, to be completed on 5/3/13. 5. R12's Primary Care Physician and Medical Director notified of R12's change in plan of care and Immediate Jeopardy on 5/3/13 at 4:00 p.m. by E1, Administrator. The following examples are cited at non-immediate jeopardy level: 3. Based on interview and record review, the facility staff failed to have two staff persons assist with transfers as prescribed by R6's Plan of Care. During a one-person transfer, R6 slid off the wheelchair seat, got stuck between the wall and wheelchair, was lowered to the floor, and sustained a fractured ankle. R6 is one of six residents reviewed for falls in the sample of 13. Findings include: R6's Physician order [REDACTED]. R6's Minimum Data Sets ((MDS) dated [DATE] documents that R6 requires extensive assistance with transfers with the physical assistance of two or more staff, and that R6 has bilateral upper extremity impairment and impairment of one lower extremity. R6's Fall Risk assessment dated [DATE] documents that R6 was at risk for injury from falls. Resident Accident Reports document that R6 has a history of falls. R6 fell [DATE], 07/30/12, 08/04/12, 12/03/12. R6's Care Plan dated 04/20/12 documents that R6 transfers with a gait belt and the assistance of two staff. The Facility's Resident Accident Report dated 12/03/12 at 1:45pm documents that E28, CNA, attempted to transfer R6 from the toilet to her wheelchair by herself. The Report documents that R6 slid off of the seat of her wheelchair and became stuck between the wheelchair and the wall. The Report documents that E28 then had E29, CNA, assist her in lowering R6 to the floor. R6's emergency room Report dated 12/04/12 documents that R6 sustained a left "bimalleolor fracture involving the medial and lateral malleoli." R6's Radiology Report dated 12/04/12 documents a left "fracture through the ...posterior malleolus of the distal tibia. There may be a possible fracture which extends through the base of the medial malleolus as well." On 05/08/13 at 10:45am E28 did not answer her phone and she did not return the phone call. On 05/08/13 at 10:46am E29 did not answer her phone and she did not return the phone call. On 05/08/13 at 10:50am, E13, Licensed Practical Nurse (LPN), stated that E28 told him that R6 had fallen when being transferred by her (E28) from the toilet to the electric wheelchair. E13 stated that he did not know why E28 transferred R6 by herself, and that all staff were aware that R6 required the assistance of two CNAs for transfer. Nurse's Notes written by E13 and dated 12/03/12 document that R6 "fell down off the front of her wheelchair after toileting. Res (resident) was not all the way back in seat (of the wheelchair)." The Progressive Discipline Notification dated 12/10/12 documents that E28 violated safety practices that might cause injury to self, coworker, resident, or visitor on 12/03/12 and that the (resident's) Care Plan must be followed. On 05/08/13 at 10:00am, E1, Administrator, stated that E28 and E29 no longer worked at the facility. 4. Based on record review and interview the facility failed to follow their plan of care for R13 regarding fall interventions. Failure to follow R13's plan of care by not keeping R13's wheel walker out of reach resulted in R13 trying to use the wheel walker and falling. R13 sustained a left wrist fracture due to the fall. R13 is one of six residents reviewed for falls in a sample of 13. Findings include: The physician's orders [REDACTED]. The Minimum Data Set (MDS) dated 2/25/13 documents that R13 is severely impaired in daily decision making skills, requires extensive assistance with one staff for bed mobility, transfers and toilet use. The MDS states R13's balance during walking is not steady and R13 is only able to stabilize with staff assistance. The facility Fall Risk assessment dated [DATE] documents R13 as being at moderate risk for injury. The facility's Report titled "Resident Accident Report" dated 3/11/13 at 7 AM states R13 was found sitting up with back against bed and legs straight out. Bleeding from cut above left eye and left wrist swollen and painful... No socks on and on a diuretic..." The facility's report titled " Resident Post-Fall Assessment" dated 3/11/13 documents the reason R13 was getting up was R13 wanted to get walker to go to the bathroom. The section stating " Was Resident 's Environment Free of Obstacles" documents "No, walker next to bed." R13's Nurses Notes dated 3/11/13 at 7 AM reads "....(R13) attempted to get out of bed by herself to use bathroom, (R13) stood up with walker and fell on to her left side..." Nurses Notes dated 3/11/13 at 11:15 AM documents ...Orders received to send to hospital .." R13's Portable X-ray Report dated 3/11/13 documents "Left Wrist, 3 Views There is an acute mildly displaced fracture of the distal radial metaphysis, with dorsal angulation. The ulnar styloid is also fractured....." R13's Plan of Care dated 3/1/13 documents as interventions for prevention of falls: "Encourage me to wear non-skid shoes or non-skid slippers or non-skid socks before I stand, transfer or ambulate--encourage me to wear non-skid socks during the night-make sure the gripper side is towards the floor...Keep my walker out of my reach until I am stronger." On 5/7/13 at 1:30 PM E1, Administrator confirmed that R13's walker was within the reach of R13 and the walker should have been out of R13's reach. E1 also confirmed R13 did not have on her non-skid slippers.