Every finding on record at Belle Maison Nursing & Rehabilitation Center, LLC

Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure:1. Staff utilized proper Personal Protective Equipment (PPE) while providing care for 3 (#1, #56, and #70) of 4 sampled residents observed on Enhanced Barrier Precautions (EBP).2. Staff followed proper glove usage and perineal wipe supply management to prevent cross contamination for 1 (#2) of 3 residents observed during incontinence and perineal care. Review of the facility's policy titled Enhanced Barrier Precautions dated 08/2024 revealed the following, in part:Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes. This involves gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices.High-contact resident activities include: bathing, providing hygiene, wound care. Review of the facility's undated policy titled Catheter Management revealed the following, in part: Procedure: 5. Perform cleansing and care of the catheter insertion site: a. put on clean gloves. b. Cleanse genitalia. Note: Do not contaminate area with feces. If resident has had an involuntary bowel movement, clean this area first. Then obtain clean equipment for catheter care and begin the procedure. 1.Resident #1Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with the diagnoses which included Gastrostomy Status.Review of Resident #1's current Physician's Orders revealed the following: Enhanced Barrier Precautions utilized when performing high-contact resident care activities related to feeding tube.On 06/08/2026 at 9:15 a.m., an observation made of Resident #1's door sign indicated he was currently on Enhanced Barrier Precautions. Observed S6CNA perform a bed bath for Resident #1. S6CNA did not don a gown during this direct care.On 06/08/2026 at 9:20 a.m., an interview was conducted with S6CNA. She stated Resident #1 had a feeding tube and was currently on Enhanced Barrier Precautions. She confirmed she did not wear a gown during his direct care and should have.Resident #56Review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE] with the diagnoses which included Other Soft Tissue Disorder Right Ankle and Foot. Review of Resident #56's current Physician's Orders revealed the following: Enhanced Barrier Precautions utilized when performing high-contact resident care activities.On 06/08/2026 at 9:30 a.m., an observation made of Resident #56's door sign indicated she was currently on Enhanced Barrier Precautions. Observed S6CNA perform a bed bath for Resident #56. S6CNA did not don a gown during this direct care.On 06/08/2026 at 9:40 a.m., an interview was conducted with S6CNA. She stated Resident #56 had a wound and was currently on Enhanced Barrier Precautions. She confirmed she did not wear a gown during her direct care and should have.Resident #70Review of Resident #70's Clinical Record revealed she was admitted to the facility on [DATE] with the diagnoses which included Non-Pressure Chronic Ulcer of Other Part of Left Lower Leg with Unspecified Severity and Encounter for Change or Removal of Nonsurgical Wound Dressing. Review of Resident #70's current Physician's Orders revealed the following: Enhanced Barrier Precautions utilized when performing high-contact resident care activities related to venous stasis ulcer bilateral lower extremities (chronic wounds). Wound care to be completed to as needed and Monday, Wednesday and Friday to bilateral lower extremity venous stasis ulcers. On 06/08/2026 at 9:13 a.m., an observation made of Resident #70's door sign indicated she was currently on Enhanced Barrier Precautions. On 06/08/2026 at 9:14 a.m., an observation was made of S8WC performing wound care to Resident #70. S8WC was observed applying clean dressings to Resident #70's lower extremities. S8WC did not have a gown donned. On 06/08/2026 at 9:21 a.m., an interview was conducted with S8WC. She stated Resident #70 had chronic venous stasis ulcers and was currently on Enhanced Barrier Precautions. She stated if a resident had chronic wounds she should don a gown, gloves, and mask when preforming care. She stated she did not have a gown on during Resident #70's wound care, but should have. 2.Resident #2 Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Obstructive and Reflux Uropathy and Unspecified Bladder-Neck Obstruction, Urinary Tract Infection, Infection and Inflammatory Reaction Due to Indwelling Urethral Catheter. Review of Resident #2's most recent Quarterly MDS, with an ARD of 04/21/2026 indicated he had bowel incontinence. On 06/09/2026 at 11:47 a.m., an observation was made in Resident #2's room. S5CNA entered Resident #2's room with perineal care supplies, which included a pack of wipes, and donned a gown and gloves. S5CNA placed the wipe pack on Resident #2's bed and used the wipes to clean his buttocks which was soiled with feces. Without removing the soiled gloves, she touched the top and side of the wipe pack and pulled out more wipes two times to completely clean feces from Resident #2's buttocks. Without removing the soiled gloves, S5CNA removed the feces soiled diaper, touched a clean diaper and Resident #2's hands. Without removing the soiled gloves, S5CNA touched the top and side of the wipe pack and pulled out wipes to clean Resident #2's penis and urinary catheter. Without removing the soiled gloves, S5CNA touched two wedge pillows, the right and left leg boots, repositioned Resident #2, and used the bed remote to elevate the bed. S5CNA removed the gown and soiled gloves and exited Resident #2's room. S5CNA reentered Resident #2's room and got the wipe pack from Resident #2's bed, exited the room, and placed the contaminated wipes on the cart in the hallway. On 06/09/2026 at 12:09 p.m., an interview was conducted with S5CNA. S5CNA confirmed during perineal care she cleaned feces from Resident #2's buttocks and did not change her soiled gloves before she cleaned his penis and urinary catheter and should have. She further confirmed she did not change her gloves after she cleaned the urinary catheter and before she touched Resident #2 and clean items in the room and should have. S5CNA confirmed she placed the wipe pack on Resident #2's bed and used the pack of wipes during perineal care, removed the pack of wipes from the bed, and placed it on the cart in the hall to use for the next resident and should not have. On 06/10/2026 at 12:55 p.m., an interview was conducted with S2DON. S2DON confirmed a resident with a feeding tube or a wound would be on Enhanced Barrier Precautions. She stated she expected all staff to don a gown and gloves during direct resident care when a resident was on Enhanced Barrier Precautions. S2DON confirmed during perineal care, she expected staff to remove soiled gloves before cleaning the urinary catheter and before touching any other clean items in the resident's room.

Based on observations and interviews, the facility failed to ensure medications were properly stored in 2 (Medication Cart 1 and Medication Storage room [ROOM NUMBER]) of 4 medication carts/storage rooms observed for medication storage.Findings:Review of the facility's undated policy titled Medication Storage In The Facility revealed in part, the following:Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the suppliers. Procedure:13. Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. On 06/08/2026 at 9:00 a.m., an observation was conducted with S2DON of Medication Storage room [ROOM NUMBER]. An observation of the medication storage room refrigerator revealed 6 unopened boxes of Flucelvax 2025-2026 with an expiration date of 05/20/2026. Resident #5Review of Resident #5's clinical record revealed an admission date of 09/20/2024 with diagnosis of Functional Dyspepsia. Review of Resident #5's Physician Orders revealed the following:Start Date: 09/03/2024- Ondansetron 4mg one tablet orally every four hours as needed for nausea vomiting. Review of Resident #5's Medication Administration Record for May/June 2026 revealed administration of Ondansetron 4mg on 05/21/2026 and 06/04/2026. Resident #94Review of Resident #94's clinical record revealed an admission date of 12/18/2024 with diagnosis of Chronic Pain Syndrome Review of Resident #94's Physician Orders revealed the following:Start Date: 12/18/2024- Meloxicam 15mg one tablet by mouth every twenty-four hours as needed for pain. On 06/08/2026 at 9:20 a.m., an observation was conducted with S2DON of Medication Cart 1. An observation of the medication cart revealed the following medications were expired:Resident #5- Ondansetron 4mg, expired 04/20/2026Resident #94- Meloxicam 15mg, expired 03/27/2026 On 06/08/2026 at 2:05 p.m., an interview was conducted with S3RN. She stated she conducted weekly audits of Medication Storage room [ROOM NUMBER] and random audits on Medication Cart 1. S3RN was made aware of the aforementioned findings of expired medications observed. S3RN stated she failed to identify medications as being expired. S3RN confirmed expired medications should be discarded immediately and should not be available for resident use. On 06/08/2026 at 9:30 a.m., an interview was conducted with S2DON. She observed and confirmed the above findings of stored pharmacologicals were expired and should have been discarded and not available for resident use.

Based on observations, interviews, and record review, the facility failed to store foods under sanitary conditions. The facility failed to ensure Food items were dated after opening. This deficient practice had the potential to affect 116 residents who were provided meals from the facility's kitchen.Findings: Review of the facility's undated policy titled Date Marking for Food Safety revealed in part, the following:2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or prepared. During the initial tour of the facility's kitchen on 06/08/2026 at 8:15 a.m. with S4DM, the following observations were made: Freezer: 1 Chocolate pie, partially consumed, undated Pantry/Dry Storage: 3 16 oz boxes of corn starch, opened, undated 1 Beef Flavoring Base container, opened, undated 1 Medium cookie pieces, opened, undated 1 Box/container/bag of Pasta Enriched Noodles, opened, undated An interview was conducted on 06/08/2026 at 8:30 a.m. with S4DM. S4DM confirmed the aforementioned items in the Freezer and Pantry/Dry Storage being opened with no date or label. S4DM confirmed all opened food items should be dated and labeled with an open date and were not. An interview was conducted on 06/09/2026 at 4:30 p.m. with S1ADM. S1ADM confirmed all opened food items should be dated and labeled with an available fluorescent sticker to indicate when it was opened as well as with an expiration date to indicate when it needed to be discarded.

Based on observations, interviews, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevention of infection. The facility failed to timely complete pressure ulcer dressing change as needed for wound dressing soilage for 1 (#2) of 2 residents who were observed for wound care.Findings:Review of the facility's undated policy titled Dressing Changes (Sterile/Clean) revealed the following, in part:Policy:Dressings are used to protect a wound from contamination, provide support and pressure as needed to absorb drainage, and prevent drying of an open wound. Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Osteomyelitis of Sacral and Sacrococcygeal Region. Review of the Resident #2's current Physician Orders revealed the following, in part:Start Date: 06/02/2026. Pressure ulcer to left buttock- Clean with wound cleanser, pat dry, apply Santyl to wound bed and cover with bordered foam dressing as needed for dislodgement or strikethrough until resolved. Every 5 minutes as needed; andStart Date: 5/11/2026. Pressure ulcer to sacrum- Clean with wound cleanser, pat dry, apply xeroform to wound bed, cover with hydrafera blue foam, and secure with dry bordered dressing every day as needed for soilage and strikethrough until resolved. Every 5 minutes as needed An observation was made on 06/09/2026 at 11:47 a.m. of S5CNA entering Resident #2's room to perform perineal care after a small bowel movement. S5CNA turned Resident #2 to his right side and his sacral wound and left buttock wound was visible with no dressing. S5CNA completed perineal care and exited Resident #2's room. An interview was conducted on 06/09/2026 at 12:09 p.m. with S5CNA. S5CNA confirmed Resident #2 did not currently have a dressing to the sacral and left buttock wound because she removed them. S5CNA stated this morning right before breakfast Resident #2 had a large bowel movement, and she completed perineal care. S5CNA stated Resident #2 did have a dressing on the sacral and left buttock wounds, which were both wet, soiled, and not intact. S5CNA stated she removed the sacral and left buttock wound dressings. S5CNA stated she notified, S8WC, between 8:00 a.m.-9:00 a.m., the dressings were removed and needed redressing. An observation was conducted on 06/09/2026 at 2:13 p.m. of S8WC performing Resident #2's wound care. S5CNA turned Resident #2 to his right side and his sacral wound and left buttock wound was visible with no dressing. S8WC completed wound care and applied dressings to the sacral wound and left buttock and exited the room. An interview was conducted on 06/09/2026 at 3:29 p.m. with S8WC. S8WC stated at 12:00 p.m. S5CNA reported to her the sacral and left buttock wound dressings were removed and was not aware he had a large bowel movement. S8WC stated the CNAs were expected to immediately notify her when Resident #2's wound dressings was soiled and/or removed and did not. An interview was conducted on 06/10/2026 at 12:58 p.m. with S2DON. S2DON stated she expected CNA's to immediately report to the nurse or wound care nurse of a resident who had a large bowel movement and wound dressings were soiled and/or removed. S2DON stated Resident #2 should have been provided wound care as needed per wound care orders and wound dressing change performed immediately after soiled dressings were identified for infection control.

Based on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure free water flushes were administered per physician's orders for 2 (#1 and #75) of 2 residents reviewed for tube feedings.Review of the facility's undated policy titled Gastrostomy Tube revealed in part, the following:1. Flush tube as ordered by doctor.Resident #1Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status.Review of Resident #1's current physician orders revealed in part, the following:Every shift, flush tube with 40 mL of free water an hour.An observation was made on 06/08/2026 at 9:15 a.m. of Resident #1's tube feeding pump. Observed water flush infusing at 30 mL/hr.An observation was made on 06/08/2026 at 1:25 p.m. of Resident #1's tube feeding pump. Observed water flush infusing at 30 mL/hr.Resident #75Review of Resident #75's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Encounter for Attention to Gastrostomy added on 07/31/2025.Review of Resident #75's current physician orders revealed in part, the following:Every shift, continuous free water flush 40mL/hr.An observation was made on 06/08/2026 at 9:31 a.m. of Resident #75's tube feeding pump. Observed water flush infusing at 30 mL/hr.An observation was made on 06/08/2026 at 1:30 p.m. of Resident #75's tube feeding pump. Observed water flush infusing at 30 mL/hr.An interview was conducted on 06/08/2026 at 1:30 p.m. with S6LPN. She reviewed Resident #1 orders and stated water flushes should be 30mL/hr and were currently infusing at 30mL/hr. She reviewed Resident #75's orders and stated water flushes should be 30mL/hr and were currently infusing at 30mL/hr. She would not confirm Resident #1 and Resident #75's current orders were for water flushes at 40mL/hr.An interview was conducted on 06/08/2026 at 1:40 p.m. with S2DON. She reviewed Resident #1 and Resident #75's orders and confirmed water flushes should be 40mL/hr. She stated she expected water flushes to be infused at the ordered rate.

Based on record review and interviews, the facility failed to ensure staff completely and accurately documented resident tube feeding administration and monitoring per physician orders for 1 (#2) of 26 sampled residents' MARs reviewed. Findings: Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection, Infection and Vascular Dementia with Mood Disturbance. Review of the Resident #2's current Physician Orders revealed an order for an antipsychotic medication.Further review revealed the following Physician Orders, in part:Start date: 10/30/2025. Monitor for side effects of psychotropic meds. Document any side effects in the nurse's notes and notify the MD. Start date: 10/30/2025. Monitor for behaviors (is on psychotropic med). Document any behaviors in the nurse's notes and notify the MD. Every shift;Start date: 10/30/2025. Monitor for signs/symptoms of COVID-19. Signs/symptoms could include sore throat, cough, fever, nausea, vomiting, or headache. If signs/symptoms present, implement contact/droplet precautions, notify MD and document in nurse's notes. Every shift;Start date: 12/19/2025. Enteral Feed every night shift. Change open feeding system administration set daily; label the formula bag and administration set with resident's identifying information; andStart date: 01/20/2026. Monitor color of urine every shift for retention Additional directions: 1 = light yellow; 2 = dark yellow; 3 = amber; 4 = bloody; 5 = other. Call MD if changes occur. Review of Resident #2's Medication Administration Record dated May 2026 revealed the following medication administration and monitoring with blank boxes on 05/17/2026 at 2200 for the following physician orders, in part:Monitor for side effects of psychotropic meds;Monitor for behaviors (is on psychotropic med); Monitor for signs/symptoms of COVID-19;Enteral Feed every night shift; andMonitor color of urine every shift for retention. Review of Resident #2's Nursing Notes dated May 2026 revealed no documentation of the above mentioned physician orders were completed for 05/17/2026. Review of the facility's May 2026 staff schedule revealed S9LPN worked the night shift, 10:00 p.m. to 6:00 p.m., on 05/17/2026. An interview was conducted on 06/10/2026 at 3:26 p.m. with S9LPN. S9LPN stated she worked with Resident #2 in May 2026. Resident #2's missing MAR documentation was reviewed with S9LPN. S9LPN stated a blank box on the MAR indicated she did not completely and accurately document, and she should have. An interview was conducted on 06/10/2026 at 12:58 p.m. with S2DON. S2DON stated she expected nurses to document immediately after providing care/ and or administering tube feeding and completing monitoring per MD orders. She stated when there was a blank box on the MAR, it indicated there was no documentation accurately completed. She reviewed Resident #2's MAR dated May 2026 and confirmed the above missing documentation. She stated the nurse should have ensured Resident #2's MAR documentation was accurate and complete and did not.

Based on record reviews and interviews, the facility failed to develop a comprehensive person centered care plan, which addressed the type of feeding assistance needed for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for comprehensive person centered care plans.Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Sequelae of Cerebral Infarction, Dysphagia, Need for Assistance with Personal Care, Specified Forms of Tremor, Hereditary and Idiopathic Neuropathy, and Muscle Weakness. Review of Resident #1's most recent comprehensive person centered care plan revealed no documented evidence of feeding assistance interventions. An observation was made on 09/03/2025 at 8:32 a.m. of S3CNA providing feeding assistance to Resident #1. Resident #1 noted to have bilateral upper extremities resting on bed while S3CNA delivered food and hydration to Resident #1's mouth without his assistance. An interview was conducted on 09/03/2025 at 8:35 a.m. with S3CNA. S3CNA confirmed Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/03/2025 at 8:45 a.m. with S2LPN. S2LPN confirmed Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/04/2025 at 8:45 a.m. with S4CNA. S4CNA confirmed Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/04/2025 at 8:50 a.m. with S5LPN. S5LPN confirmed Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/04/2025 at 9:25 a.m. with S6TD. S6TD stated she had provided Occupational Therapy services to Resident #1. S6TD stated Resident #1 was dependent upon staff to feed him all meals. An interview was conducted on 09/04/2025 at 9:50 a.m. with S7CCC. S7CCC stated she was responsible for Resident #1's comprehensive person centered care plan. S7CCC confirmed Resident #1 did not have any interventions care planned for feeding assistance and should have. An interview was conducted on 09/04/2025 at 11:20 a.m. with S1DON. S1DON confirmed residents requiring feeding assistance should have a comprehensive person centered care plan that reflected individualized feeding interventions to ensure the resident received proper care and support.

Based on interviews and record reviews, the facility failed to maintain accurate documentation for 2 (#66 and #122) of 22 (#1, #2, #3, #5, #7, #8, #10, #11, #32, #37, #44, #48, #50, #51, #58, #62, #68, #72, #75, #96, #97, and #113) sampled residents. The facility failed to ensure:1. Resident #66's oxygen use was accurately documented; and2. Resident #122's death note was accurately documented.1.Review of Resident #66’s clinical record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Dementia. Review of Resident #66’s Physician Orders revealed in part, the following: [DATE] Check Oxygen (O2) saturation routinely, every shift Notify Medical Doctor (MD) if less than 90%. Review of Resident #66’s [DATE]-[DATE] Medication Administration Record (MAR) revealed in part, the following: No evidence of documentation of oxygen saturation every shift, on the following dates: [DATE] day shift, [DATE] day shift, [DATE] day shift, [DATE] day shift, [DATE] day shift, [DATE] day shift and evening shift, [DATE] day shift and evening shift, [DATE] day shift and evening shift, [DATE] day shift and evening shift, [DATE] day shift and evening shift, [DATE] day shift, [DATE] day shift, and [DATE] day shift. On [DATE] at 2:01 p.m., a telephone interview was conducted with S3LPN. S3LPN stated Resident #66 at times would refuse getting her O2 checked. Review of the nurses’ notes of the aforementioned dates revealed no nurses’ notes related to Resident #66's refusal of treatment or oxygen saturation. On [DATE] at 2:16 p.m., an interview was conducted with S1DON. S1DON confirmed there was no documentation for the aforementioned dates of Resident #66’s oxygen saturation and no nurses’ notes documenting Resident #66’s refusal of treatment and there should have been. 2. Review of the facility’s undated policy titled “Death of a Resident” revealed in part, the following:Upon the death of a resident, nursing documentation must include:1. Date and time of death of resident.2. Pertinent details related to death event.3. Physician notification.4. Family notification, name of person to whom body was released. Review of Resident #122’s clinical record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #122 expired while on hospice care on [DATE]. Review of nurse's notes dated [DATE] revealed in part, the following:[DATE] at 1:58 p.m. - expired. On [DATE] at 2:30 p.m., an interview was conducted with S1DON. S1DON reviewed Resident #122’s physical and electronic medical record. She stated a death note should consist of at least the following: notification to the hospice nurse, assessment of resident, notification to the family, name of person who called time of death, time of death, notification to the coroner, body release number, and who the body was released to. She confirmed a death note which simply stated expired was not sufficient and a complete death note should have been present in Resident #122’s medical record.

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable infection by failing to ensure staff performed appropriate infection control practices during and after incontinence care for 1 (#5) of 1 (#5) resident observed for catheter care. Findings: Review of the facility's undated policy titled, Hand Hygiene revealed the following, in part:Policy: Hand hygiene is the single most important procedure in preventing infection.Staff should change gloves before touching a patient, before a clean/aseptic technique, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. Review of Resident #5's clinical record, revealed she was admitted to the facility on [DATE]. Review of Resident #5's current care plan, revealed clean catheter with soap and water every shift. On 07/22/2025 at 9:30 a.m., an observation was made of catheter care performed by S4CNA and S5CNA on Resident #5. S4CNA and S5CNA donned clean gloves. S4CNA cleaned the catheter tubing and, without changing her gloves and performing hand hygiene, she picked up two clean soapy washcloths, performed perineal care to Resident #5, disposed of wash clothes, touched Resident #5, and touched draw sheet. Then, S5CNA used a wet wipe to wipe resident's buttocks three times and removed the dirty brief. Then without changing their gloves, both S4CNA and S5CNA touched the clean brief, draw sheet, gown, pillow between Resident #5's legs, neck pillow, a pillow under her left arm, sheet, and call light. Both CNAs then removed dirty gloves and performed hand hygiene. On 07/22/2025 at 9:52 a.m., an interview was conducted with S4CNA. She stated she did not change her gloves and perform hand hygiene once she touched Resident #5's dirty catheter and she should have. She stated she should change gloves and perform hand hygiene any time she goes from a dirty to a clean area. On 07/22/2025 at 10:00 a.m., an interview was conducted with S5CNA. She stated she did not change her gloves and perform hand hygiene once she touched Resident #5's catheter and she should have. She stated she should change gloves and perform hand hygiene any time she goes from a dirty to a clean area. On 07/22/2025 at 1:25 p.m., an interview was conducted with S1DON. She stated she expected all staff to change gloves and perform hand hygiene when going from dirty to clean while performing catheter care.

Based on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status for 1 (#1) of 3 (#1, #2, and #3) residents reviewed. Findings: Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #1 had a diagnosis of Generalized Edema with an onset date of 05/25/2018. Review of Resident #1's current Physician Orders revealed the following: Start Date: 09/03/2024 Furosemide 20 mg give one tablet orally one time a day related to Generalized Edema Review of Resident #1's MAR dated September 2024 revealed the following; in part, Resident #1 received Furosemide 20 mg by mouth daily as prescribed. Review of Resident #1's Quarterly MDS with an ARD of 09/07/2024 revealed Generalized Edema was not coded as an active diagnosis. On 10/03/2024 at 11:30 a.m., an interview was conducted with S2CCC. S2CCC confirmed Resident #1's MDS with an ARD of 09/07/2024 was not coded for the diagnosis of Generalized Edema. On 10/03/2024 at 11:40 a.m., an interview was conducted with S1DON. S1DON stated she was not sure if the MDS for Resident #1 should have been coded for Generalized Edema diagnosis.

Based on observations and interview, the facility failed to store, prepare, and distribute foods in accordance with professional standards for food service safety. There were 108 residents who received meals prepared by the kitchen. On 07/08/2024 at 8:15 a.m., an observation was conducted of the kitchen meal prep area. Lemon pepper seasonings, 28 ounces, was found to be open and unlabeled. The following items were found to be open, unsealed and unlabeled: 25 lbs. bag of lima beans 25 lbs. bag of flour 25 lbs. bag of panko crumbs 5 lbs. bag of white rice 6 lbs. box tea bags On 07/08/2024 at 8:20 a.m., an observation was conducted of the walk in cooler with the following items opened and unlabeled: 1 gallon container of slaw dressing 1 gallon container of mayonnaise 1 gallon container of salad dressing On 07/08/2024 at 8:30 a.m., an interview was conducted with S5DM. She confirmed all opened food items should be sealed and labeled with an open dated. She confirmed the above items were not labeled with an open dated and should have been. She further confirmed the rice, flour, lima beans, panko crumbs and tea bags should have been stored in a sealed container and were not.

47173 Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 4 (#38, #45, #62 and #119) residents out of a total of 24 sampled residents. The facility failed to ensure: 1. Resident #38 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #45 was coded correctly for anxiety; 3. Resident #62 was coded correctly for hospice; and 4. Resident #119 was correctly for discharge. Findings: 1. Review of Resident #38's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Anxiety, Depression, Schizophrenia and Schizoaffective Disorder. Review of Resident #38's Form 142 revealed resident was approved for admission by Level II Authority for a temporary period effective 02/19/2024 through 05/10/2024. Sign and dated on 02/26/2024 by Agency Representative. Review of Resident #38's OBH-Level II Evaluation Summary & Determination Notice dated 02/26/2024 revealed: The individual has a serious mental illness. Review of Resident #38's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2024 revealed Section A1500 PASRR was coded as 0. No. Further review revealed the following: Section A1510A: Serious Mental Illness was blank and Section A1510B: Intellectual Disability was blank. On 07/09/2024 at 1:50 p.m., an interview was conducted with S8MDS. She stated she was responsible for completing resident MDS assessments. She reviewed Resident #38's Level II PASARR dated 02/26/2024 indicating Resident #38 had a serious mental illness. She reviewed Resident #38's Annual MDS with an ARD of 03/05/2024 and confirmed Section A1500, A1510A and A1510B was not coded as yes and should have been. 2. Review of Resident #45's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder (09/28/2023). Review of Resident #45's Annual MDS with an ARD of 04/23/2024 revealed Anxiety was not coded as an active diagnosis in Section I. On 07/10/2024 at 8:45 a.m., an interview was conducted with S8MDS. She stated she was responsible for completing resident MDS assessments. She stated when a MDS assessment was performed, all diagnoses should have been coded accurately. She reviewed the Annual MDS for Residents #45 with an ARD of 04/23/2024 and confirmed the MDS was not coded accurately for Anxiety in Section I. 3. Review of Resident #62's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #62's Annual MDS with an ARD of 05/21/2024 revealed Hospice was not coded in Section O. Review of Resident #62's Physician Orders dated July 2024 revealed the following: Order date: 04/13/2023- Admit to Hospice for terminal diagnosis. On 07/10/2024 at 3:51 p.m., an interview was conducted with S8MDS. She stated she was responsible for completing resident MDS assessments. She reviewed Resident #62's Physician Orders and confirmed Resident #62 was admitted to Hospice on 4/13/2023. She reviewed the Annual MDS with an ARD of 04/23/24 and confirmed the MDS was not coded accurately for Hospice in Section O and should have been. 4. Review of Resident #119's Clinical Record revealed she was admitted to the facility on [DATE] and discharged on [DATE]. Review of Resident #119's Discharge MDS with an ARD of 05/29/2024 revealed Section A2105 Discharge Status: Short Term General Hospital. Review of Resident #119's Nurse's Note dated 05/17/2024 included the following, in part: Discharge home with nephew. On 07/10/2024 at 3:17 p.m., an interview was conducted with S8MDS. She reviewed Resident #119's Discharge MDS with an ARD of 05/29/2024. She confirmed Resident #119 was coded as being discharged to the hospital and should have been coded as being discharged home. On 07/10/2024 at 4:30 p.m., an interview was conducted with S2DON. She reviewed the aforementioned findings and confirmed Residents' #38, #45, #62, and #119 MDS assessments should have been coded correctly.

Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#9 and #27) of 6 (#9, #20, #27, #45, #69 and #71) residents reviewed for unnecessary psychotropic medications. Findings: Resident #9 Review of Resident #9's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #9's July 2024 Physician's Orders revealed the following: Start date: 09/22/2023-Vistaril 50 mg by mouth every 8 hours as needed for anxiety. Further review revealed the PRN medication had no stop date or duration. Review of Resident #9's July 2024 Medication Administration Record (MAR) revealed the following: Start date: 09/22/2023-Vistaril 50 mg by mouth every 8 hours as needed for anxiety. Further review revealed the PRN medication had no stop date or duration. On 07/10/2024 at 4:15 p.m., an interview was conducted with S2DON. She reviewed Resident #9's Physician orders and MAR dated July 2024. She confirmed Vistaril was ordered PRN longer than 14 days with no end date or duration documented. Resident #27 Review of Resident #27's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #27's July 2024 Physician's Orders revealed the following: Start date: 03/26/2024-Diazepam 5 mg tablet by mouth every 6 hours as needed; and Start date: 07/04/2024-Xanaz 0.25 mg tablet by mouth every 6 hours as needed. Further review revealed the above PRN medications had no stop date or duration. Review of Resident #27's July 2024 Medication Administration Record (MAR) revealed the following: Start date: 03/26/2024-Diazepam 5 mg tablet by mouth every 6 hours as needed; and Start date: 07/04/2024-Xanaz 0.25 mg tablet by mouth every 6 hours as needed. Further review revealed the above PRN medications had no stop date or duration. On 07/10/2024 at 4:15 p.m., an interview was conducted with S2DON. She reviewed Resident #27's Physician orders and MAR dated July 2024. She confirmed Valium was ordered PRN for longer than 14 days with no end date or duration documented. She confirmed Xanax was ordered PRN with no end date or duration.

Based on interviews, and record reviews, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice and the resident's preferences for 1 of 1 (#56) residents sampled for dialysis services. The facility failed to ensure staff maintained ongoing communication with the dialysis center to ensure Resident #56 received meals during dialysis treatments. Findings: Review of Resident #56's medical record revealed an admitted [DATE] with diagnoses that included, in part, End Stage Renal Disease, Dependence on Renal Dialysis, and Type II Diabetes Mellitus without Complications. Review of Resident #56's care plan revealed in part, Potential for Altered Nutrition related to therapeutic diet, ESRD (End Stage Renal Disease), and Diabetes Mellitus Type II. On 07/08/2024 at 3:43 p.m., an interview was conducted with Resident #56. She stated she felt tired and weak following her dialysis treatments. She stated she was a diabetic, and she was sent to dialysis 3 days per week from 9:30 a.m. to almost 3:00 p.m. or later with no juice, snacks, or supplements. She stated she has told her nurses and Administrative staff she needed a snack during the time she was gone, but the facility has not provided any snacks. On 07/09/2024 at 9:30 a.m., an interview was conducted with S4LPN. She stated the facility did not send Resident #56, a diabetic resident, to her dialysis treatments on Mondays, Wednesdays, and Fridays with snacks, meals, juice or supplements. She stated since COVID-19, Resident #56's Dialysis Center does not allow the residents to come with food. She stated she did not communicate with Resident #56's Dialysis Center to determine if those restrictions were still in place, and she should have. She stated she was aware of the complaints from Resident #56 about being sent to dialysis with no juice, snacks or supplements during her treatments. On 07/10/2024 at 2:40 p.m., an interview was conducted with the Area Clinical Manager of the Dialysis Center Resident #56 attends for treatment. She stated residents can come with snacks, supplements, juice, or appropriate meals to the Dialysis Center. She stated the COVID-19 restrictions have been lifted, and the facility should be aware of that. On 07/10/2024 at 12:05 p.m., an interview was conducted with S9LPN. She stated she was responsible for communication with the Dialysis Centers. She stated since March of 2020 no snacks were allowed at the Dialysis Centers. She stated Resident #56, a diabetic resident, has not been sent with snacks, juice, or supplements to her Dialysis treatments. She stated she has not communicated with Resident #56's Dialysis Center regarding any restrictions for juice, snacks or supplements being sent for residents during treatments in the last 8 months, and she should have. On 07/10/2024 at 11:58 a.m., an interview was conducted with S2DON. She confirmed Resident #56, a diabetic resident, had not been sent to her dialysis treatments with snacks, supplements, or juice. She stated S9LPN was responsible for all communication with the Dialysis Centers. She stated residents were not allowed to bring snacks to the Dialysis Centers to her knowledge. She confirmed she had not communicated with Resident #56's Dialysis Center to confirm if the restrictions were lifted and she should have.

Based on observations, interviews and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1(#108) of 4 (#27, #65, #75, and #108) residents reviewed for falls. Findings: Review of the clinical record for Resident #108 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Repeated Falls, Difficulty in Walking, Reduced Mobility, Cognitive Communication Deficit, and Alzheimer's Disease. Review of the most recent MDS with an ARD of 06/10/2024, revealed Resident #108 had a BIMS of 3, which indicated severe cognitive impairment. Review of the most current Care Plan revealed the following: Problem: At high risk for falls . 06/14/24 unwitnessed fall in room . Intervention: 06/15/2024- Replaced wheelchair cushion with a cushion to improve positioning. Remains high fall risk. On 07/10/2024 at 11:20 a.m., an observation was made of Resident #108 sitting in his wheelchair by the nurse's station when he fell out of his wheelchair and onto the floor. No cushion was observed in the resident's wheelchair. On 07/10/2024 at 11:55 a.m., an observation and interview was conducted with S6LPN. She stated Resident #108 was considered a high fall risk. S6LPN reviewed Resident #108's care plan and verified one of the interventions for falls was to replace his wheelchair cushion with a cushion to improve positioning. S6LPN verified there was no cushion on Resident #108's wheelchair and should have been according to his care plan. On 07/10/2024 at 1:20 p.m., an interview was conducted with S7IP. She stated she is responsible for completing and investigating incident reports and updating resident care plans after an incident occurs. She reviewed Resident #108's care plan interventions listed. S7IP confirmed the cushion should have been in Resident #108's wheelchair since it was listed as a care plan intervention for falls. On 07/10/2024 at 2:59 p.m., an interview was conducted with S2DON. She confirmed Resident #108's care plan had a fall intervention to replace his wheelchair cushion with a cushion to improve positioning, and it should have been implemented.

Based on record review and interviews the facility failed to ensure the resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#108) out of 4 (#27, #65, #75, and #108) residents reviewed for falls. Findings: Review of Resident #108's clinical record revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Repeated Falls, Difficulty in Walking, Reduced Mobility, Cognitive Communication Deficit, and Alzheimer's Disease. Review of Resident #108's Nurse's Note dated 07/07/2024 revealed, in part, the following: Notified by CNA at 4:30 a.m., when making rounds that resident was laying on floor, upon entering room resident laying on right side at side of bed, bedside chair also at bedside, assessed range of motion, able to move arms and legs, denies pain, unable to state how he got there, assisted to bed via two staff, noted dime size skin tear to back of right hand, no skin flap present . Review of Resident #108's care plan revealed it was not revised to include fall interventions for falls after 06/17/2024. The care plan did not include interventions to address Resident #108's fall that occurred on 07/07/2024. On 07/10/2024 at 1:20 p.m., an interview was conducted with S7IP. She stated she was responsible for completing and investigating incident reports and updating resident care plans after an incident occurs. She stated care plans and interventions should be revised within 24 hours of the incident occurring. She verified she was aware Resident #108 had a fall on 07/07/2024, and confirmed she had not revised or implemented any further interventions for falls on his care plan and should have. On 07/10/2024 at 2:59 p.m., an interview was conducted with S2DON. She stated when a resident had a fall, the care plan and interventions were to be revised with updated interventions after each fall. S2DON confirmed Resident #108 had a fall on 07/07/2024 and after reviewing his care plan, confirmed no revisions had been made to his fall interventions after 06/17/2024 and should have been.

Based on observation and interview, the facility failed to ensure nurse staffing data, including resident census, total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 116 residents residing in the facility. Findings: On 07/08/2024 at 11:00 a.m., an observation of the facility revealed no nursing staffing data posted in a prominent place readily assessable for residents and visitors. On 07/08/2024 at 11:10 a.m., an interview was conducted with S4LPN. She stated she was unaware of any nursing staff data being posted in the facility. On 07/08/2024 at 11:40 a.m., an interview was conducted with S3ADON. She stated there was no nursing data posted in the facility that accessible to residents and visitors. On 07/08/2024 at 12:15 p.m., an interview was conducted with S2DON. She confirmed there was no nursing staff data posted in the facility accessible to residents and visitors.

Based on record review, observations, and interview, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to effect 114 residents who were served meals from the kitchen. Findings: Review of the facility's Food Service Operation Standards for Purchasing, Cooking and Storage revealed: Policy: The facility stores, preparers, distributes and serves food under sanitary condition to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. Procedure: 4. Preparation a. All potentially hazardous food should be prepared so they will spend less than a total of 4 hours in the temperature danger zone of 40 degrees -140 degrees 7. Holding: a. Holding equipment should keep hot foods at 140 degrees or above and cold foods at 40 degrees or below. On 03/04/3024 at 10:18 a.m., a review of the facility's daily food temperature monitoring log, cooking holding, storage dated 12/01/2023-03/04/2024 revealed food temperatures were not being completed 270 of 273 total meals served. On 03/04/2024 at 10:18 a.m., an interview was conducted with S1DM. She confirmed the dietary staff had not preformed or recorded foods temperatures prior to serving 270 of 273 total meals to the residents on the dates of 12/01/2023-03/04/2024.

Based on observations, interviews, and record review, the facility failed to maintain a resident's privacy and dignity by staff failing to close privacy curtains while care was being performed for 1 (#2) of 2 (#2 and R1) residents reviewed. Findings: Review of the policy Titled, Conduct of Nursing Personnel revealed the following, in part: It is the policy of this facility that all nursing care personnel conduct themselves in a manner that promotes dignity and respect to residents. Policy Interpretation and Implementation: 12. Close room doors and/or cubicle curtains when providing nursing care to the resident. Resident #2 Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE] and had diagnoses which included Incontinence, Contractures, and Cognitive Communication Disorder. Review of the Quarterly MDS with an ARD of 07/25/2023 for Resident #2 revealed, in part, she had a BIMS of 2, which indicated she was severely cognitively impaired. Further review revealed, she required maximum assistance with ADL care. On 10/02/2023 at 12:50 p.m., an observation was made of incontinent care performed by S1CNA and S2CNA on Resident #2. Resident #2's roommate was in bed watching television while Resident #2 was exposed. Without pulling the privacy curtain, S1CNA and S2CNA exposed Resident #2's perineal area and performed incontinent care. Resident #2 was visualized in her bed by her roommate throughout care performed by S1CNA and S2CNA. On 10/02/2023 at 1:32 p.m., an interview was conducted with S1CNA. She confirmed she did not pull the privacy curtain during incontinence care for Resident #2. She stated residents' privacy should always be maintained, and the privacy curtain should have been pulled. On 10/02/2023 at 1:33 p.m., an interview was conducted with S2CNA. She confirmed the privacy curtain should have been pulled during incontinence care for Resident #2, and it was not. On 10/02/2023 at 1:35 p.m., an interview was conducted with S3CNAS. She stated she would have expected S1CNA and S2CNA to close the privacy curtain in the room to ensure Resident #2 was not visible to her roommate during care. She stated she expected the CNA staff to provide privacy at all times for residents. On 10/02/2023 at 2:00 p.m., an interview was conducted with S4ADON. She stated she would have expected the CNAs to use the privacy curtains as to not expose a resident to their roommate or anyone in the hallway during incontinence care. On 10/02/2023 at 2:05 p.m., an interview was conducted with S5DON. She stated she would have expected the CNAs to use the privacy curtains as to not expose a resident to their roommate or anyone in the hallway during incontinence care. 47732

47732 Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced appropriate infection control practices, hand hygiene, and proper glove use for 2 (#2 and R1) of 2 (#2 and R1) residents observed for incontinence care. Findings: Review of the facility's policy titled, Incontinent Care: Bladder revealed the following, in part: Procedure: 2. Perform handwashing or use alcohol gel. 8. Put on disposable gloves. 9. For female perineal care: b. Wash the mons pubis, rinse, and dry. 11. Remove and discard gloves. 12. Perform handwashing or use alcohol gel. Resident #2 Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included Contractures, and Cognitive Communication Disorder. Review of Resident #2's Quarterly MDS with an ARD of 07/25/2023 revealed she had a BIMS of 2, which indicated she was severely cognitively impaired. It further revealed, she required total assistance with ADL care and was always incontinent. R1 Review of the Clinical Record revealed R1 was admitted to the facility on [DATE] with diagnoses, which included Cerebral Palsy, Epilepsy, and Incontinence, and UTI. Review of R1's Quarterly MDS with an ARD of 08/29/2023 revealed he had a BIMS of 9, which indicated he was moderately cognitively impaired. It further revealed, he required total assistance with ADL care. On 10/02/2023 at 12:50 p.m., an observation was made of incontinent care performed by S1CNA and S2CNA on Resident #2. Without performing hand hygiene, S1CNA and S2CNA donned clean gloves and pulled back Resident #2's bed linens. S1CNA unfastened and removed Resident #2's soiled brief then cleaned Resident #2's perineal area. S1CNA did not remove her soiled gloves or perform hand hygiene and proceeded to place a clean brief on Resident #2, reposition the pad underneath her, straighten her gown, touch the resident's linens, reposition her in bed, adjust the pillow behind her head, and adjust bed linens. S1CNA removed her gloves and kept them in her hand, and without discarding the soiled gloves or performing hand hygiene entered R1's room. On 10/02/2023 at 1:00 p.m., an observation was made of incontinent care performed by S1CNA and S2CNA on R1. S1CNA entered R1's room with dirty gloves from Resident #2 in her hand and discarded them in the trash can in R1's room. Without performing hand hygiene, S1CNA donned clean gloves. S1CNA unfastened and removed R1's soiled brief then cleaned his perineal area. S1CNA removed soiled gloves, donned clean gloves without performing hand hygiene, placed a clean brief on R1, and redressed the resident. S1CNA removed her gloves, and without performing hand hygiene, bagged the trash, touched the door handle, exited the room and placed the soiled brief in the trash bin in the hall. In an interview following the above observation, S1CNA confirmed that she entered R1's room with soiled gloves in her hands, and should not have. S1CNA confirmed that she did not use hand hygiene prior to or after providing care to R1, and should have. S1CNA confirmed that she did not perform hand hygiene prior to opening the door, and discarding the soiled diaper in the trash. S1CNA confirmed she should have changed gloves and performed hand hygiene after soiling gloves. On 10/02/2023 at 1:33 p.m., an interview was conducted with S2CNA. She confirmed hand hygiene should be performed before and after incontinent care. She confirmed she did not perform hand hygiene prior to donning gloves and assisting with incontinent care on R1, and should have. On 10/02/2023 at 1:35 p.m., an interview was conducted with S3CNAS. She stated she would expect staff to perform hand hygiene prior to and after completing incontinence care. She stated she would expect staff to change gloves and perform hand hygiene after performing perineal care, prior to applying a clean brief, and prior to touching the resident or their personal items. She stated the CNA staff should not exit a resident's room with soiled gloves and without performing hand hygiene. On 10/02/2023 at 2:00 p.m., an interview was conducted with S4ADON. She stated she would expect staff to perform hand hygiene prior to and after completing incontinence care. She stated she would expect staff to change gloves and perform hand hygiene after performing perineal care, prior to applying a clean brief, and prior to touching the resident or their personal items. She stated the CNA staff should not exit a resident's room with soiled gloves and without performing hand hygiene. On 10/02/2023 at 2:05 p.m., an interview was conducted with S5DON. She stated she would expect staff to perform hand hygiene prior to and after completing incontinence care. She stated she would expect staff to change gloves and perform hand hygiene after performing perineal care, prior to applying a clean brief, and prior to touching the resident or their personal items. She stated the CNA staff should not exit a resident's room with soiled gloves and without performing hand hygiene.

Based on record review and interview, the facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers, and did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (#22) of 4 (#22, #37, #70, #83) sampled residents investigated for pressure ulcers. This deficient practice resulted in actual harm for Resident #22 when an unstageable sacral pressure ulcer with slough was assessed by S6NP on 08/06/18. The resident was admitted to the facility on [DATE] and care planned for pressure wounds to buttock/right and left heel, decreased mobility, dehydration, history of ulcers. On 08/05/18 an LPN documented the pressure ulcer as a Stage 2. The facility did not have any documented evidence of skin assessments/body audits for the month of (MONTH) (YEAR) and the month of (MONTH) (YEAR) prior to 08/05/18. There was no documentation a registered nurse assessed and staged the wound on 08/05/18. Findings: Review of Resident #22's record revealed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #22's quarterly MDS dated with ARD of 08/27/18 revealed the resident's cognition was severely impaired, the resident was non-ambulatory and required extensive assistance with all ADLs. In addition, the resident was always incontinent of bowel and bladder and had a Stage 3 pressure ulcer since admit, and had an un-staged pressure ulcer with slough. Record review of Resident #22's care plan revealed on 05/21/18, the resident was care planned for actual/potential for pressure ulcer/injury due to total incontinence, admission pressure wounds to buttock/right and left heel, decreased mobility, dehydration, history of ulcers, and the interventions included in part: Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the skin inspection reports revealed the following: 08/05/18 Skin not intact - New Entered by: S5LPN 08/21/18 Skin not intact - Existing Entered by: S2ADON 09/26/18 Skin not intact - Existing Entered by: S7LPN There was no documented evidence of skin assessment/body audits for the month of (MONTH) (YEAR) and the month of (MONTH) prior to 08/05/18. Review of the nursing notes revealed no documented evidence of the date, time, and assessment of the sacral wound identified on 08/05/18 by S5LPN. There was also no documentation the sacral wound was assessed and staged by a registered nurse. Review of the Wound Assessment Report dated 08/05/18 revealed the following: Wound type: Pressure Ulcer Wound location: Sacral/Coccyx area Date wound identified: 08/05/18 Present upon admission: No Assessment occasion: New wound Stage: 2 Measurements: Length: 3.50 cm Width: 2.60 cm Depth: 0.10 cm Wound bed: [MEDICATION NAME] tissue: 0.00% Granulation tissue: 40.0% Slough: 0.00% Eschar: 60.00% Wound Edges: Border definition: Distinct, outline clearly visible Description: Normal healthy skin Surrounding skin: Normal Date electronically signed: 09/07/18 by S1DON Further review of the facility's Wound Assessment reports revealed the next documentation of the sacral wound assessment was dated 09/07/18, approximately 33 days after the sacral wound was identified. The nurse practitioner saw Resident # 22 on 08/06/18. Review of the S6NP's progress notes dated 08/06/18 revealed the following in part: Chief complaint: Patient seen this morning on wound care rounds on the memory unit of nursing facility. Nurse reports new wound to sacrum found over the weekend. Physical Exam: Wound #7 Sacrum - Pressure Wound Assessment: Wound #7 Active. Wound location: Sacrum. Length: 3.8 cm, Width: 3.1 cm, Depth: 0.1 cm. Etiology: Pressure. Grade/Stage/Thickness: Unstageable. Wound Progress: Initial Exam. Slough: 51 -75%. Granular: 1-25%. Eschar: None. Epithelization: None. Impression and Plan: 4. New ulcer to sacrum, unstageable, nurse to apply honey for autolytic debridement and dry foam dressing. Will plan for sharps debridement if increase in devitalized tissue. 5. Strict offloading, ALAL mattress, turn every 2 hours, wedge, football wraps, body audits. Review of the facility's treatment record for (MONTH) (YEAR) revealed the resident did not receive wound care from the facility's staff to the sacral wound until 08/11/18, 6 days after the sacral wound was identified. An interview was conducted on 11/08/18 at 8:58 a.m. with S4LPN. She verified she was currently the wound care nurse for the facility. She was asked who staged the resident's pressure wounds. She stated S6NP came to the facility and would stage the pressure wounds. She explained S6NP came to see Resident #22 once a week. On 11/08/18 at 12:32 p.m., an interview was conducted with S3LPN. She was asked if the facility had any skin assessments/body audits from (MONTH) (YEAR) until (MONTH) 5, (YEAR). She stated, No. She was asked to review initial wound assessment for Resident # 22's sacral wound dated 08/05/18. She was asked if she knew what staff member staged the sacral wound. She stated she didn't have any documentation of who staged the sacral wound. She verified S1DON signed the document on 09/07/18. She further explained S1DON began her position sometime in the beginning of (MONTH) (YEAR) and identified problems with pressure ulcers when she began working here. After she reviewed the wound assessment report again, she verified the sacral wound was identified on 08/05/18 as a Stage 2. She was asked who found the sacral wound. She stated, S5LPN. She was asked who staged the sacral wound. She stated, I don't know. I don't know what was going on. She was asked if the facility had any nursing notes regarding the sacral wound. She stated, No, the only documentation we have was on the wound assessment report dated 08/05/18. She was asked to review S6NP's progress note dated 08/06/18. After she reviewed the progress note, she verified S6NP assessed the sacral wound as unstageable with slough. She stated, The facility put out a skin assessment schedule around this time, but there's no way to find that out. There are no nurse's notes from S5LPN. I've been looking. In an interview on 11/08/18 at 1:59 p.m. with S2ADON, she was asked how often skin assessments should be completed by the staff. She stated, It should be done weekly. She was asked to review the skin inspection reports dated 08/05/18, 08/21/18, and 09/26/18. She verified the skin assessments were not completed weekly as per facility protocol. She reviewed the wound assessment report dated 08/05/18 and S6NP's progress noted dated 08/06/18. She verified the sacral wound was unstageable with slough at 51 - 75%. She stated, The sacral wound couldn't have been a stage 2 because the very next day it was assessed unstageable by the S6NP. On 11/09/18 at 9:25 a.m., an interview was conducted with S6NP. She stated when she assessed the wound on 08/06/18 the sacral wound was unstageable with slough. She stated she was first notified of the wound at that time (08/06/18) when she went to perform wound care on the resident. On 11/09/18 at 9:37 a.m., an interview was conducted with S1DON. She stated she started at the facility and assumed the role of director of nursing on 09/04/18. She explained the staff could not do a new assessment on a wound unless someone closed out the assessment in the computer. She stated, That's why my signature was on the 08/05/18 wound assessment report. She was asked to review the sacral wound documentation dated 08/05/18 and the S6NP's progress note dated 08/06/18. She was asked if the facility had any further documentation regarding the sacral wound that was identified on 08/05/18 by S5LPN. She stated, No. She further explained the facility searched for nursing notes regarding the sacral wound found on 08/05/18 and was not able to locate them. She was asked who staged the sacral wound as a Stage 2. She stated, she didn't know because the facility did not have the documentation. She was asked to explain the facility's protocol for staging a pressure wound. She stated, The LPN was not supposed to stage wounds and we are doing education regarding wounds. After she reviewed the skin inspection reports dated 08/05/18, 08/21/18, 09/26/18, she verified the skin assessments were not completed weekly as per the facility protocol. She stated, The resident's skin assessments should be completed weekly. She also verified the facility had no skin assessments/body audits documented for (MONTH) (YEAR) and the month of (MONTH) (YEAR) prior to 08/05/18. She was asked to review the wound assessment reports. After she completed her review, she verified the wound assessment report for the sacral wound was first documented on 08/05/18 and the next wound assessment report was dated 09/07/18. She was asked if the facility had any documentation of the wound assessment reports after 08/05/18 until 09/07/18. She stated, No. She was asked to review the Treatment Record for (MONTH) (YEAR). After she reviewed the treatment record, she verified the staff did not perform wound care until 08/11/18. She stated, the nursing staff did not transcribe S6NP's orders from 08/06/18 and begin wound care as they should have.

Based on observation, interview and record review, the facility failed to ensure that 1 (#4) of 5 sampled residents (#1, #2, #3,#4,#5) was free of abuse by failing to: 1. Ensure staff immediately notifies Administration of a resident being abused (#4); 2. Initiate an investigation of abuse upon discovery (3/16/17) of a bed pad placed over the face of a non-verbal quadriplegic resident (#4); 3. Ensure staff protect Resident #4 to prevent further abuse from Resident #5 (Resident #4's roommate) who had been known to voice remarks that he wanted to harm Resident #4. This failed practice resulted in an Immediate Jeopardy (IJ) situation for Resident #4, a non-verbal quadriplegic resident, on 3/16/17 between 4:00pm -6:00pm, when S8CNA discovered a bed pad placed over Resident #4's face. S8CNA described the resident's face as blood shot red upon removal of the pad. Resident #4 was physically unable to remove the pad or call out for help. Approximately 1 1/2 hours after discovering the bed pad on Resident #4's face, S8CNA entered Resident #4's room and observed that Resident #4's legs and feet were hanging off of his bed. S8CNA reported these incidents to S6LPN and told that she felt Resident #4's roommate, Resident #5 may have done this. On 3/16/17 during shift change at 6:00pm, S6LPN reported these incidents to S7LPN. S6LPN and S7LPN did not take any action to protect Resident #4 from further abuse nor did they notify anyone of these incidents. Then on 3/20/17 at 7:00pm, S7LPN discovered a blanket over the face that was tucked in under the head of Resident #4. S7LPN removed the blanket and described the resident as crying, his face red and warm. S7LPN did not remove either of the residents from the room at that time, nor did S7LPN notify anyone until 3/21/17 at 7:00am when she informed S12MDS who instructed her to call the DON. The facility has agency staff that also worked in their facility and it was identified that not all agency staff had been trained on how to identify and report abuse. S1Asst.Adm. and S2DON were informed of the IJ situation on 4/20/17 at 11:05am. The facility provided their plan of removal on 4/20/17 as follows: Plan of Removal for Resident #4: Resident #5 was removed from the room he shared with Resident #4 and was discharged to a behavioral health hospital on [DATE]. Plan of Removal for Entire Building: On 3/21/17, DON identified the additional at risk residents (non-verbal and/or unable to move extremities). An evaluation of their roommates was conducted. The roommates were reviewed for current medical condition, review of history of behaviors and assessment of the two roommates relationship via staff interview and observation (e.g. has the at risk resident's roommate made verbal threats or derogatory comments about the at risk resident). On 3/21/17, the facility's Administrative Nurses began including, as part of their on-going periodic room rounds, questions to the floor staff (CNAs and LPNs) about any signs or concerns of resident abuse or neglect. On 3/24/17, the facility began providing in-service training to all staff regarding the facility's Abuse and Neglect Policy and Procedure. Specifically, this in-service training focused on each staff member's individual responsibility to report suspected abuse or neglect to their supervisor and directly to the DON or Administrator if their immediate supervisor does not begin an investigation. The immediacy of the IJ for Resident #4 was removed when Resident #5 was removed from their shared room on 3/21/17 at 7:15am. The deficiency remains at a potential for harm for the 11 residents identified by the facility with physical inability to move and/or were non-verbal. The facility had a total census of 119 residents according to the Resident Census and Conditions of Residents provided by the facility dated 4/19/17. Findings: Resident #4: A review of the clinical record for Resident #4 revealed the resident was [AGE] years of age with [DIAGNOSES REDACTED]. The resident resided on a hall. On 4/19/17 at 1:45pm an observation of Resident #4 was conducted with S3CNA. Resident #4 was lying in his bed with his eyes closed. He had rolled up gauze in the palms of each hand and his fingers were bent inward holding the gauze, his feet were contracted and in heel protectors. His continuous feeding was infusing via pump. S3CNA stated that he has no roommate. His bed was located in the back of the room close to the bathroom. There was an empty bed in the room, closest to the entrance door of the room. S3CNA stated that Resident #4 can hear and is non-verbal. She stated he's a quadriplegic and can't move. Resident #4 followed S3CNA with his eyes and slightly moved his head in her direction as she talked to him and moved about the room. Resident #5 A review of the clinical record for Resident #5 revealed [DIAGNOSES REDACTED]. The resident resided on a hall. Resident #5 was transferred to an acute care hospital on [DATE] and never returned to the facility. A review of the facility's assessed MDS - Cognitive Pattern for Resident #5, dated 1/16/17 revealed a score of 15. A review of MAR for monitoring of resident behaviors revealed nursing staff documented on each shift that Resident #5 had no behaviors in March 2017. A review of Nursing Notes for Resident #5 from January - April 2017 revealed as follows: January - No documented behaviors February - No documented behaviors March - Documentation of Resident #5 putting a blanket on his roommate's head on 3/20/17 at approximately 7:00pm. - There was no documentation of behaviors before 3/20/17 or any documentation of statements he made against his roommate, Resident #4. A review of Hospital Triage Notes, dated 3/21/17, 9:13am, regarding Resident #4 revealed the following: Comments: [AGE] year old male, non-verbal, sent here today per ambulance personnel, because one of his roommates tried to smother him last night with a blanket. On patient's arrival here, noticed that he had noisy respirations and an Oxygen saturation of 90% on room air. Physician Exam: Course expiratory rhonchi all lung fields Impression: [MEDICAL CONDITION] A review of the facility's Quality Assurance Monthly Incident/Accident Tracking Log for March 1-31, 2017 revealed no documentation of incidents involving Resident #4 or #5. A review of the March 2017 Nurses Notes for Resident #4 revealed no documentation of incidents on 3/16/17, 3/20/17 or 3/21/17. A review of the typed statement from S11LPN to the facility, dated 2/27/17 revealed the following: I went to the behavioral hospital and asked Resident #5 regarding the matter between him and his roommate. I asked Resident #5 if he remembered the incident and he said what incident, so I reminded him about the nurse and staff found his roommate with blankets and other items covering his face. He said yes, I remember that, he wouldn't stop staring at me when I went to the toilet. Note: S2DON reviewed this statement and stated that the date was incorrect, it should be 3/27/17. A review of S12MDS's handwritten statement to the facility dated 3/21/17 revealed the following: 6:30-7:00am - This nurse went to a hall to gather information from the 24 hour report book. Noticed that the book was empty and asked the night nurse if anything occurred on her shift. She stated, Nothing, except Resident #5 tried to suffocate Resident #4. She stated Resident #4 was OK, I wrote an incident report on Resident #5. I asked where was Resident #5 and she stated he was in his room sleeping. I asked nurse, Why didn't you move him? Replied, I watched him every hour. He slept all night. I responded, What if he had wakened in a half hour. Nurse replied, I watched him. I asked did you call Resident #4's family or doctor or even the DON? Replied, No. This nurse stated, I thought you did an incident report? You are required to do this. No response to question. Asked nurse, did you call Resident #5's doctor or family? Nurse replied, No, I didn't really know what to do. Nurse stated He did the same thing last week on S6LPN. Day nurse, S6LPN present and agreed. I informed the night nurse that she needed to call the DON, families and the doctors of both residents. Informed her that Resident #5 was to be removed immediately. Night nurse stated again that she didn't know what she was supposed to do and proceeded to start making the appropriate phone calls. A review of S6LPN's handwritten statement dated 3/21/17 revealed the following: On the evening of 3/16/17, S8CNA reported to me that she observed Resident #4 with a bed pad over his face and that she removed it. She shared her concern that the resident's roommate, Resident #5, may have done this. I assessed the resident and observed no acute distress. I approached Resident #5 about the situation and he stated, I'm not staying with that s__t. He had stated other things that were unintelligible He was aggressive in his manner. In report, I let the oncoming nurse know of the resident's behavior during the shift and advised her to monitor them. On 3/20/17, I received a report from S3CNA that Resident #5 had been staring at Resident #4. Reported this to the oncoming nurse and discussed that Resident #5 possibly needs to be removed from the room. The oncoming nurse agreed to monitor both residents closely. On 3/21/17, I received report from S7LPN that Resident #5 had placed a blanket over Resident #4's face during her shift. On 4/19/17 at 3:09pm an interview was conducted with S3CNA for Resident #4. She stated about 2-3 months ago, while working the 6:00am-2:00pm shift, she saw a blanket on Resident #4's face. She stated that she removed it and continued with her rounds. She stated that was the first time she had seen that. She stated that she was new to the hall Resident #4 was on and she wasn't sure what Resident #4 could or could not do for himself at that time. She stated, later on that same day, after she finished rounds, she went into Resident #4's room and saw the blanket on his face and over his mouth again. She stated that this time she knew he couldn't put it there himself. She stated that Resident #4 was just lying there with his eyes open. She stated that it was bothering her, because she thought that maybe she left the blanket on the resident's face, but the 2nd time she saw it, she knew she did not leave a blanket on Resident #4's face. She stated that she told the nurse about it. She stated that she didn't know which nurse she reported it to because there were so many agency nurses working there. She stated that she would report immediately to the nurse if anything like that happened again. She stated that if the nurse did not do anything about it, then she would go up the chain of command, but how would I know if the nurse didn't do anything about it. She stated that Resident #5 would sometimes complain about the smell of Resident #4's bowel movements. She stated that Resident #5 was always in and out of the room. She stated that he could be in the room and she might be down the hall or something. She stated that it never crossed her mind that anyone would be doing that to Resident #4. On 4/19/17 at 3:54pm an interview was conducted with S10SW. She stated that she was notified by one of the MDS nurses that Resident #5 had placed a blanket over Resident #4's face. She stated that she didn't recall when it happened and she didn't document it. She stated she didn't document anything until Resident #5 was discharged . She stated that she was not told of any other incidents between Residents #4 and #5. She stated that she is involved if residents have problems with roommates when it is reported to her. She stated that she was aware that Resident #5 had problems with his prior roommates. She stated that she would have expected someone would have told her of any incidents between Residents #4 and #5. She stated that she would have acted on it. She stated that Resident #4 is not able to verbalize, he is not able to move unless someone moves him, he is vulnerable. On 4/19/17 at 4:33pm an interview was conducted with S11LPN. She stated that she is the clinical liaison and the admissions nurse. She stated that she was told Resident #5 put a material bed pad on Resident #4's face. She stated that Resident #5 would have 2-3 blankets on his bed at a time because he would complain that he was cold. She stated that I guess he was using one of those blankets to put on Resident #4's face. She stated that she interviewed Resident #5 while he was at the behavioral hospital and asked him why he did those things and why he was angry with Resident #4. She stated that he told me that Resident #4 watched him and he did not like it. She stated that Resident #4 knew when you were in the room, he knew when you spoke to him. She stated that Resident #4 responds in that he will follow you with his eyes. She stated that she had never seen him cry, never seen tears. She stated that Resident #4 was extremely vulnerable. He could not yell out when Resident #5 did those things to him. That was the worst part of it because Resident #4 could not cry out for help. On 4/19/17 at 4:57pm an interview was conducted with S2DON. She stated that on 3/20/17, S7LPN was the overnight (6:00pm-6:00am) agency nurse assigned to a hall where Residents #4 and #5 shared a room. She stated that on 3/21/17 at 7:13am, she notified me of the incident. S2DON stated that S12MDS Nurse was at the desk talking to S7LPN and told her to call me. She stated that S7LPN relieved S6LPN at 6:00pm on 3/20/17. She stated that S6LPN had told S7LPN that Resident #5 had been harassing Resident #4 and had mentioned some concerns to S7LPN (the incidents on 3/16/17 and 3/20/17). She stated that the first time the aides reported it to S6LPN she should have reported to me immediately and removed Resident #5 from the room. S7LPN should have also notified me the first time it was reported to her. She did not have the aide sit outside the door or inside their room on 3/20/17 after 7:00pm. She stated that Resident #4 was vulnerable. On 4/20/17 at 9:15am an interview was conducted with S1Asst. Adm. He stated that they began again in-servicing their staff on 3/24/17 regarding abuse/neglect. He stated that we removed Resident #5 from their room on 3/21/17 and sent him to a behavioral hospital that same day. He stated that Resident #5 did not return to the facility and was discharged from the facility on 3/29/17. On 04/20/17 at 9:45am, an interview was conducted with S5LPN. She stated she was an agency nurse working at the facility. She stated she had training when she first came to work at the facility on blood sugars, but had not been trained by this facility on abuse and neglect or how to report it. A follow up interview was conducted with S5LPN on 4/20/17 at 1:45pm who stated that she had received today, after 9:45am, an inservice by the facility on their Abuse/Neglect Policy and Procedure. On 4/20/17 at 2:16pm an interview was conducted with S12MDS Nurse for the facility. She stated that the oncoming and the offgoing nurse meet at shift change and are supposed to go into each resident room, actually looking at the resident, together during nursing rounds. She stated that the aides are also supposed to do room rounds at shift change. She stated on the morning of 3/21/17, S7LPN told her that Resident #5 tried to suffocate Resident #4. She stated that she asked S7LPN where the residents were and she told me that they were both in their room. She stated that she told S7LPN to write a report on both Residents #4 and #5. She stated she asked S7LPN what caused Resident #5 to do this and if she had called anyone and she said no she had not notified anyone. S7LPN told her that S6LPN had reported to her it happened last week. On 4/20/17 at 3:00pm, an interview was conducted with S7LPN. She stated that was an agency nurse and worked the night shift at the facility (6:00pm - 6:00am) on 3/16/17 and 3/20/17. She stated that at 6:00pm on 3/16/17, she relieved S6LPN. She stated that S6LPN told her that the aides reported a bed pad had been placed on Resident #4's face earlier today. She stated that on 3/20/17 at 6:00pm, she relieved S6LPN. S7LPN stated that on 3/20/17 two incidents occurred with Resident #4. The first incident was when an aide reported to her that Resident #4's feet were hanging out of the bed. She stated that she couldn't remember the time or the aide's name. She stated the second incident occurred at 7:00pm, when she went into Resident #4 and #5's shared room and saw a white blanket over Resident #4's head and tucked in around his face. She stated that she removed it and Resident #4's face was red and he was crying. She stated that Resident #5 could stand, get himself in and out of the wheelchair. She stated that he had a [DIAGNOSES REDACTED].#5's bed was closest to the hall door and Resident #4's bed was in the back of the room with a privacy curtain separating their beds. She stated that Resident #5 would always pull the curtain between them closed. She stated that after she removed the blanket from Resident #4's face, she opened the door to their room, pulled the curtain open and moved her medication cart outside of the their door. She stated that she did not stay in Residents #4 and #5's room the entire night. She stated that she could not say that there was anyone visually monitoring Residents #4 and #5 throughout the night. She stated that she has not had any training on abuse or neglect from the facility. S7LPN stated that there is no unit supervisor on the night shift at the facility, so we report to the DON. She stated she waited until the end of the shift and then notified the DON on the morning of 3/21/17. S7LPN stated that she did not remove Resident #5 from the room because she didn't know if there was not an empty room available on her station and that she did not report the incident immediately because she didn't know what the facility's protocol was. On 4/20/17 at 4:20pm an interview was conducted with S6LPN. She stated that she works the day shift (6:00am-6:00pm). She stated that there were some incidents with Resident #4 on 3/16/17 and 3/20/17. She stated that there was also another incident, but she did not know the date or time of it. She stated that On 3/16/17, S8CNA reported to her that she found a bed pad on Resident #4's face and she removed it. She stated that she could not recall if Resident #5 was in the room or not at that time. She stated that S8CNA asked her at that time, if Resident #5 could be messing with Resident #4. She stated that she reported this to the oncoming nurse, S7LPN, at 6:00pm on 3/16/17. She stated that this was the first incident that occurred. She stated that she talked to Resident #5 about it and he said that he didn't have to stay with that s__t. She stated that she did not notify the DON of this incident as it occurred after 4:00pm and the DON had gone home for the day. She stated that on another day, she could not recall the date or time, a ward clerk told her that Resident #4's legs were dangling off the bed and she put him back in bed. She stated that at that point in time, she did not do anything. She stated then on 3/20/17, a CNA told her that she was concerned about Resident #4 and that his roommate, Resident #5 was in their room eyeballing Resident #4. She stated that she went to the room, but Resident #5 had already left the room. She stated that she reported this incident on 3/20/17 to the oncoming nurse, S7LPN, at shift change. She stated that she didn't document any of the incidents regarding Residents #4 and #5 in her nurses notes or elsewhere. She further stated that she did not notify the DON or other Administrative staff of these incidents involving Resident #4 and #5. On 4/21/17 at 1045 a.m. an interview was conducted with S1Asst.Adm. He stated there is no smoking gun proving that Resident #5 did anything to Resident #4. He stated that what we saw on video corroborates staff statements. He stated that on 3/20/17 at 6:58pm, S7LPN enters the room and finds the blanket over Resident #4's head. He stated that Resident #5 was milling in and out of the room. Resident #5 was looking around suspiciously. He stated that Resident #5 was not seen on the facility's video going to the linen closet on 3/20/17. He stated that the resident used linen that was already in the room to cover Resident #4's face. He stated that Residents #4 and #5 were in the room, alone together, from 5:41pm. until 6:58pm. S1Asst.Adm. stated all evidence points to Resident #5. On 4/21/17 at 11:45am an observation was made of Resident #4 in his room with S2DON present. His bed had been moved closest to the entrance door. An empty bed was in the back of the room near the restroom. S2DON stated that Resident #4 was moved closer to the entrance of the room. She stated that Resident #5 would use the toilet which was observed to be near the bed at the back of the room. She stated that Resident #5 would not close the bathroom door. She stated that is why Resident #5 felt that Resident #4 was looking at him when he went to the toilet. On 4/21/17 at 12:03pm an interview was conducted with S4LPN. She stated that they only have 1 full time nurse on the night shift, the rest are agency nurses. She stated she never got any report from any aides that anything was going on with Resident #4 and #5. She stated no one ever never told her that anything might be going on with Resident #4 or #5. She stated that she didn't think Resident #4 could move his legs or feet off the bed because his legs are stiff and his feet and arms are contracted. She stated that he can move his arms a tiny bit and he can move his head a little bit from side to side. She stated that he was moved to the bed closest to the door of the room today. She stated that when Resident #4 was in the back of the room, you could not see him when you walked past his room. She stated now that he is in the front bed you can see him whenever you pass his room. She stated that Resident #4 should have been in the bed closest to the door. On 4/21/17 at 12:20pm an interview was conducted with S3CNA for Residents #4 and #5. She stated she had seen no problems or behaviors with Resident #5. He only complained about Resident #4's bowel movements. She stated that Resident #4's bed was closest to the bathroom at the back of the room. She stated that we would pull the privacy curtains between Residents #4 and #5 midway and you could Resident #4 when you were walking the hall. She stated that Resident #5 could go to the bathroom for a bowel movement. She stated that Resident #5 had a drawsheet and a pad on his bed. She stated that he had a blue blanket on his bed. She stated that once, she could not remember the date or time, she discovered a white blanket on Resident #4, that is the one from the linen closet. She stated that Resident #5 could get to the linen closet, it was not kept locked. She stated that he could stand up. She stated that Resident #5 was hard of hearing and it seemed like he knew what he was talking about. 4/21/17 at 1:45pm an interview was conducted with S2DON. She stated that on 3/21/17, after we were notified of the incident, we began to do administrative room rounds and asked the CNAs if they reported anything to the nurse. We instructed the administrative staff to talk to the floor staff to identify anything that the nurse didn't identify or report. She stated that this was being done daily on morning rounds by the administrative staff. On 4/21/17 at 2:00pm an interview was conducted with S8CNA. She stated that about 2-3 months ago, she saw Resident #4's feet and legs hanging off of his bed. She could not recall the date of this incident. She stated that she reported this to both S6LPN and S7LPN. She stated that another incident occurred to Resident #4 on 3/16/17 when she saw a bed pad folded over Resident #4's face. She stated that she didn't think that he could do that since he was paralyzed. She stated that she reported this to the nurses and didn't know to do anything else. She stated that S9CNA knew about it. She stated that S9CNA asked Resident #5 why he didn't like Resident #4 and what was wrong. Resident #5 just said he was going to get him, talking about Resident #4. She stated that was about 2-3 days after the bed pad was on Resident #4's face. She stated that she reported it to S13CNA. She stated that S14CNA knew about it. She stated that she would tell the aide who relieved her about these instances, but they were agency aides. She stated she didn't know that she should tell anyone else. She stated that she thought she was doing what she was supposed to do by telling the nurse. She stated that we wondered why Resident #1 and #4 were not together in the same room and we asked S6LPN and sometimes we would ask the coordinator, but they would just blow it off. On 4/20/17 at 2:18pm an interview was conducted with S2DON. She stated there are only 2 quadriplegics in the building, Resident #4 and Resident #1. She stated that Resident #1 can speak and Resident #4 cannot speak. On 4/21/17 at 2:53pm an interview was conducted with S13CNA. She stated that she was a CNA Coordinator. She stated that she was familiar with Residents #4 and #5. She stated that S8CNA first reported to her that a bed pad was over Resident #4's face and then a couple of days later she told me his legs were hanging out of the bed. She stated that S8CNA asked her if she thought that Resident #4 could move his legs off the bed and she told S8CNA, no. She stated that Resident #4 can't defend himself. S13CNA stated that she, herself, did not tell anyone else about the incidents. She stated that she was not aware of any other incidents involving Resident #4. S13CNA stated that she did not attend morning meetings with the DON to discuss daily occurrences.

Based on observation, interview and record review, the facility failed to ensure that 2 (#4 and #5) of 5 sampled residents (#1, #2, #3, #4, #5) were free of neglect by failing to: 1. Report to facility administration all incidents of suspected abuse to a resident (#4); 2. Ensure staff document a resident's verbally abusive comments (#5) toward another resident (#4); 3. Ensure protection of a quadriplegic and non-verbal resident, who was found on 3/16/17 with a bed pad placed on the resident's face (#4). This failed practice resulted in an Immediate Jeopardy (IJ) situation for Resident #4, a non-verbal quadriplegic resident on 3/16/17 between 4:00pm -6:00pm, when S8CNA discovered a bed pad placed over Resident #4's face. S8CNA described the resident's face as blood shot red upon removal of the pad. Resident #4 was physically unable to remove the pad or call out for help. Approximately 1 1/2 hours after discovering the bed pad on Resident #4's face, S8CNA entered Resident #4's room and observed that Resident #4's legs and feet were hanging off of his bed. S8CNA reported these incidents to S6LPN and told that she felt Resident #4's roommate, Resident #5 may have done this. On 3/16/17 during shift change at 6:00pm, S6LPN reported these incidents to S7LPN. S6LPN and S7LPN did not take any action to protect Resident #4 from further abuse nor did they notify anyone of these incidents. Then on 3/20/17 at 7:00pm, S7LPN discovered a blanket over the face that was tucked in under the head of Resident #4. S7LPN removed the blanket and described the resident as crying, his face red and warm. S7LPN did not remove either of the residents from the room at that time, nor did S7LPN notify anyone until 3/21/17 at 7:00am when she informed S12MDS who instructed her to call the DON. S1Asst.Adm. and S2DON were informed of the IJ situation on 4/20/17 at 11:05am. The facility provided their plan of removal on 4/20/17 as follows: Plan of Removal for Resident #4: Resident #5 was removed from the room he shared with Resident #4 and was discharged to a behavioral health hospital on [DATE]. Plan of Removal for Entire Building: On 3/21/17, DON identified the additional at risk residents (non-verbal and/or unable to move extremities). An evaluation of their roommates was conducted. The roommates were reviewed for current medical condition, review of history of behaviors and assessment of the two roommates relationship via staff interview and observation (e.g. has the at risk resident's roommate made verbal threats or derogatory comments about the at risk resident). On 3/21/17, the facility's Administrative Nurses began including, as part of their on-going periodic room rounds, questions to the floor staff (CNAs and LPNs) about any signs or concerns of resident abuse or neglect. On 3/24/17, the facility began providing in-service training to all staff regarding the facility's Abuse and Neglect Policy and Procedure. Specifically, this in-service training focused on each staff member's individual responsibility to report suspected abuse or neglect to their supervisor and directly to the DON or Administrator if their immediate supervisor does not begin an investigation. The immediacy of the IJ for Resident #4 was removed when Resident #5 was removed from their shared room on 3/21/17 at 7:15am. The deficiency remains at a potential for harm for the 11 residents identified by the facility with physical inability to move and/or were non-verbal. The facility had a total census of 119 residents according to the Resident Census and Conditions of Residents provided by the facility dated 4/19/17. Findings: Resident #4: A review of the clinical record for Resident #4 revealed the resident was [AGE] years of age with [DIAGNOSES REDACTED]. Resident #4 resided on a hall. On 4/19/17 at 1:45pm, an observation of Resident #4 was conducted with S3CNA. Resident #4 was lying in his bed with his eyes closed. He had rolled up gauze in the palms of each hand and his fingers were bent inward holding the gauze, his feet were contracted and in heel protectors. His continuous feeding was infusing via pump. S3CNA stated that he has no roommate. His bed was located in the back of the room close to the bathroom. There was an empty bed in the room, closest to the entrance door of the room. S3CNA stated that Resident #4 can hear and is non-verbal. She stated he's a quadriplegic and can't move. Resident #4 followed S3CNA with his eyes and slightly moved his head in her direction as she talked to him and moved about the room. Resident #5 A review of the clinical record for Resident #5 revealed [DIAGNOSES REDACTED]. Resident #5 resided on a hall. Resident #5 was transferred to an acute care hospital on [DATE] and never returned to the facility. A review of the Medication Review Report for Resident #5 revealed the physician discontinued in January 2017: [MEDICATION NAME] 7.5 mg every day (treatment of [REDACTED]. A review of the facility's assessed Cognitive Pattern for Resident #5, dated 1/16/17 revealed a score of 15. On 4/19/17 at 3:09pm an interview was conducted with S3CNA for Resident #4. She stated about 2-3 months ago, while working the 6:00am-2:00pm shift, she saw a blanket on Resident #4's face. She stated that she removed it and continued with her rounds. She stated that was the first time she had seen that. She stated that she was new to the hall Resident #4 was on and she wasn't sure what Resident #4 could or could not do for himself at that time. She stated, later on that same day, after she finished rounds, she went into Resident #4's room and saw the blanket on his face and over his mouth again. She stated that this time she knew he couldn't put it there himself. She stated that Resident #4 was just lying there with his eyes open. She stated that it was bothering her, because she thought that maybe she left the blanket on the resident's face, but the 2nd time she saw it, she knew she did not leave a blanket on Resident #4's face. She stated that she told the nurse about it. She stated that she didn't know which nurse she reported it to because there were so many agency nurses working there. She stated that she would report immediately to the nurse if anything like that happened again. She stated that if the nurse did not do anything about it, then she would go up the chain of command, but how would I know if the nurse didn't do anything about it. She stated that Resident #5 would sometimes complain about the smell of Resident #4's bowel movements. She stated that Resident #5 was always in and out of the room. She stated that he could be in the room and she might be down the hall or something. She stated that it never crossed her mind that anyone would be doing that to Resident #4. On 4/19/17 at 3:54pm an interview was conducted with S10SW. She stated that she was notified by one of the MDS nurses that Resident #5 had placed a blanket over Resident #4's face. She stated that she didn't recall when it happened and she didn't document it. She stated she didn't document anything until Resident #5 was discharged . She stated that she was not told of any other incidents between Residents #4 and #5. She stated that she is involved if residents have problems with roommates when it is reported to her. She stated that she was aware that Resident #5 had problems with his prior roommates. She stated that she would have expected someone would have told her of any incidents between Residents #4 and #5. She stated that she would have acted on it. She stated that Resident #4 is not able to verbalize, he is not able to move unless someone moves him, he is vulnerable. On 4/19/17 at 4:33pm an interview was conducted with S11LPN. She stated that she is the clinical liaison and the admissions nurse. She stated that she interviewed Resident #5 while he was at the behavioral hospital and asked him why he did those things and why he was angry with Resident #4. She stated that he told me that Resident #4 watched him and he did not like it. She stated that Resident #4 was extremely vulnerable. He could not yell out when Resident #5 did those things to him. That was the worst part of it because Resident #4 could not cry out for help. A review of the typed statement from S11LPN to the facility, dated 2/27/17 revealed the following: I went to the behavioral hospital and asked Resident #5 regarding the matter between him and his roommate. I asked Resident #5 if he remembered the incident and he said what incident, so I reminded him about the nurse and other staff found his roommate with blankets and other items such blankets covering his face. He said yes, I remember that, he wouldn't stop staring at me when I went to the toilet. On 4/19/17 at 4:57pm an interview was conducted with S2DON. She stated that on 3/20/17, S7LPN was the overnight (6:00pm-6:00am) agency nurse assigned to a hall where Residents #4 and #5 shared a room. She stated that on 3/21/17 at 7:13am, she was contacted by S7LPN who informed her that when she made her rounds at 7:00pm, she went into Resident #4's room and found him with a thick cover over his face and tucked behind his head. S7LPN said that she immediately uncovered his face and noticed that he was crying and his face was red and warm. S2DON stated that S12MDS Nurse was at the desk talking to S7LPN that morning and told her to call me. She stated that S7LPN had relieved S6LPN on 3/20/17. She stated that S6LPN told S7LPN that Resident #5 had been harassing Resident #4 and had mentioned some concerns to S7LPN about 1 week before this incident and again on 3/20/17. She stated that the first time, the aides reported it to S6LPN she should have reported to me immediately and removed Resident #5 from the room. S7LPN should have also notified me the first time it was reported to her. She did not have the aide sit outside the door or inside their room on 3/20/17 after 7:00pm. Resident #4 is vulnerable. She stated that she thought Resident #4 could feel fear and didn't think he would have been crying if he didn't. Surveyor was unable to interview S9CNA as S2DON stated that she no longer worked at the facility. S2DON stated that they had attempted to contact S9CNA via telephone to allow for surveyor interview without success. S2DON provided surveyor with an undated, handwritten statement with S9CNA's signature on it. A review of this statement revealed the following: Went in the room to assist S8CNA with Resident #4. Enter the room and his legs were hanging out the bed. After we had left out the room asked Resident #5 did he mess with Resident #4 and he stated that he was tired of that M__ F__ staring at him when he uses the bathroom and he told that M__ F__ that he was gonna get him. We continued to change Resident #4 and Resident #5 said that he needs to get paid for smelling that all day. After that Resident #5 told us that he had put the pad over his face. Reported this to S6LPN and she talked to Resident #5 in the hallway about the situation. On 4/20/17 at 2:16pm an interview was conducted with S12MDS Nurse for the facility. She stated on the morning of 3/21/17, S7LPN told her that Resident #5 tried to suffocate Resident #4. She stated that she asked S7LPN where the residents were and she told me that they were both in their room. She stated that she told S7LPN to write an incident report on both Residents #4 and #5. She stated she asked S7LPN what caused Resident #5 to do this and if she had called anyone. She said no she had not notified anyone. S7LPN told her that S6LPN had reported to her it happened last week. A review of S12MDS' handwritten statement to the facility dated 3/21/17 revealed the following: 6:30-7:00am - This nurse went to a hall to gather information from the 24 hour report book. Noticed that the book was empty and asked the night nurse if anything occurred on her shift. She stated, Nothing, except Resident #5 tried to suffocate Resident #4. She stated Resident #4 was OK, I wrote an incident report on Resident #5. I asked where was Resident #5 and she stated he was in his room sleeping. I asked nurse Why didn't you move him? Replied, I watched him every hour. He slept all night. I responded What if he had wakened in a half hour. Nurse replied, I watched him. I asked did you call Resident #4's family or doctor or even the DON? Replied No. This nurse stated, I thought you did an incident report? You are required to do this. No response to question. Asked nurse, did you call Resident #5's doctor or family? Nurse replied, No, I didn't really know what to do. Nurse stated He did the same thing last week on S6LPN. Day nurse, S6LPN present and agreed. I informed the night nurse that she needed to call the DON, families and doctors of both residents. Informed her that Resident #5 was to be removed immediately. Informed both nurses that on 1/27/17 Resident #5's [MEDICATION NAME] and [MEDICATION NAME] were discontinued and that he has [DIAGNOSES REDACTED]. On 4/20/17 at 2:18pm an interview was conducted with S2DON. She stated there are only 2 quadriplegic residents in the building, Resident #4 and Resident #1. She stated that Resident #1 can speak and Resident #4 cannot speak. On 4/20/17 at 3:00pm, an interview was conducted with S7LPN. She stated that was an agency nurse and worked the night shift at the facility (6:00pm - 6:00am) on 3/16/17 and 3/20/17. She stated that at 6:00pm on 3/16/17, she relieved S6LPN. She stated that S6LPN told her that the aides reported a bed pad had been placed on Resident #4's face earlier today. She stated that on 3/20/17 at 6:00pm, she relieved S6LPN. S7LPN stated that on 3/20/17 two incidents occurred with Resident #4. The first incident was when an aide reported to her that Resident #4's feet were hanging out of the bed. She stated that she couldn't remember the time or the aide's name. She stated the second incident occurred at 7:00pm, when she went into Resident #4 and #5's shared room and saw a white blanket over Resident #4's head and tucked in around his face. She stated that she removed it and Resident #4's face was red and he was crying. She stated that Resident #5 could stand, get himself in and out of the wheelchair. She stated that he had a [DIAGNOSES REDACTED].#5's bed was closest to the hall door and Resident #4's bed was in the back of the room with a privacy curtain separating their beds. She stated that Resident #5 would always pull the curtain between them closed. She stated that after she removed the blanket from Resident #4's face, she opened the door to their room, pulled the curtain open and moved her medication cart outside of the their door. She stated that she did not stay in Residents #4 and #5's room the entire night. She stated that she could not say that there was anyone visually monitoring Residents #4 and #5 throughout the night. S7LPN stated that there is no unit supervisor on the night shift at the facility, so we report to the DON. She stated she waited until the end of the shift and then notified the DON on the morning of 3/21/17. S7LPN stated that she did not remove Resident #5 from the room because she didn't know if there was not an empty room available on her station and that she did not report the incident immediately because she didn't know what the facility's protocol was. On 4/20/17 at 4:20pm an interview was conducted with S6LPN. She stated that she works the day shift (6:00am-6:00pm). She stated that there were some incidents with Resident #4 on 3/16/17 and 3/20/17. She stated that there was also another incident, but she did not know the date or time of it. She stated that On 3/16/17, S8CNA reported to her that she found a bed pad on Resident #4's face and she removed it. She stated that she could not recall if Resident #5 was in the room or not at that time. She stated that S8CNA asked her at that time, if Resident #5 could be messing with Resident #4. She stated that she reported this to the oncoming nurse, S7LPN, at 6:00pm on 3/16/17. She stated that this was the first incident that occurred. She stated that she talked to Resident #5 about it and he said that he didn't have to stay with that s__t. She stated that she did not notify the DON of this incident as it occurred after 4:00pm and the DON had gone home for the day. She stated that on another day, she could not recall the date or time, a ward clerk told her that Resident #4's legs were dangling off the bed and she put him back in bed. She stated that at that point in time, she did not do anything. She stated then on 3/20/17, a CNA told her that she was concerned about Resident #4 and that his roommate, Resident #5 was in their room eyeballing Resident #4. She stated that she went to the room, but Resident #5 had already left the room. She stated that she reported this incident on 3/20/17 to the oncoming nurse, S7LPN, at shift change. She stated that she didn't document any of the incidents regarding Residents #4 and #5 in her nurses notes or elsewhere. She further stated that she did not notify the DON or other Administrative staff of these incidents involving Resident #4 and #5. On 4/21/17 at 11:45am an observation was made of Resident #4 in his room with S2DON present. His bed had been moved closest to the entrance door. An empty bed was in the back of the room near the restroom. S2DON stated that Resident #4 was moved closer to the entrance of the room. She stated that Resident #5 would use the toilet which was observed to be near the bed at the back of the room. She stated that Resident #5 would not close the bathroom door. She stated that is why Resident #5 felt that Resident #4 was looking at him when he went to the toilet. On 4/21/17 at 12:03pm an interview was conducted with S4LPN. She stated that they only have 1 full time nurse on the night shift, the rest are agency nurses. She stated that Resident #5 was quiet and he would stay in his room a lot. She stated that she worked on a hall several times within the past 2 months. She stated she never got any report from any aides that anything was going on with Resident #4 and #5. She stated no one ever never told her that anything might be going on with Resident #4 or #5. She stated that she didn't think Resident #4 could move his legs or feet off the bed because his legs are stiff and his feet and arms are contracted. She stated that he can move his arms a tiny bit and he can move his head a little bit from side to side. She stated that he was moved to the bed closest to the door of the room today. She stated that when Resident #4 was in the back of the room, you could not see him when you walked past his room. She stated now that he is in the front bed you can see him whenever you pass his room. She stated that Resident #4 should have been in the bed closest to the door. A review of the handwritten statement provided by S8CNA to the facility, dated 3/21/17 revealed the following: Two weeks before, I walked in the room and Resident #4 had a pad unfolded on his face. I told S6LPN he was bloodshot red and we didn't know what to think. So she said watch him more. About 1 and a half hours later, I went in his room to and he was hanging off the bed, his feet and legs. I told S6LPN that unless Resident #4 is about to start walking again, I think Resident #5 is messing with him. She said I'm go to have a talk with him. Every now and then I will find Resident #4 with his feet handing down off the bed and he's not at the top of the bed like when we pull him up and change him. The next day after the pad was over his face, S9CNA asked him why he did it. We still did not know who did it. His words were I'm tired of that M___ F___ looking at me while I p__s and s__t every day. I told him I was goona get him. S9CNA and I both told S6LPN. She said she was going to talk to him. I don't know what she did about it, but we told her. Yesterday, 3/20/17 about 5:30pm we, S13CNA and I, changed Resident #4 and pulled him up and round 6:40pm, almost 7:00pm, S7LPN asked when was the last time we checked Resident #4 and I said about 5:30pm. On 4/21/17 at 2:00pm an interview was conducted with S8CNA. She stated that about 2-3 months ago, she saw Resident #4's feet and legs hanging off of his bed. She could not recall the date of this incident. She stated that she reported this to both S6LPN and S7LPN. She stated that another incident occurred to Resident #4 on 3/16/17 when she saw a bed pad folded over Resident #4's face. She stated that she didn't think that he could do that since he was paralyzed. She stated that she reported this to the nurses and didn't know to do anything else. She stated that S9CNA knew about it. She stated that S9CNA asked Resident #5 why he didn't like Resident #4 and what was wrong. Resident #5 just said he was going to get him, talking about Resident #4. She stated that was about 2-3 days after the bed pad was on Resident #4's face. She stated that she reported it to S13CNA. She stated that S14CNA knew about it. She stated that she would tell the aide who relieved her about these instances, but they were agency aides. She stated she didn't know that she should tell anyone else. She stated that she thought she was doing what she was supposed to do by telling the nurse. She stated that we wondered why Resident #1 and #4 were not together in the same room and we asked S6LPN and sometimes we would ask the coordinator, but they would just blow it off. On 4/21/17 at 2:53pm an interview was conducted with S13CNA. She stated that she was a CNA Coordinator making sure that things are getting done and the aides on the floor are doing what they are supposed to do. She stated that she was familiar with Residents #4 and #5. She stated that S8CNA first reported to her that a bed pad was over Resident #4's face and then a couple of days later she told me his legs were hanging out of the bed. She stated that S8CNA asked her if she thought that Resident #4 could move his legs off the bed and she told S8CNA, no. She stated that Resident #4 can't defend himself. S13CNA stated that she, herself, did not tell anyone else about the incidents. She stated that she was not aware of any other incidents involving Resident #4. S13CNA stated that she did not attend morning meetings with the DON to discuss daily occurrences.

Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#4) of 5 sampled residents (#1, #2, #3, #4, #5). The facility failed to: 1.) Implement its policies and procedures that prohibit and prevent abuse/neglect by failing to ensure incidents of suspected abuse are thoroughly investigated, reported and interventions are put in place to prevent abuse; and 2.) Ensure staff protect the resident (#4) from the potential of harm when they had knowledge that resident #5 had voiced feelings of retaliation against Resident #4 for no known reason. This failed practice resulted in an Immediate Jeopardy (IJ) situation for Resident #4, a non-verbal quadriplegic resident, on 3/16/17 between 4:00pm -6:00pm, when S8CNA discovered a bed pad placed over Resident #4's face. S8CNA described the resident's face as blood shot red upon removal of the pad. Resident #4 was physically unable to remove the pad or call out for help. Approximately 1 1/2 hours after discovering the bed pad on Resident #4's face, S8CNA entered Resident #4's room and observed that Resident #4's legs and feet were hanging off of his bed. S8CNA reported these incidents to S6LPN and told that she felt Resident #4's roommate, Resident #5 may have done this. On 3/16/17 during shift change at 6:00pm, S6LPN reported these incidents to S7LPN. S6LPN and S7LPN did not take any action to protect Resident #4 from further abuse nor did they notify anyone of these incidents. Then on 3/20/17 at 7:00pm, S7LPN discovered a blanket over the face that was tucked in under the head of Resident #4. S7LPN removed the blanket and described the resident as crying, his face red and warm. S7LPN did not remove either of the residents from the room at that time, nor did S7LPN notify anyone until 3/21/17 at 7:00am when she informed S12MDS who instructed her to call the DON. The facility has agency staff that also worked in their facility and it was identified that not all agency staff had been trained on how to identify and report abuse. S1Asst.Adm. and S2DON were informed of the IJ situation on 4/20/17 at 11:05am. The facility provided their plan of removal on 4/20/17 as follows: Plan of Removal for Resident #4: Resident #5 was removed from the room he shared with Resident #4 and was discharged to a behavioral health hospital on [DATE]. Plan of Removal for Entire Building: On 3/21/17, DON identified the additional at risk residents (non-verbal and/or unable to move extremities). An evaluation of their roommates was conducted. The roommates were reviewed for current medical condition, review of history of behaviors and assessment of the two roommates relationship via staff interview and observation (e.g. has the at risk resident's roommate made verbal threats or derogatory comments about the at risk resident). On 3/21/17, the facility's Administrative Nurses began including, as part of their on-going periodic room rounds, questions to the floor staff (CNAs and LPNs) about any signs or concerns of resident abuse or neglect. On 3/24/17, the facility began providing in-service training to all staff regarding the facility's Abuse and Neglect Policy and Procedure. Specifically, this in-service training focused on each staff member's individual responsibility to report suspected abuse or neglect to their supervisor and directly to the DON or Administrator if their immediate supervisor does not begin an investigation. The immediacy of the IJ for Resident #4 was removed when Resident #5 was removed from their shared room on 3/21/17 at 7:15am. The deficiency remains at a potential for harm for the 11 residents identified by the facility with physical inability to move and/or were non-verbal. The facility had a total census of 119 residents according to the Resident Census and Conditions of Residents provided by the facility dated 4/19/17. Findings: 1.) Refer to findings at tag F223; 2.) Refer to findings at tag F224; 3.) Refer to findings at tag F226; On 4/19/17 at 3:54pm an interview was conducted with S10SW. She stated that she was notified by one of the MDS nurses that Resident #5 had placed a blanket over Resident #4's face. She stated that she didn't recall when it happened and she didn't document it. She stated she didn't document anything until Resident #5 was discharged . She stated that she was not told of any other incidents between Residents #4 and #5. She stated that she is involved if residents have problems with roommates when it is reported to her. She stated that she was aware that Resident #5 had problems with his prior roommates. She stated that she would have expected someone would have told her of any incidents between Residents #4 and #5. She stated that she would have acted on it. She stated that Resident #4 is not able to verbalize, he is not able to move unless someone moves him, he is vulnerable. On 4/19/17 at 4:57pm an interview was conducted with S2DON. She stated that on 3/20/17, S7LPN was the overnight (6:00pm-6:00am) agency nurse assigned to a hall where Residents #4 and #5 shared a room. She stated that on 3/21/17 at 7:13am, she notified me of the incident. S2DON stated that S12MDS Nurse was at the desk talking to S7LPN and told her to call me. She stated that S7LPN relieved S6LPN at 6:00pm on 3/20/17. She stated that S6LPN had told S7LPN that Resident #5 had been harassing Resident #4 and had mentioned some concerns to S7LPN (the incidents on 3/16/17 and 3/20/17). She stated that the first time the aides reported it to S6LPN she should have reported to me immediately and removed Resident #5 from the room. S7LPN should have also notified me the first time it was reported to her. She did not have the aide sit outside the door or inside their room on 3/20/17 after 7:00pm. She stated that Resident #4 was vulnerable. On 4/20/17 at 9:15am an interview was conducted with S1Asst. Adm. He stated that they began again in-servicing their staff on 3/24/17 regarding abuse/neglect. He stated that we removed Resident #5 from their room on 3/21/17 and sent him to a behavioral hospital that same day. He stated that Resident #5 did not return to the facility and was discharged from the facility on 3/29/17. On 4/21/17 at 10:45am, an interview was conducted with S1Asst.Adm. He stated that there is no smoking gun proving that Resident #5 did anything to Resident #4. He stated that what we saw on video corroborates staff statements. He stated that on 3/20/17 at 6:58pm, S7LPN enters the room and finds the blanket over Resident #4's head. He stated that Resident #5 was milling in and out of the room. Resident #5 was looking around suspiciously. He stated that Resident #5 was not seen on the facility's video going to the linen closet on 3/20/17. He stated that the resident used linen that was already in the room to cover Resident #4's face. He stated that Residents #4 and #5 were in the room, alone together, from 5:41pm until 6:58pm. S1Asst. Adm. stated all evidence points to Resident #5. 4/21/17 at 1:45pm an interview was conducted with S2DON. She stated that on 3/21/17, after we were notified of the incident, we began to do administrative room rounds and asked the CNAs if they reported anything to the nurse. We instructed the administrative staff to talk to the floor staff to identify anything that the nurse didn't identify or report. She stated that this was being done daily on morning rounds by the administrative staff.

Based on record review and interview the facility failed to implement their policy/procedures to prohibit abuse and neglect and thoroughly investigate and report a resident to resident abuse to the Administrator immediately for 1 (#4) of 5 sampled residents (#1, #2, #3, #4, #5). This failed practice resulted in an Immediate Jeopardy (IJ) situation for Resident #4, a non-verbal quadriplegic resident, on 3/16/17 between 4:00pm -6:00pm, when S8CNA discovered a bed pad placed over Resident #4's face. S8CNA described the resident's face as blood shot red upon removal of the pad. Resident #4 was physically unable to remove the pad or call out for help. Approximately 1 1/2 hours after discovering the bed pad on Resident #4's face, S8CNA entered Resident #4's room and observed that Resident #4's legs and feet were hanging off of his bed. S8CNA reported these incidents to S6LPN and told that she felt Resident #4's roommate, Resident #5 may have done this. On 3/16/17 during shift change at 6:00pm, S6LPN reported these incidents to S7LPN. S6LPN and S7LPN did not take any action to protect Resident #4 from further abuse nor did they notify anyone of these incidents. Then on 3/20/17 at 7:00pm, S7LPN discovered a blanket over the face that was tucked in under the head of Resident #4. S7LPN removed the blanket and described the resident as crying, his face red and warm. S7LPN did not remove either of the residents from the room at that time, nor did S7LPN notify anyone until 3/21/17 at 7:00am when she informed S12MDS who instructed her to call the DON. The facility has agency staff that also worked in their facility and it was identified that not all agency staff had been trained on how to identify and report abuse. S1Asst.Adm. and S2DON were informed of the IJ situation on 4/20/17 at 11:05am. The facility provided their plan of removal on 4/20/17 as follows: Plan of Removal for Resident #4: Resident #5 was removed from the room he shared with Resident #4 and was discharged to a behavioral health hospital on [DATE]. Plan of Removal for Entire Building: On 3/21/17, DON identified the additional at risk residents (non-verbal and/or unable to move extremities). An evaluation of their roommates was conducted. The roommates were reviewed for current medical condition, review of history of behaviors and assessment of the two roommates relationship via staff interview and observation (e.g. has the at risk resident's roommate made verbal threats or derogatory comments about the at risk resident). On 3/21/17, the facility's Administrative Nurses began including, as part of their on-going periodic room rounds, questions to the floor staff (CNAs and LPNs) about any signs or concerns of resident abuse or neglect. On 3/24/17, the facility began providing in-service training to all staff regarding the facility's Abuse and Neglect Policy and Procedure. Specifically, this in-service training focused on each staff member's individual responsibility to report suspected abuse or neglect to their supervisor and directly to the DON or Administrator if their immediate supervisor does not begin an investigation. The immediacy of the IJ for Resident #4 was removed when Resident #5 was removed from their shared room on 3/21/17 at 7:15am. The deficiency remains at a potential for harm for the 11 residents identified by the facility with physical inability to move and/or were non-verbal. The facility had a total census of 119 residents according to the Resident Census and Conditions of Residents provided by the facility dated 4/19/17. Findings: 1.) Refer to findings at tag F223; 2.) Refer to findings at tag F224; A review of the facility's Policy & Procedure for Abuse/Neglect revealed, in part, the following: ---Training of Employee: Yearly in-service will be conducted in order to: Teach appropriate intervention for aggressive behavior Educate employees regarding their knowledge related to reporting abuse or neglect allegations ---Prevention: Monitor all incident occurring to identify any trends/patterns -Identification: Review of all incident reports by the DON or designee Referral of all suspicious incidents and complaints to the DON & Adm. Review of incident reports Investigate all report of suspected neglect/abuse (employee, family, resident) ---Investigation: Review incident report for history of previous incidents/injuries Review accused person's record regarding previous performance/behavior ---Protection: Resident on Resident: Residents are to be separated (different rooms, placed on different units if possible, etc.) ---Reporting/Response: Report all alleged violations and all substantial incidents. On 4/19/17 at 4:57pm an interview was conducted with S2DON. She stated that on 3/20/17, S7LPN was the overnight (6:00pm-6:00am) agency nurse assigned to a hall where Residents #4 and #5 shared a room. She stated that on 3/21/17 at 7:13am, she was contacted by S7LPN who informed her that when she made her rounds at 7:00pm, she went into Resident #4's room and found him with a thick cover over his face and tucked behind his head. S7LPN said that she immediately uncovered his face and noticed that he was crying and his face was red and warm. S2DON stated that S12MDS Nurse was at the desk talking to S7LPN and told her to call me. She stated that S7LPN had relieved S6LPN on 3/20/17. She stated that S6LPN told S7LPN that Resident #5 had been harassing Resident #4 and had mentioned some concerns to S7LPN about 1 week before this incident and again on 3/20/17. She stated that the first time, the aides reported it to S6LPN she should have reported to me immediately and removed Resident #5 from the room. S7LPN should have also notified me the first time it was reported to her. On 4/20/17 at 3:00pm, an interview was conducted with S7LPN. She stated that was an agency nurse and worked the night shift at the facility (6:00pm - 6:00am) on 3/16/17 and 3/20/17. She stated that at 6:00pm on 3/16/17, she relieved S6LPN. She stated that S6LPN told her that the aides reported a bed pad had been placed on Resident #4's face earlier today. She stated that on 3/20/17 at 6:00pm, she relieved S6LPN. S7LPN stated that on 3/20/17 two incidents occurred with Resident #4. The first incident was when an aide reported to her that Resident #4's feet were hanging out of the bed. She stated that she couldn't remember the time or the aide's name. She stated the second incident occurred at 7:00pm, when she went into Resident #4 and #5's shared room and saw a white blanket over Resident #4's head and tucked in around his face. She stated that she removed it and Resident #4's face was red and he was crying. She stated that Resident #5 could stand, get himself in and out of the wheelchair. She stated that he had a [DIAGNOSES REDACTED].#5's bed was closest to the hall door and Resident #4's bed was in the back of the room with a privacy curtain separating their beds. She stated that Resident #5 would always pull the curtain between them closed. She stated that after she removed the blanket from Resident #4's face, she opened the door to their room, pulled the curtain open and moved her medication cart outside of the their door. She stated that she did not stay in Residents #4 and #5's room the entire night. She stated that she could not say that there was anyone visually monitoring Residents #4 and #5 throughout the night. She stated that she has not had any training on abuse or neglect from the facility. S7LPN stated that there is no unit supervisor on the night shift at the facility, so we report to the DON. She stated she waited until the end of the shift and then notified the DON on the morning of 3/21/17. S7LPN stated that she did not remove Resident #5 from the room because she didn't know if there was not an empty room available on her station and that she did not report the incident immediately because she didn't know what the facility's protocol was. On 4/20/17 at 4:20pm an interview was conducted with S6LPN. She stated that she works the day shift (6:00am-6:00pm). She stated that there were some incidents with Resident #4 on 3/16/17 and 3/20/17. She stated that there was also another incident, but she did not know the date or time of it. She stated that On 3/16/17, S8CNA reported to her that she found a bed pad on Resident #4's face and she removed it. She stated that she could not recall if Resident #5 was in the room or not at that time. She stated that S8CNA asked her at that time, if Resident #5 could be messing with Resident #4. She stated that she reported this to the oncoming nurse, S7LPN, at 6:00pm on 3/16/17. She stated that this was the first incident that occurred. She stated that she talked to Resident #5 about it and he said that he didn't have to stay with that s__t. She stated that she did not notify the DON of this incident as it occurred after 4:00pm and the DON had gone home for the day. She stated that on another day, she could not recall the date or time, a ward clerk told her that Resident #4's legs were dangling off the bed and she put him back in bed. She stated that at that point in time, she did not do anything. She stated then on 3/20/17, a CNA told her that she was concerned about Resident #4 and that his roommate, Resident #5 was in their room eyeballing Resident #4. She stated that she went to the room, but Resident #5 had already left the room. She stated that she reported this incident on 3/20/17 to the oncoming nurse, S7LPN, at shift change. She stated that she didn't document any of the incidents regarding Residents #4 and #5 in her nurses notes or elsewhere. She further stated that she did not notify the DON or other Administrative staff of these incidents involving Resident #4 and #5. On 4/19/17 at 3:09pm an interview was conducted with S3CNA for Resident #4. She stated about 2-3 months ago, while working the 6:00am-2:00pm shift, she saw a blanket on Resident #4's face. She stated that she removed it and continued with her rounds. She stated that was the first time she had seen that. She stated that she was new to the hall Resident #4 was on and she wasn't sure what Resident #4 could or could not do for himself at that time. She stated, later on that same day, after she finished rounds, she went into Resident #4's room and saw the blanket on his face and over his mouth again. She stated that this time she knew he couldn't put it there himself. She stated that Resident #4 was just lying there with his eyes open. She stated that it was bothering her, because she thought that maybe she left the blanket on the resident's face, but the 2nd time she saw it, she knew she did not leave a blanket on Resident #4's face. She stated that she told the nurse about it. She stated that she would report immediately to the nurse if anything like that happened again. She stated that if the nurse did not do anything about it, then she would go up the chain of command, but how would I know if the nurse didn't do anything about it. On 4/20/17, a further review of the facility's Policy and Procedure for Abuse/Neglect revealed that the policy contained no documentation that staff should go up the chain of command if no action was taken to address reports of abuse or neglect.

Based on interview and record review the facility failed to ensure staff adequately supervised 2 (Resident #2, & Resident #4) of 5 (Resident #1, #2, #3, #4, #5) sampled residents assessed by the facility as high risk for elopement to prevent Resident #2 and Resident #4 from eloping the facility and a possible accident hazard. The facility failed to: 1) Have a system in place which ensured a resident(s) identified by the facility as high risk for elopement received adequate supervision and care and services to prevent elopements undetected by staff; 2) Supervise a resident diagnosed with [REDACTED]. 3) Implement interventions to increase monitoring and supervision for a resident that had a history of [REDACTED]. 4) Monitor the resident every 2 hours; This resulted in an Immediate Jeopardy situation for Resident #2 and #4 when the facility failed to ensure a system was in place to ensure each resident that was a risk for elopement were supervised and/or monitored closely enough to prevent elopement. The Immediate Jeopardy began for Resident #4 on 04/27/14 at 7:30 a.m. when the resident, in her wheelchair, was found in the front parking lot of the facility. The Immediate Jeopardy began for Resident #2 on 05/13/14 at 5:00 p.m. when the resident, in his wheelchair, was found in the front parking lot of the facility. S1ADM, S2AADM and S3ADON were notified of the Immediate Jeopardy situation on 05/29/14 at 9:45 a.m. The Immediate Jeopardy was removed for both residents on 05/29/14 at 6:30 p.m. when the facility presented an acceptable plan of removal by S1Adm, S2AADM, and S3ADON that included: 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Resident #4 was placed on the secured unit without any other issues. Resident #2 remains in the general population. The front entrance/porch is locked from 9:00 p.m. to 6:00 a.m. The front entrance/porch is monitored by assigned staff members from 6:00 a.m. to 9:00 p.m. The assigned staff members will remain on the porch while assigned to monitor the front entrance/porch and will not leave the front porch area until the relieving staff member arrives on the front porch. The Maintenance Exit - Battery operated alarm is installed. If a staff member needs to access the Maintenance Shed Area, they will turn the alarm off to exit and have another staff member turn the alarm back on while they are outside in the Maintenance Shed Area. They will then call the nurses' station to request someone turn the alarm off again for them to return into the building and will turn the alarm back on when they return inside the building. A large, clear and readily visible warning identifying this process will be placed on the Maintenance Exit door. 2. How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken: Each resident identified as an elopement risk has the potential to be affected. 3. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur: The front entrance/porch are locked from 9:00 p.m. to 6:00 a.m. The front entrance/porch is monitored by assigned staff members from 6:00 a.m. to 9:00 p.m. The assigned staff members will remain on the porch while assigned to monitor the front entrance/porch and will not leave the front porch area until the relieving staff member arrives on the front porch. The Maintenance Exit - Battery operated alarm is installed. If a staff member needs to access the Maintenance Shed Area, they will turn the alarm off to exit and have another staff member turn the alarm back on while they are outside in the Maintenance Shed Area. They will then call the nurses' station to request someone turn the alarm off again for them to return into the building and will turn the alarm back on when they return inside the building. A large, clear and readily visible warning identifying this process will be placed on the Maintenance Exit door. This will remain in place until the following permanent security system is in place. - Front Entrance /Porch- a gate will be installed with a key pad lock at the end of the front porch to prevent residents from leaving the front porch and gaining access to the front parking lot area. - Maintenance Exit- a key pad lock will be installed on the inside and outside of the door to prevent residents form leaving exiting through the Maintenance Exit and gaining access to the Maintenance Shed Area. The policy and procedure regarding Unsafe Wandering/Elopement Risk Assessment and Mitigation was updated and revised. In-service training to staff on the revised policy and procedure began. Staff that has not been in-serviced will be prior to returning to work. 4. How the corrective actions will be monitored to ensure the practice will not recur, i.e. what quality assurance program will be put into place. The Administrator and his designee will monitor compliance with both of the revised policies and procedure changes on a daily basis until consistent compliance is achieved. The Quality Assurance Team will monitor compliance thereafter. The deficient practice remains at a level 2. Findings: On 05/27/14 at 8:35 a.m. a general tour was performed of the entire facility. All exits were checked. There were 2 exit doors on Unit A. One of the exits led to the front of the building and had to code pad. It was locked, when staff entered the code it opened. The other door on Unit A led to the back of the building and was unlocked. No code was needed to open the door and the no alarm went off when it was opened. The Main dining room had an exit door that led to the side/front of the building. S1ADM was present when the door was checked. The door was unlocked and when it was opened it did not alarm. S1ADM stated, "That 's not good. " He acknowledged that the door should have alarmed when it was opened. He stated he would have maintenance look at it. He stated maintenance checks it monthly. The front entrance to the facility is an automatic sliding door. The door was recessed with a wall 8-10 feet to the left and a reception office to the right. The reception office had a door for entry and glass window covered by closed blinds. . People entering or exiting cannot be viewed from this office with the blinds down. S1ADM stated the front entrance to the facility had automatic doors that do not alarm when entered or exited. He also stated the facility does not use wanderguards with their residents. They identify the residents with high risk for elopement with yellow wrist bands. He stated they monitored them closely. He stated if the family consents to it the residents would be put on the locked unit. On 5/28/14 at 9:30 a.m. an observation was performed of Unit A door that leads to back of facility (maintenance area), the door was unlocked. The door is not visible from the nurses' station. On 5/29/14 at 8:05 a.m. an observation was performed of Unit A door that leads to back of facility. This door was opened by the surveyor and it did not alarm. A review of the Quality Assurance Monthly Incident/Accident Tracking Log for the month of April 2014 revealed there were 2 residents that eloped. Resident #4 eloped on 4/27/14 and Resident #2 eloped on 5/13/14. Resident #4: A review of the faciliy's Elopement Risk Policy revealed the following: Resident who voices the need to leave the facility or who attempts to leave the facility without authorization will need to be closely monitored by staff. Staff will be assigned to monitor resident during times when other job duties are completed. When staff is performing other job duties which prohibit close supervision of the resident, the resident is to be placed on the special care secured unit for safety. The assigned staff is to assist the resident with ADL needs during the time the resident is on the secured unit. The resident will be evaluated for frequency of incidents to determine appropriate permanent placement on unit. Upon receiving notice that a resident is missing from the facility, the nurse should determine if the resident is out on an authorized leave or pass. If not, the nurse should: h. Notify regulatory agencies per state guidelines. A review of the resident's clinical record revealed Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 04/28/14 revealed, in part, the following: Section C: Cognitive Patterns - BIMS (Brief Interview for Mental Status) revealed the resident had a summary score of 3 which is indicative of severe cognitive impairment. Section E: Behavior - Delusions- Resident was assessed as having delusions - behaviors of this type occurred 1 to 3 days. Wandering- Resident was assessed as having wandering behavior- behavior of this type occurred 1 to 3 days Wandering impact- Resident was assessed as the wandering placing the resident at significant risk for getting to a potentially dangerous place. Change in behavior or other symptoms- Resident was assessed as N/A because no prior MDS assessment. Section G: Functional Status - D- locomotion on unit- limited assist. F- Locomotion off unit - limited assist. Mobility Devices- Wheelchair. A review of the resident's Care Plan dated 4/21/14 revealed, in part, the following: Problem Start Date: 04/21/14- Category- Cognitive loss/Dementia-Elopement Assessment identifies resident as a potential for elopement. Goal Target Date: 07/17/14- Promote decrease risk in injury R/T elopement. Approach Start Date: 04/21/14- Be observant at all times of resident ' s location. Approach Start Date: 04/21/14- Encourage activity attendance/ participation. Approach Start Date: 04/21/14- If elopement occurs, complete report, contact MD(medical doctor)/RP( Responsible Party)/DON ( Director of Nursing). Approach Start Date: 04/21/14- Labs as ordered, notify MD of results. Approach Start Date: 04/21/14- Move to special care unit, nurse to monitor. Approach Start Date: 04/21/14- Provide quiet /pleasant environment. Approach Start Date: 04/21/14- Re-direct as needed to place and time. Approach Start Date: 04/21/14- Reorient to surroundings as needed, reassure when confused, Notify MD/family. Problem Start Date: 04/21/14- Category- Cognitive loss/Dementia-Potential for Cognitive Impairment due to Dementia. Goal Target Date: 07/17/14- Promote decrease of injury related to cognitive status. Review every 90 days. Approach Start Date: 04/21/14- Administer medications as ordered, monitor for effectiveness, S/E ( side effects). Approach Start Date: 04/21/14- Assist with decision making as needed. Approach Start Date: 04/21/14- Calm resident if signs of distress develops during decision Making process (feeling overwhelmed, fatigue, agitation, Restlessness, withdrawn) Approach Start Date: 04/21/14- Encourage to participate in daily activities as tolerated. Approach Start Date: 04/21/14- Keep explanations simple. Approach Start Date: 04/21/14- Labs as ordered, notify MD of results. Approach Start Date: 04/21/14- Report any changes in cognitive status to family, MD, SS.ST & RSD. Approach Start Date: 04/21/14- Support and reassure resident in new situations. Approach Start Date: 04/21/14- Use appropriate safety measures to protect resident from Injury. A review of Resident #4 's Elopement Risk Screening revealed the resident was screened for elopement risk on 04/21/14 and was determined to be an elopement risk due, in part, to having verbally expressed the desire to go home, packed belongings to go home, recent admit within 30days, cognitively impaired with poor decision making skills and has [DIAGNOSES REDACTED]. A review of Resident #4 's Social Service assessment dated [DATE] revealed, in part, the following: Mood State/Behavior Problems/Psychosocial Adjustment- There are no moods or behaviors at this time. She has [DIAGNOSES REDACTED]. Physical/Functional Status- the resident uses a wheelchair to mobility and she is able to propel herself. She needs assistance with her transfers and ADL 's. She is receiving wound care. Cognitive/Mental Status- She thought she was at H____Nursing Home. She could not recall any 3 words after 5 minutes. She could not recall the year, month or day. She needs some assistance with decision making. She does have a [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. Resident #4 was moved to the locked unit on 4/30/14. A review of the Physician order [REDACTED]. Psychological Assessment and Treatment as necessary was ordered along with services to be provided by ___________ or Other. Under referral reasons the resident's MD had checked the following: Agitations, Delusions, Wandering, Sadness/Depression, Resisting Care/Meds, Paranoia, Assess Efficacy of Psych. Meds. The resident continued to be in the unsecured population. A review of the residents MAR (Medication Administration Record) for the month of April revealed the resident was to be monitored every 2 hours for wandering starting 4/27/14 at 8 a.m. and ending when she was admitted to the locked unit on 4/30/14. The resident's MAR had no documentation of 2 hour checks from 4 p.m. through 10 p.m. on 04/29/14. A review of the Nurses Notes on Resident #4 revealed the following: 4/22/14 @ 12 a.m. - Resident sitting up in wheelchair in dayroom. She is persistently stating that we kidnapped her and that she is ready to go home. Extremely agitated and refusing care. 4/22/14 @ 3 p.m. - Able to voice needs, confusion noted. Resident believes that someone in a station wagon is picking her up at 5 p.m. Propels self in wheelchair. 4/23/14 @ 3:30 p.m. - Noted confusion, believes she comes to sit with a friend and will be picked up around 8pm. 4/26/14 @ 2 p.m. Verbalizing need to go home, poor STM states "I brought myself here and I haven't received my meds since I 've been here. My family has no idea where I am. Showed resident her meds and she calmed down. 4/27/14 @ 6:50 a.m. Resident sitting up in wheelchair in main D.R.( dining room) drinking coffee, pleasant mood, 0 distress noted, protective boot to LT ( left) foot. Continue to monitor. 4/27/14 @ 7:30 a.m. Observed resident in front parking lot, resident states "I 'm going home to eat breakfast; I have to leave this place. My son is trying to steal my house. "Attempted to redirect resident to facility. Cont. to refuse X 3 staff to assist back into facility, resident resistive states "I'm going to get out of this place." Upon resident returning to facility cont. to wander in W/C. Staff cont. to monitor. DON notified. 4/27/14 @ 9:25 a.m. Resident moved to special care unit for monitoring of wandering. Cont. resistive to care. 4/27/14 @ 9:27 a.m. Notified RP (responsible party)______ _______ states "She has expressed feelings that her kids are stealing her house, this is normal behavior for her. She is on meds for this. She has some good and she has some bad days." 4/27/14 @ 10 a.m. Resident brought to in for toileting, calm m mood and states "I 'm sorry for the way I acted. " Sitting in w/c in day area @ dining table and resistive behavior noted. 4/27/14 @ 12:01 p.m. ______(on call for ______) verbally notified of elopement/ resident [DIAGNOSES REDACTED]. to monitor. 4/27/14 @ 2 p.m. Pleasant mood, 0 resistances noted. 4/27/14 @ 9:30 p.m. wandering in building, cont. to monitor. 4/27/14 @ 12:30 Resident in wheelchair sitting down by Unit A. Wandering precautions in place. Resident still confused. 4/28/14 @ 1:30 p.m. Resident has made no further attempts to elope. I spoke with resident this A.M. regarding leaving facility. Resident stated, "I didn 't try to leave." Review with resident (illegible) of her being outside in parking lot on 4/27/14. Resident denied report. I spoke with son and daughter. Both siblings agree resident is at risk for further elopement attempts. Son reports he believes this is resident's master plan to come here to this facility so she can be closer to Ponchatoula and leave facility. Son/Dtr in agreement resident would benefit from Special Care (locked) Unit. While resident is in transition for move to SCU, place arm band of identification and instructed staff. Cont. to monitor closely. 4/29/14 @ 9 p.m. Was knocking on doors of SCU at shift beginning. States she wants to go home and stressed out. Resident was admitted to the Special Care (locked) Unit on 4/30/14. A review of the Resident's Social Progress Notes and Evaluation revealed the following: 4/28/14- She (resident) does have delusions noted. For ex., on 4/22/14, per N.N., she was up at 12 a.m. She was agitated. She stated the staff had "kidnapped" her. She also believed that someone will be picking her up. She also refused care from staff on 4/23/14, per N.N. She again stated that someone will be picking her up. On 4/27/14, ______(resident) was observed by staff to be in the front parking lot. She stated that she was trying to go home and that her family was trying to steal her house. She resisted staff who was trying to get her inside the facility. Her fly (family) was notified and she was placed in SCU for monitoring. On 4/28/14, this S.W. placed a name bracelet on _______wrist. She was later moved permanently to the Special Care Unit, Rm. 167A. 4/29/14- Was notified by DON that ________ (resident) was requesting to speak to the social worker. She spoke repeatedly of her son,_________, secretly trying to steal her house. She stated that she was capable of taking care of herself. She even stated she took a shower by herself this morning. She stated that just last month she was paying her bills and taking care of business at her house. I reoriented her to taking care of business at her house. I reoriented her to being at H-Nursing Home prior to coming here and she stated "I know I was there." She was not aware of where she was today; she believed she was at a hospital. She stated she is tired of people lying to her. She stated, "I 'm not crazy, you can get a psychologist. I may talk to him, I may not." She stated, "The only way you are going to keep me here is to handcuff me. " ______(resident) believes that she is able to live independently at home. She has a fixation on her son taking her house away from her. She became upset when I mentioned calling her son. She stated she had 5 other children that need to be involved, not just ____. She at times can become a little agitated. She was recently moved to the Special Care Unit due to wandering and being at high risk to elope. There was no re-orienting her to the current situation and why she needed assistance. On 5/27/14 at 10:30 a.m. an observation was performed. She was attending church services. She states she does not remember how long she has been here. She states she came here from her house. She is appropriately dressed. She is in a wheel chair with her LT foot /ankle in an ace wrap and her foot in a heel protector with it elevated with the foot rest. She was asked what happened to her foot and she states she stepped on a nail at her house. She states she has not been to the doctor; she is "doctoring it herself. " She states she likes it here but wants to go home. On 5/27/14 at 3:30 p.m. an observation was performed of the resident. She was seated a table with other residents in the day room of the special secure unit. She did not recognize me from earlier in the day. She smiled when I spoke to her. I asked her how she was doing and she stated, "Fine, I just had coffee. They serve coffee here." I asked her if she remembered talking with me earlier. She stated, "No." On 5/28/14 at 9:45 am an observation was performed of Resident #4 on the secure unit. She was seated at the table with her head down on her chest sleeping. She looked up when I called her name and smiled. She is clean and neatly dressed. She states she is doing well. On 5/28/14 at 10:00 a.m. an interview was conducted with S14CNA. She was asked to explain what occurred when Resident#4 eloped. She stated the resident was up in her wheel chair and she took her to the dining room for breakfast. She placed her at the table and got her a cup of coffee. S14CNA then left the dining area. She saw a supervisor come running down the hall. She asked her what was wrong and the supervisor told her that the resident was in the parking lot and didn 't want to come back in. The S14CNA went outside with the supervisor and talked her back into the facility. She stated the resident went out the front door and wheeled herself down the parking lot and was down by Unit A door. She ate her breakfast once back in the building. At this time the aide took her with her to fill ice carts. She became upset and got loud. She wanted to go outside so they put her on the secure unit. She was asked what the aides do to monitor the residents that are identified as risk for elopement. She stated the CNA 's report to each other, shift to shift, when someone is elopement risk. S14CNA was asked how the residents are identified when they are at risk. She stated they have an orange bracelet on and a red flag on their wheelchair. She was asked what documentation was done on a resident that required monitoring every 2 hours. She stated the nurse did most of the documentation. The CNA 's just monitored the resident as they usually did. On 5/28/14 at 10:15 a.m. an interview was conducted with S8CNA. She was asked how they identify residents that are at risk for elopement. She stated they have an orange bracelet and the wheelchairs have a red flag. She stated if they wanted to go outside someone goes with them. When asked how they document monitoring of elopement risk she stated they are documented the same as everyone else we just watch them closer. On 5/28/14 at 9:50 a.m. an interview was conducted with S7LPN. She was shown an in-service form regarding elopement and asked to identify her signature on the back. Next to her signature she had written "front is blank." She stated the in-service was held and she attended. She wrote the statement on the back as a joke. She was asked how staff identified residents that were elopement risk. She stated they have an orange band on their arm and staff report off, shift to shift, who is on elopement risk. She was asked what is done differently with these residents. She stated they are monitored every 2 hours and it is documented on the MAR(medication administration record). CNA 's are informed to monitor the resident more closely. She also stated, "If I see someone wandering down the hall I will find out where they are going. " On 5/29/14 at 10:15 am an interview was conducted with S3ADON. He was shown the in-service sheet dated 5/21/14 regarding review of the elopement policy. The back was signed by a nurse who put "front not completed." The S3ADON explained the in-service sheet was blank as they signed and then when the in-service was complete the front was filled in the presence of all who attended. On 5/28/14 at 8:30 a.m. an interview was conducted with S3ADON. He was shown a completed Risk Assessment and asked to explain what criteria on this assessment would qualify the resident to be at risk for elopement. He stated they must be cognitively impaired with poor decision making skills, have [DIAGNOSES REDACTED]. He also stated if they are at risk the facility processed to care plan for implantation of intervention for risk of elopement. He was asked what the interventions included. He stated close monitoring. He was asked what is close monitoring and who does that and how often. He stated the CNA and the nurses should document once a shift and if they elopement or attempt to elope then they document every 2 hrs. If the staff is busy and cannot document every 2 hours the resident is placed on the secure unit until the nurse is free and can monitor the resident one on one at the nurses' station. He was asked where the CNA and LPN 's are located during their shift. He stated they should be in an area where they can monitor all the rooms. On 5/28/14 at 9:40 A.M. S3ADON was asked what was done after the investigation to prevent the residents from eloping again. He stated closely monitor the residents and that Resident #4 was placed on a secure unit. Resident #2 was closely monitored. He was explained that he could not leave. Resident #2 has dementia off and on and he continued to ask for his wife and look for her. He was asked if in-services were conducted in the facility after the incident. He stated, "Yes and he provided them." The S3ADON also stated the facility now has red American flags on the w/c of the residents with elopement risk to also identify them as being at risk. He stated until the staff was in-serviced the maintenance guy thought it was because they were veterans. The S3ADON provide an in-service dated 5/21/14 for LPN 's on review of elopement policies. He also stated disciplinary action was taken on the nurse for not following facility procedures on the elopement risk form on admit. On 5/29/14 at 3:50 p.m. an interview was conducted S3ADON. He confirmed that the facility just started porch monitoring 2 days ago (5/27/14). When asked for all the monitoring schedules back to the date of the 1st elopement (4/27/14) he stated there were none. We just started the monitoring. Resident #2 Findings: Review of the clinical record revealed Resident #2 was an [AGE] year old male that was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the MDS with an ARD 05/20/14 revealed Resident #2 had a BIMS score of 4 which indicated severe cognitive impairment. The staff assessment for behavior indicated he had no hallucinations or delusions. He did not exhibit wandering behavior. He required two person, extensive assistance with transfer. He required supervision for locomotion off unit. He required one person, extensive assistance with dressing. He required supervision with eating. He required two person, extensive assistance for toilet use. Further review of the MDS revealed the resident was not steady during transitions and walking. Review of the facility's Incident/Accident Form revealed the following: Date of Incident: 05/13/14 Time of Incident: 5:00 p.m. Location of Incident: Outside Resident ' s condition before the incident: Confused Events of the incident: Resident was found in the front parking lot of the nursing home. He stated he was looking for his wife. He was already an elopement risk and has been monitored by staff. His wife and daughter were here earlier in the day singing Karaoke and when they left he couldn ' t understand why he couldn ' t go and went looking for them. Will continue to monitor. 6:00 p.m. Xanax 0.25 mg given PO crushed in apple sauce due to increase anxiety. 9:00 p.m. Resident wandering around building in w/c looking for family members. Redirected to bed. Additional Information on the facility's Incident/Accident Form revealed the following: 05/15/14 documented, "Late Entry On 5/13/14 at 5:00 p.m.: " DON spoke with daughter and wife regarding incident of being in parking lot on 05/13/14. Explained to wife and daughter facility is concerned about resident's safety as resident is intermittently confused. Family pleaded for resident not to be placed on S.C.U. stating, "That would just kill him." Family spoke to resident about safety and stressed to resident not to go outside in parking lot. Resident remarked to wife he would not go back to parking lot and stated, "I was out there looking for my wife." 05/14/14 - Staff has been monitoring resident closely. Resident has agreed to eat meals in TV area to allow for staff supervision. DON has had numerous conversations with resident about safety. Residents able to recall to DON #1 He will not go to parking lot and #2 He will eat in TV area. Instructed staff to continue to closely monitor. Review of the Elopement Risk Screening which was completed on 05/07/14 revealed the following: A. He was identified as cognitively impaired with poor decision-making skills. B. He had the following Diagnosis: [REDACTED]. C. He ambulated independently with his wheelchair. D. He had a history or was currently experiencing the following: Wanders aimlessly, Verbally expressed the desire to go home, Recent admit within 30 days E. His family or responsible party did not voice concerns that indicated the resident would have wandering tendencies or try to leave. F. He was assessed at risk for elopement and the following interventions were written on the form: Placed on MAR to monitor closely 5/13/14 Resident to eat meals in TV area Review of the physician's orders [REDACTED]. 05/07/14 Psychotropic behavior Monitor, Psychotropic Drug Target Behavior Q shift 05/07/14 Psychotropic drug S/E Q shift 05/07/14 Psychotropic motor S/E QD 05/07/14 Seroquel 50 mg PO QHS 05/07/14 Xanax 0.25 mg PO Give 1 tablet by mouth every 12 hours as needed for anxiety Review of the Nursing Departmental Notes included: 05/13/14 at 9:00 p.m.: Resident wandering around facility in wheelchair. Appears very restless tonight. Xanax 0.25 mg given at 6:00 p.m. No effectiveness noted. Resident was found in parking lot earlier today looking for family. Family was here earlier in the day singing Karaoke. When family left he didn ' t comprehend he couldn ' t leave also. Family came back for dance and was informed of incident. 05/13/14 at 11:50 p.m.: Resident is at risk for elopement, regular supervision per staff. 05/13/14 at 9:00 p.m.: Resident was wandering around in wheelchair wanting to call his wife. 05/15/14 documented, " Late Entry On 5/13/14 at 5:00 p.m.: " DON spoke with daughter and wife regarding incident of being in parking lot on 05/13/14. Explained to wife and daughter facility is concerned about resident ' s safety as resident is intermittently confused. Family pleaded for resident not to be placed on S.C.U. stating, "That would just kill him." Family spoke to resident about safety and stressed to resident not to go outside in parking lot. Resident remarked to wife he would not go back to parking lot and stated, "I was out there looking for my wife." (Resident 's wife had visited and left te

Based on record review and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 (Resident #2, and #4) of 5 (Resident #1, #2, #3, #4, #5) residents reviewed for elopement. The facility failed to: 1) Ensure a system was in place to identify residents at high risk for elopement receive adequate supervision and care and services to prevent elopements undetected by staff; 2) Ensure staff monitors residents assessed as high risk for elopement from exiting the facility through unlocked exit doors; 3) Ensure interventions were implemented to increase monitoring and supervision for a resident that had a history of [REDACTED]. 4) Ensure staff monitored high risk for elopement residents every 2 hours. This resulted in an Immediate Jeopardy situation for Resident #2 and #4 when the facility failed to ensure a system was in place to ensure each resident that was a risk for elopement were supervised and/or monitored closely to prevent elopement. The Immediate Jeopardy began for Resident #4 on 04/27/14 at 7:30 a.m. when the resident, in her wheelchair, was found in the front parking lot of the facility. The Immediate Jeopardy began for Resident #2 on 05/13/14 at 5:00 p.m. when the resident, in his wheelchair, was found in the front parking lot of the facility. S1Adm, S2AAdm. and S3ADON were notified of the Immediate Jeopardy situation on 05/29/14 at 9:45 a.m. The Immediate Jeopardy was removed for both residents on 05/29/14 at 6:30 p.m. when the facility presented an acceptable plan of removal by S1Adm, S2AADM, and S3ADON that included: 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Resident #4 was placed on the secured unit without any other issues. Resident #2 remains in the general population. The front entrance /porch is locked from 9:00 p.m. to 6:00 a.m. The front entrance/porch is monitored by assigned staff members from 6:00 a.m. to 9:00 p.m. The assigned staff members will remain on the porch while assigned to monitor the front entrance/porch and will not leave the front porch area until the relieving staff member arrives on the front porch. The Maintenance Exit - Battery operated alarm is installed. Is a staff member needs to access the Maintenance Shed Area, they will turn the alarm off to exit and have another staff member turn the alarm back on while they are outside in the Maintenance Shed Area. They will then call the nurses ' station to request someone turn the alarm off again for them to return into the building and will turn the alarm back on when they return inside the building. A large, clear and readily visible warning identifying this process will be place on the Maintenance Exit door. 2. How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken: Each resident identified as an elopement risk has the potential to be affected. 3. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur: The front entrance /porch are locked from 9:00 p.m. to 6:00 a.m. The front entrance/porch is monitored by assigned staff members from 6:00 a.m. to 9:00 p.m. The assigned staff members will remain on the porch while assigned to monitor the front entrance/porch and will not leave the front porch area until the relieving staff member arrives on the front porch. The Maintenance Exit - Battery operated alarm is installed. Is a staff member needs to access the Maintenance Shed Area, they will turn the alarm off to exit and have another staff member turn the alarm back on while they are outside in the Maintenance Shed Area. They will then call the nurses' station to request someone turn the alarm off again for them to return into the building and will turn the alarm back on when they return inside the building. A large, clear and readily visible warning identifying this process will be place on the Maintenance Exit door. This will remain in place until the following permanent security system is in place. - Front Entrance /Porch- a gate will be installed with a key pad lock at the end of the front porch to prevent residents from leaving the front porch and gaining access to the front parking lot area. - Maintenance Exit- a key pad lock will be installed on the inside and outside of the door to prevent residents form leaving exiting through the Maintenance Exit and gaining access to the Maintenance Shed Area. The policy and procedure regarding Unsafe Wandering/Elopement Risk Assessment and Mitigation was updated and revised. In-service training to staff on the revised policy and procedure began. Staff that has not been in-serviced will be prior to returning to work. 4. How the corrective actions will be monitored to ensure the practice will not recur, i.e. what quality assurance program will be put into place. The Administrator and his designee will monitor compliance with both of the revised policies and procedure changes on a daily basis until consistent compliance is achieved. The Quality Assurance Team will monitor compliance thereafter. The deficient practice remains at a level 2. Findings: 1. Cross reference to findings at F323 2. Cross reference to findings at F221 On 05/27/14 at 8:35 a.m. a general tour was performed of the entire facility. All exits were checked. There were 2 exit doors on Unit A. One of the exits led to the front of the building out to the parking lot and had a code pad locking device to exit. This door opened when staff entered the correct access code. The other door at the opposite end of the hall led to the back of the building (Maintanence area) and was unlocked. No code pad was available to open the door. The door was opened and no alarm went off. The Main dining room had an exit door that led to the side/front of the building. S1ADM was present when the door was checked. The door was unlocked and when it was opened it did not alarm. S1ADM stated, "That's not good." He acknowledged that the door should have alarmed when it was opened. He stated he would have maintenance look at it. He stated maintenance checks it monthly. The front entrance to the facility was an automatic sliding door. The door is recessed with a wall 8-10 feet to the left and a reception office to the right. The reception office has a door for entry and glass window covered by closed blinds. . People entering or exiting cannot be viewed from this office with the blinds down. S1ADM stated the front entrance to the facility had automatic doors that do not alarm when entered or exited. He also stated the facility does not use wanderguards with their residents. They identify the residents with high risk for elopement with yellow wrist bands. He stated they monitored them closely. He stated if the family consents to it the residents would be put on the locked unit. On 5/28/14 at 9:30 a.m. an observation was performed of Unit A door that leads to back of facility (maintenance area), the door was unlocked. The door is not visible from the nurses' station. On 5/29/14 at 8:05 a.m. an observation was performed of Unit A door that leads to back of facility. This door was opened by the surveyor and it did not alarm. A review of the Quality Assurance Monthly Incident/Accident Tracking Log for the month of April 2014 revealed there were 2 residents that eloped. Resident #4 eloped on 4/27/14 and Resident #2 eloped on 5/13/14. Resident #4: A review of the facilities Elopement Risk Policy revealed the following: Resident who voices the need to leave the facility or who attempts to leave the facility without authorization will need to be closely monitored by staff. Staff will be assigned to monitor resident during times when other job duties are completed. When staff is performing other job duties which prohibit close supervision of the resident, the resident is to be placed on the special care secured unit for safety. The assigned staff is to assist the resident with ADL needs during the time the resident tis on the secured unit. The resident will be evaluated for frequency of incidents to determine appropriate permanent placement on unit. Upon receiving notice that a resident is missing from the facility, the nurse should determine if the resident is out on an authorized leave or pass. If not, the nurse should: h. Notify regulatory agencies per state guidelines. A review of the resident's clinical record revealed Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 04/28/14 revealed, in part, the following: Section C: Cognitive Patterns - BIMS (Brief Interview for Mental Status) revealed the resident had a summary score of 3 which is indicative of severe cognitive impairment. Section E: Behavior - Delusions- Resident was assessed as having delusions - behaviors of this type occurred 1 to 3 days. Wandering- Resident was assessed as having wandering behavior- behavior of this type occurred 1 to 3 days Wandering impact- Resident was assessed as the wandering placing the resident at significant risk for getting to a potentially dangerous place. Change in behavior or other symptoms- Resident was assessed as N/A because no prior MDS assessment. Section G: Functional Status - D- locomotion on unit- limited assist. F- Locomotion off unit - limited assist. Mobility Devices- Wheelchair. A review of the resident's Care Plan dated 4/21/14 revealed, in part, the following: Problem Start Date: 04/21/14- Category- Cognitive loss/Dementia-Elopement Assessment identifies resident as a potential for elopement. Goal Target Date: 07/17/14- Promote decrease risk in injury R/T elopement. Approach Start Date: 04/21/14- Be observant at all times of resident ' s location. Approach Start Date: 04/21/14- Encourage activity attendance/ participation. Approach Start Date: 04/21/14- If elopement occurs, complete report, contact MD(medical doctor)/RP( Responsible Party)/DON ( Director of Nursing). Approach Start Date: 04/21/14- Labs as ordered, notify MD of results. Approach Start Date: 04/21/14- Move to special care unit, nurse to monitor. Approach Start Date: 04/21/14- Provide quiet /pleasant environment. Approach Start Date: 04/21/14- Re-direct as needed to place and time. Approach Start Date: 04/21/14- Reorient to surroundings as needed, reassure when confused, Notify MD/family. Problem Start Date: 04/21/14- Category- Cognitive loss/Dementia-Potential for Cognitive Impairment due to Dementia. Goal Target Date: 07/17/14- Promote decrease of injury related to cognitive status. Review every 90 days. Approach Start Date: 04/21/14- Administer medications as ordered, monitor for effectiveness, S/E ( side effects). Approach Start Date: 04/21/14- Assist with decision making as needed. Approach Start Date: 04/21/14- Calm resident if signs of distress develops during decision Making process (feeling overwhelmed, fatigue, agitation, Restlessness, withdrawn) Approach Start Date: 04/21/14- Encourage to participate in daily activities as tolerated. Approach Start Date: 04/21/14- Keep explanations simple. Approach Start Date: 04/21/14- Labs as ordered, notify MD of results. Approach Start Date: 04/21/14- Report any changes in cognitive status to family, MD, SS.ST & RSD. Approach Start Date: 04/21/14- Support and reassure resident in new situations. Approach Start Date: 04/21/14- Use appropriate safety measures to protect resident from Injury. A review of Resident #4 ' s Elopement Risk Screening revealed the resident was screened for elopement risk on 04/21/14 and was determined to be an elopement risk due, in part, to having verbally expressed the desire to go home, packed belongings to go home, recent admit within 30days, cognitively impaired with poor decision making skills and has [DIAGNOSES REDACTED]. A review of Resident #4 ' s Social Service assessment dated [DATE] revealed, in part, the following: Mood State/Behavior Problems/Psychosocial Adjustment- There are no moods or behaviors at this time. She has [DIAGNOSES REDACTED]. Physical/Functional Status- the resident uses a wheelchair to mobility and she is able to propel herself. She needs assistance with her transfers and ADL ' s. She is receiving wound care. Cognitive/Mental Status- She thought she was at H____Nursing Home. She could not recall any 3 words after 5 minutes. She could not recall the year, month or day. She needs some assistance with decision making. She does have a [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. Resident #4 was moved to the locked unit on 4/30/14. A review of the Physician order [REDACTED]. Psychological Assessment and Treatment as necessary was ordered along with services to be provided by ___________ or Other. Under referral reasons the resident ' s MD had checked the following: Agitations, Delusions, Wandering, Sadness/Depression, Resisting Care/ Meds, Paranoia, Assess Efficacy of Psych. Meds. The resident continued to be in the unsecured population. A review of the residents MAR (Medication Administration Record) for the month of April revealed the resident was to be monitored every 2 hours for wandering starting 4/27/14 at 8 a.m. and ending when she was admitted to the locked unit on 4/30/14. The resident ' s MAR had no documentation of 2 hour checks from 4 p.m. through 10 p.m. on 04/29/14. A review of the Nurses Notes on Resident #4 revealed the following: 4/22/14 @ 12 a.m. - Resident sitting up in wheelchair in dayroom. She is persistently stating that we kidnapped her and that she is ready to go home. Extremely agitated and refusing care. 4/22/14 @ 3 p.m. - Able to voice needs, confusion noted. Resident believes that someone in a station wagon is picking her up at 5 p.m. Propels self in wheelchair. 4/23/14 @ 3:30 p.m. - Noted confusion, believes she comes to sit with a friend and will be picked up around 8pm. 4/26/14 @ 2 p.m. Verbalizing need to go home, poor STM states " I brought myself here and I haven ' t received my meds since I ' ve been here. My family has no idea where I am. Showed resident her meds and she calmed down. 4/27/14 @ 6:50 a.m. Resident sitting up in wheelchair in main D.R.( dining room) drinking coffee, pleasant mood, 0 distress noted, protective boot to LT ( left) foot. Continue to monitor. 4/27/14 @ 7:30 a.m. Observed resident in front parking lot, resident states " I ' m going home to eat breakfast; I have to leave this place. My son is trying to steal my house. " Attempted to redirect resident to facility. Cont. to refuse X 3 staff to assist back into facility, resident resistive states " I ' m going to get out of this place. " Upon resident returning to facility cont. to wander in W/C. Staff cont. to monitor. DON notified. 4/27/14 @ 9:25 a.m. Resident moved to special care unit for monitoring of wandering. Cont. resistive to care. 4/27/14 @ 9:27 a.m. Notified RP (responsible party)______ _______ states " She has expressed feelings that her kids are stealing her house, this is normal behavior for her. She is on meds for this. She has some good and she has some bad days. " 4/27/14 @ 10 a.m. Resident brought to in for toileting, calm m mood and states " I ' m sorry for the way I acted. " Sitting in w/c in day area @ dining table and resistive behavior noted. 4/27/14 @ 12:01 p.m. ______(on call for ______) verbally notified of elopement/ resident [DIAGNOSES REDACTED]. to monitor. 4/27/14 @ 2 p.m. Pleasant mood, 0 resistances noted. 4/27/14 @ 9:30 p.m. wandering in building, cont. to monitor. 4/27/14 @ 12:30 Resident in wheelchair sitting down by The Retreat. Wandering precautions in place. Resident still confused. 4/28/14 @ 1:30 p.m. Resident has made no further attempts to elope. I spoke with resident this A.M. regarding leaving facility. Resident stated, " I didn ' t try to leave. " Review with resident reoirt of her being outside in parking lot on 4/27/14. Resident denied report. I spoke with son and daughter. Both siblings agree resident is at risk for further elopement attempts. Son reports he believes this is resident ' s master plan to come here to this facility so she can be closer to Ponchatoula and leave facility. Son/ Dtr in agreement resident would benefit from Special Care (locked) Unit. While resident is in transition for move to SCU, place arm band of identification and instructed staff. Cont. to monitor closely. 4/29/14 @ 9 p.m. Was knocking on doors of SCU at shift beginning. States she wants to go home and stressed out. Resident was admitted to the Special Care (locked) Unit on 4/30/14. A review of the Resident's Social Progress Notes and Evaluation revealed the following: 4/28/14- She ( resident) does have delusions noted. For ex., on 4/22/14, per N.N., she was up at 12 a.m. She was agitated. She stated the staff had " kidnapped " her. She also believed that someone will be picking her up. She also refused care from staff on 4/23/14, per N.N. She again stated that someone will be picking her up. On 4/27/14, ______(resident) was observed by staff to be in the front parking lot. She stated that she was trying to go home and that her family was trying to steal her house. She resisted staff who was trying to get her inside the facility. Her fly (family) was notified and she was placed in SCU for monitoring. On 4/28/14, this S.W. placed a name bracelet on _______wrist. She was later moved permanently to the Special Care Unit, Rm. 167A. 4/29/14- Was notified by DON that ________ (resident) was requesting to speak to the social worker. She spoke repeatedly of her son,_________, secretly trying to steal her house. She stated that she was capable of taking care of herself. She even stated she took a shower by herself this morning. She stated that just last month she was paying her bills and taking care of business at her house. I reoriented her to taking care of business at her house. I reoriented her to being at Hammond Nursing Home prior to coming here and she stated " I know I was there. " She was not aware of where she was today; she believed she was at a hospital. She stated she is tired of people lying to her. She stated, " I ' m not crazy, you can get a psychologist. I may talk to him, I may not. " She stated, " The only way you are going to keep me here is to handcuff me. " ______(resident) believes that she is able to live independently at home. She has a fixation on her son taking her house away from her. She became upset when I mentioned calling her son. She stated she had 5 other children that need to be involved, not just ____. She at times can become a little agitated. She was recently moved to the Special Care Unit due to wandering and being at high risk to elope. There was no re-orienting her to the current situation and why she needed assistance. On 5/27/14 at 10:30 a.m. an observation was performed. She was attending church services. She states she does not remember how long she has been here. She states she came here from her house. She is appropriately dressed. She is in a wheel chair with her LT foot /ankle in an ace wrap and her foot in a heel protector with it elevated with the foot rest. She was asked what happened to her foot and she states she stepped on a nail at her house. She states she has not been to the doctor; she is "doctoring it herself. " She states she likes it here but wants to go home. On 5/27/14 at 3:30 p.m. an observation was performed of the resident. She was seated a table with other residents in the day room of the special secure unit. She did not recognize me from earlier in the day. She smiled when I spoke to her. I asked her how she was doing and she stated, " Fine, I just had coffee. They serve coffee here. " I asked her if she remembered talking with me earlier. She stated, " No. " On 5/28/14 at 9:45 am an observation was performed of Resident #4 on the secure unit. She was seated at the table with her head down on her chest sleeping. She looked up when I called her name and smiled. She is clean and neatly dressed. She states she is doing well. On 5/28/14 at 10:00 a.m. an interview was conducted with S14CNA. She was asked to explain what occurred when Resident#4 eloped. She stated the resident was up in her wheel chair and she took her to the dining room for breakfast. She placed her at the table and got her a cup of coffee. S14CNA then left the dining area. She saw a supervisor come running down the hall. She asked her what was wrong and the supervisor told her that the resident was in the parking lot and didn ' t want to come back in. The S14CNA went outside with the supervisor and talked her back into the facility. She stated the resident went out the front door and wheeled herself down the parking lot and was down by The Retreat door. She ate her breakfast once back in the building. At this time the aide took her with her to fill ice carts. She became upset and got loud. She wanted to go outside so they put her on the secure unit. She was asked what the aides do to monitor the residents that are identified as risk for elopement. She stated the CNA ' s report to each other, shift to shift, when someone is elopement risk. S14CNA was asked how the residents are identified when they are at risk. She stated they have an orange bracelet on and a red flag on their wheelchair. She was asked what documentation was done on a resident that required monitoring every 2 hours. She stated the nurse did most of the documentation. The CNA ' s just monitored the resident as they usually did. On 5/28/14 at 10:15 a.m. an interview was conducted with S8CNA. She was asked how they identify residents that are at risk for elopement. She stated they have an orange bracelet and the wheelchairs have a red flag. If they want to go outside someone goes with them. When asked how they document monitoring of elopement risk she stated they are documented the same as everyone else we just watch them closer. On 5/28/14 at 9:50 a.m. an interview was conducted with S7LPN. She was shown an in-service form regarding elopement and asked to identify her signature on the back. Next to her signature she had written " front is blank. " She stated the in-service was held and she attended. She wrote the statement on the back as a joke. She was asked how staff identified residents that were elopement risk. She stated they have an orange band on their arm and staff report off, shift to shift, who is on elopement risk. She was asked what is done differently with these residents. She stated they are monitored every 2 hours and it is documented on the MAR(medication administration record). CNA ' s are informed to monitor the resident more closely. She also stated, " If I see someone wandering down the hall I will find out where they are going. " On 5/29/14 at 10:15 am an interview was conducted with S3ADON. He was shown the in-service sheet dated 5/21/14 regarding review of the elopement policy. The back was signed by a nurse who put " front not completed. " The S3ADON explained the in-service sheet was blank as they signed and then when the in-service was complete the front was filled in in the presents of all who attended. On 5/28/14 at 8:30 a.m. an interview was conducted with S3ADON. He was shown a completed Risk Assessment and asked to explain what criteria on this assessment would qualify the resident to be at risk for elopement? He stated they must be cognitively impaired with poor decision making skills, have [DIAGNOSES REDACTED]. , verbally expressed desire to go home, packed belongings to go home and wanders, and is a resent admit. He also stated if they are at risk the facility processed to care plan for implantation of intervention for risk of elopement. He was asked what the interventions included. He stated close monitoring. He was asked what is close monitoring and who does that and how often? He stated the CNA and the nurses should document once a shift and if they elopement or attempt to elope then they document every 2 hrs. If the staff is busy and cannot document every 2 hours the resident is placed on the secure unit until the nurse is free and can monitor the resident one on one at the nurses ' station. He was asked where the CNA and LPN ' s are located during their shift. He stated they should be in an area where they can monitor all the rooms. On 5/28/14 at 9:40 A.M. S3ADON was asked what was done after the investigation to prevent the residents from eloping again. He stated closely monitor the residents and that Resident #4 was placed on a secure unit. Resident #2 was closely monitored. He was explained that he could not leave. Resident #2 has dementia off and on and he continued to ask for his wife and look for her. He was asked if in-services were conducted in the facility after the incident. He stated, " Yes and he provided them. " The S3ADON also stated the facility now has red American flags on the w/c of the residents with elopement risk to also identify them as being at risk. He stated until the staff was in-serviced the maintenance guy thought it was because they were veterans. The S3ADON provide an in-service dated 5/21/14 for LPN ' s on review of elopement policies. He also stated disciplinary action was taken on the nurse for not following facility procedures on the elopement risk form on admit. On 5/29/14 at 3:50 p.m. an interview was conducted S3ADON. He confirmed that the facility just started porch monitoring 2 days ago (5/27/14). When asked for all the monitoring schedules back to the date of the 1st elopement (4/27/14) he stated there were none. He stated, "We just stated the monitoring 2 days ago." Resident #2 Review of the clinical record revealed Resident #2 was an [AGE] year old male that was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Anxiety, Urinary Tract Infection, [MEDICAL CONDITION], Dehydration, Restless Leg Syndrome, and [MEDICAL CONDITION]. Review of the MDS with an ARD 05/20/14 revealed Resident #2 had a BIMS score of 4 which indicated severe cognitive impairment. The staff assessment for behavior indicated he had no hallucinations or delusions. He did not exhibit wandering behavior. He required two person, extensive assistance with transfer. He required supervision for locomotion off unit. He required one person, extensive assistance with dressing. He required supervision with eating. He required two person, extensive assistance for toilet use. Further review of the MDS revealed the resident was not steady during transitions and walking. Review of the facility's Incident/Accident Form revealed the following: Date of Incident: 05/13/14 Time of Incident: 5:00 p.m. Location of Incident: Outside Resident ' s condition before the incident: Confused Events of the incident: Resident was found in the front parking lot of the nursing home. He stated he was looking for his wife. He was already an elopement risk and has been monitored by staff. His wife and daughter were here earlier in the day singing Karaoke and when they left he couldn ' t understand why he couldn ' t go and went looking for them. Will continue to monitor. 6:00 p.m. [MEDICATION NAME] 0.25 mg given PO crushed in apple sauce due to increase anxiety. 9:00 p.m. Resident wandering around building in w/c looking for family members. Redirected to bed. Additional Information on the facility's Incident/Accident Form revealed the following: 05/15/14 documented, "Late Entry On 5/13/14 at 5:00 p.m.: " DON spoke with daughter and wife regarding incident of being in parking lot on 05/13/14. Explained to wife and daughter facility is concerned about resident's safety as resident is intermittently confused. Family pleaded for resident not to be placed on S.C.U. stating, " That would just kill him. " Family spoke to resident about safety and stressed to resident not to go outside in parking lot. Resident remarked to wife he would not go back to parking lot and stated, " I was out there looking for my wife. " 05/14/14 - Staff has been monitoring resident closely. Resident has agreed to eat meals in TV area to allow for staff supervision. DON has had numerous conversations with resident about safety. Residents able to recall to DON #1 He will not go to parking lot and #2 He will eat in TV area. Instructed staff to continue to closely monitor. Review of the Elopement Risk Screening which was completed on 05/07/14 revealed the following: A. He was identified as cognitively impaired with poor decision-making skills. B. He had the following Diagnosis: [REDACTED]. C. He ambulated independently with his wheelchair. D. He had a history or was currently experiencing the following: Wanders aimlessly, Verbally expressed the desire to go home, Recent admit within 30 days E. His family or responsible party did not voice concerns that indicated the resident would have wandering tendencies or try to leave. F. He was assessed at risk for elopement and the following interventions were written on the form: Placed on MAR to monitor closely 5/13/14 Resident to eat meals in TV area Review of the physician's orders [REDACTED]. 05/07/14 [MEDICAL CONDITION] behavior Monitor, [MEDICAL CONDITION] Drug Target Behavior Q shift 05/07/14 [MEDICAL CONDITION] drug S/E Q shift 05/07/14 [MEDICAL CONDITION] motor S/E QD 05/07/14 [MEDICATION NAME] 50 mg PO QHS 05/07/14 [MEDICATION NAME] 0.25 mg PO Give 1 tablet by mouth every 12 hours as needed for anxiety Review of the Nursing Departmental Notes included: 05/13/14 at 9:00 p.m.: Resident wandering around facility in wheelchair. Appears very restless tonight. [MEDICATION NAME] 0.25 mg given at 6:00 p.m. No effectiveness noted. Resident was found in parking lot earlier today looking for family. Family was here earlier in the day singing Karaoke. When family left he didn ' t comprehend he couldn ' t leave also. Family came back for dance and was informed of incident. 05/13/14 at 11:50 p.m.: Resident is at risk for elopement, regular supervision per staff. 05/13/14 at 9:00 p.m.: Resident was wandering around in wheelchair wanting to call his wife. 05/15/14 documented, " Late Entry On 5/13/14 at 5:00 p.m.: " DON spoke with daughter and wife regarding incident of being in parking lot on 05/13/14. Explained to wife and daughter facility is concerned about resident ' s safety as resident is intermittently confused. Family pleaded for resident not to be placed on S.C.U. stating, " That would just kill him. " Family spoke to resident about safety and stressed t

Based on observation, interview, record review, and review of the American Nurses Association for Gerontological nursing scope and standards of practice the facility failed to provide professional standards of quality for 1 (#4) of 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) residents investigated for falls that use a lift. The facility failed to ensure that nursing staff implemented the approaches documented in the care plan by not using a lift to transfer Resident #4 on 03/22/13, which resulted in a fall with a fracture to her right radius and right fourth metacarpal. Following the fall on 03/22/13 nursing staff continued to transfer Resident #4 without a lift as care planned. The facility failed to: 1. Identify that staff transferring Resident #4 from her wheelchair to her bed without using the care planned lift would result in a fall with a fracture. 2. Implement and evaluate interventions care planned to transfer Resident #4 with a lift. This failed practice had the potential to affect 35 residents who required a lift for transfer when the facility failed to use a lift that was care planned for tranferring Resident #4 which resulted in a fall with fractures to her right radius and fourth metacarpal. Resident #4 had a history of [REDACTED]. The resident was care planned for fall risk due to her unsteady gait and right sided [MEDICAL CONDITION]/paresis, and [MEDICAL CONDITION]. She was care planned on 04/23/10 to be transferred with a stand lift prior to her fall on 03/22/13. Resident #4 was placed in immediate jeopardyon 03/22/13 when S6CNA failed to use the care planned lift when she transferred Resident #4 from her wheelchair to her bed which resulted in a fall with a fracture to her right radius and right fourth metacarpal. The resident remained in immediate jeopardy on 04/09/13 when a surveyor observed S7CNA manually transferring Resident #4 from her wheelchair to her bed and not using the care planned lift. The immediate jeopardy was lifted on 04/10/13 when the S1ADM submitted a plan to ensure all nursing staff and CNA's use a lift for Resident #4 by providing around the clock in-service training and surveyors confirmed the plan had been implemented. The in-service included "per Resident #4's care plan two employees will be present for all transfers; a total lift will be used for transfers between the bed and the chair and the chair and the bed; the CNA will notify the charge nurse each time Resident #4 needs to be transferred; the charge nurse will supervise and/or assist the CNA with the transfer of Resident #4; the charge nurse will document the events of the transfer; noncompliance with the above will result in disciplinary action at the discretion of the DON and Administrator." The deficient practice remains at an actual harm "G" for Resident #4 and at an "E" for those 35 residents who required the use of a lift for transfers. Findings: American Nurses Association. Gerontological nursing: scope and standards of practice. Silver Springs, Maryland: Nursebooks.org, October, 2010. "Standards of Practice" "Standard 1. Assessment The gerontological nurse collects comprehensive data pertinent to the older adult's physical and mental health or situation. Standard 2. Diagnosis The gerontological nurse analyzes the assessment date to determine the [DIAGNOSES REDACTED]. Standard 3. Outcome Identification The gerontological nurse identifies expected outcomes for a plan individualized to the older adult or situation. Standard 4. Planning The gerontological nurse develops a plan to attain expected outcomes. The gerontological nurse: - Provides for continuity within the plan - Uses the plan to provide direction and guidance to formal and informal caregivers and other members of the healthcare team Standard 5. Implementation The gerontological nurse implements the identified plan The gerontological nurse: - Implements the plan of care in a safe and timely manner Standard 5A. Coordination of Care The gerontological nurse coordinates care delivery. The gerontological registered nurse: - Coordinates implementation of the plan Standard 6. Evaluation The gerontological registered nurse evaluates progress toward attainment of outcomes." A review of the clinical record revealed Resident #4 was admitted to the facility initially on 05/04/00 with [DIAGNOSES REDACTED]. Resident #4 had [MEDICAL CONDITION](Cebrovascular Accident) with right sided [MEDICAL CONDITION] prior to her admission on 05/04/00. She had a history of [REDACTED]. The last fall on 03/22/13 resulted in a fracture to her right radius and right fourth metacarpal. A review of the resident's cognitive status documented by the facility revealed that Resident #4's BIMS (Brief Interview for Mental Status) score on 11/06/12 was 13 (this score indicated that resident was cognitively intact) and her score on 02/05/13 was 6 (severe impairment). During an interview with Resident #4, she was asked probing questions including how long she had been in the facility, dates of her recent falls, and how the food was in the facility and she answered all of these questions appropriately. An interview with staff caring for Resident #4 stated that she understands everything she is asked but she is slow in her response. On 04/09/13 at 9:30 a.m. an interview was conducted with Resident #4 in her room. She was alert and oriented to time, place and person. She was able to answer probing questions appropriately. She had a splint device and bandage wrapped around her right arm from her hand to her forearm. She was asked what happened to her right hand and arm. Resident #4 stated, "A couple weeks ago the nurse was helping me to my bed from my wheelchair. When I turned and started to sit on the bed I fell on the floor." She was asked if following her fall on 03/22/13 where staff transfering her with a lift. She stated, "At night they do sometimes." A review of Resident #4 ' s Fall Risk Assessments completed by the facility revealed the following: 11/5/12- (prior to falls on 01/27/13 and 03/22/13) score of 13 (high risk falls) 1/27/13- (post fall on 01/27/13) score of 13 (high risk falls) 3/22/13- (post fall on 03/22/13) score of 13 (high risk falls) A review of Resident #4's Incident and Accident reports completed by the facility revealed the following: 01/27/13 at 7:00 p.m. (time of fall) - Resident #4 called staff to her room where she was found on the floor. Resident stated she was reaching for something. There were no injuries. Physician and family were notified. 03/22/13 at 5:42 p.m. (time of fall) S6CNA called the nurse to Resident #4's room. S6CNA stated she assisted "slid" resident to floor during "bed/chair" transfer without the lift. Physician and family were notified on 3/22/12. Neuro check was within normal limits and there were no bruises noted on the initial assessment. 03/23/13 at 11:00 a.m. (17 hours following fall of 03/22/13) Resident #4 showed the nurse her right hand with swelling and bruising and complained of pain all over. Nurses notes on Incident and Accident report at this time documented "will monitor" (continue to assess the swelling, bruising, and pain in residents right hand) with no other interventions documented at this time. 03/23/13 at 6:00 p.m. (24 hours following fall) Documentation of nurses notes on the Incident and Accident report noted swelling to right hand, bruises to bilateral knees, a small scratch under left eye and resident complaining of generalized pain (relieved by pain pill). Nurse documented that she will continue to monitor these findings. 03/24/13 - "7-3" (no specific time documented) Resident #4 "In w/c in DR. C/O pain to right hand. Swelling and bruising noted to wrist and fingers. Bruises noted to bilateral knees. Swelling and redness noted to right eye with small scratch. Contacted x-press ray to come take x-ray of right FA and wrist." 03/24/13 at 1:00 p.m. (43 hours following fall on 03/22/13 at 5:42 p.m. and 26 hours following resident complaining of her right hand swollen, bruised and in pain on 03/23/13 at 11:00 a.m.) an X-ray was performed. 03/24/13 at 2:00 p.m. - S5LPN received an x-ray report with urgent findings of an acute spiral [MEDICAL CONDITION] of the fourth metacarpal and suspicious for an occult intra articular [MEDICAL CONDITION] radius. The Physician was paged and Resident #4 was sent to the emergency room to see an Orthopedic doctor. At 2:45 p.m. the resident was transferred to a local acute care hospital by ambulance. Resident #4 returned to the facility at 6:15 p.m. with a splint to her right arm. On 04/09/13 at 2:05 p.m. an interview was conducted with S6CNA. S6CNA stated she was with Resident #4 in her room on 03/22/13 when she fell . She was asked how Resident #4 fell . S6CNA stated she was the only staff in the residents room while she was assisting Resident #4 from her wheelchair to her bed. S6CNA stated she was standing between the right side of the residents wheelchair and the bed. She stated the resident stood and pivoted as she assisted Resident #4 to her bed to sit down. S6CNA was asked where on the bed and how far was the resident seated. CNA demonstrated that Resident #4 was seated in the middle of the bed and on the edge of the bed (less than six inches onto the bed) and stated, "I didn't have time to help her lay down in her bed yet." S6CNA stated she was trying to move the resident's wheelchair away from the bed when the resident yelled, "No" and the resident "slipped off the bed". CNA stated that she tried to help the resident to the floor. She stated, "I tried to tell (Resident #4) to hold on while I tried to help her but she was falling to the floor on her right side." She stated "I immediately called for the nurse." She was asked if she used the lift while she transferred Resident #4 from her wheelchair to her bed on 03/22/13, she stated, "No." A review of the care plan revealed problems/goals including Falls and ADL's as follows: Falls - Updated on 01/27/13 (following fall on 01/27/13 with no injury)- new approaches included therapy screened and "keep needed items within reach". Updated on 03/22/13 (following fall on 03/22/13 with fracture to right arm and finger) - new approaches included an In-service to CNA on proper transfer technique and Transfer x 2 assist. ADL's - Onset 05/08/12 and current approaches included "stand lift for transfer." This care plan was copied and verified with S4LPN who completed Resident #4's care plan. On 04/10/13 at 9:10 a.m. an interview was conducted with S4LPN who completed the MDS and care plans for Resident #4. She was asked what type of transfer is care planned for Resident #4. She pointed to the care plan and stated, "transfer per lift." She was asked if Resident #4 should be transferred by lift with all transfers, she stated, "Yes." She was asked the date Resident #4 was initially care planned to transfer the resident by a lift. S4LPN stated, "As long as I can remember, but at least the date of the onset on this care plan 05/08/12." She was asked how nurses and CNA's knew what type of transfer a resident required and she stated they would look at the current care plan. She was asked what problem area in the care plan is the resident's type of transfer documented as an approach. She stated that the type of transfers a resident requires is documented under the ADL's/Functional Status since this is the area completed on the MDS. S4LPN stated that if a resident had a fall, additional approaches are added to the care plan under the problem Falls. S4LPN was asked to review Resident #4's current care plan and to explain the approaches documented for Resident #4's type of transfer. S4LPN stated Resident #4 should be transferred by a lift which is documented as an approach for ADL's. She stated there were revised approaches added 03/22/13 for falls on Resident #4 that required additional staff assistance. She stated on 03/22/13 added approaches to Falls "Transfer x2 assist " required staff to always have 2 persons assisting with lift while transferring Resident #4. On 04/11/13 at 10:45 a.m. (during the survey) a review of the clinical record revealed changes were made to the care plan including a line drawn through an approach for ADL's, "stand lift for transfer," and was not signed or dated. The care plan was reviewed and copied on 04/09/13 with ADL approach "stand lift for transfer" without a line drawn through. An interview with S4LPN and DON revealed that resident was care planned to transfer via lift on 04/09/13 and 04/11/13. On 04/11/13 at 12:30 p.m. an interview was conducted with S2DON regarding the findings of lines drawn through areas of the care plan that were not previously marked and this finding was not dated or timed. She stated, "All resident charts were reviewed last night and some of them may have been changed without dates and times, I will make sure they date and time it." On 04/09/13 at 12:44 p.m. an interview was conducted with S7CNA who has worked in this facility for [AGE] years. She stated she is familiar with Resident #4 and is caring for her today. She was asked if any residents she is caring for were high risk for falls and she named Resident #4. She was asked what type of assistance Resident #4 requires on a daily basis and she stated, "to get on and off the commode, move her from her wheelchair to bed." She was asked how Resident #4 is transferred from her wheelchair to her bed and she stated, "she is paralyzed on her right side, so when I put her in the bed I hold on to her arm and pants and she uses her good side to pivot to her bed." She was asked if another staff member assisted while transferring Resident #4 and she stated, "No, I do it by myself because I know her, some people have to use the lift on her but I never have to use the lift because I know her well." On 04/09/13 at 1:05 p.m. an observation was performed of S7CNA assisting Resident #4 from her wheelchair to her bed. S7CNA removed the lap tray from the wheelchair and transferred Resident #4 without assistance from her wheelchair to the bed while resident stepped and pivoted into a seated position on her bed. S7CNA assisted the resident to a supine position in her bed with her right arm elevated on a pillow, then placed the full side rail in the up position. On 04/09/13 at 1:20 p.m. an interview was conducted with S5LPN. She stated she had worked in the facility for almost 4 years and she is familiar with Resident #4 and is caring for her today. She was asked how Resident #4 is transferred from her wheelchair to her bed. She stated, "I stand and support her on her weak side while (Resident #4) stands and pivots, then she sits on the bed." She was asked if staff use a lift for transferring resident from her wheelchair to her bed. She stated, "Not with me and some of the other staff like S7CNA who is caring for her today because (Resident #4) is comfortable with us and hasn't had a fall with us." She stated that some staff have to use a lift on Resident #4 and have another staff member with them after Resident #4 fell a couple of weeks ago. She was asked how staff knew which residents needed a lift for transfers. She stated it is care planned and written on a Kardex (a written communication for each resident). She stated the Kardex is used while giving verbal report to the next shift and the CNA ' s use this to know each residents ADL's. She provided a copy of Resident #4's Kardex which documented resident as "Lift: Assist." On 04/09/13 at 1:35 p.m. an interview was conducted with S3NM. She stated that she completes staff education and monitors staff following in-services. She was asked to provide any in-services on falls this year. She provided in-service training reports with personnel who attended an in-service dated 01/22/13 with the subject titled "Use of lifts" and an in-service dated 03/24/13 with the subject titled "(Resident #4) needs to be transferred using total lift." She was asked if all CNA's attended the in-services on these dates. She stated, "No, only the staff who work with that resident." She was asked if staff assist in other areas of the facility when staffing is needed, she stated, "Yes." The staff attending the in-service training on 03/24/13 with subject "(Resident #4) needs to be transferred using total lift," included S7CNA who was observed not using a lift for Resident #4 on 04/09/13 and an interview with S7CNA and S5LPN who stated they do not use care planned lift for Resident #4. S3NM was asked what type of monitoring following in-services is done. S3NM stated the staff demonstrated the appropriate use of a lift and take a test. S3NM showed surveyor the certificates of completion and post test following in-services. S3NM was asked to provide documented monitoring that staff were using the lift on the resident as care planned following the in-service. S3NM was not able to provide documentation that staff were actually using the lift on residents as care planned. On 04/09/13 at 12:30pm an interview was conducted with S2DON. S2DON was asked how nurses and CNA's know the type of transfer required for each resident. She stated, "The residents care plan and a Kardex for easy written communication." She was asked what type of transfer Resident #4 required. She stated Resident #4 was to be transferred via lift. She stated that recent in-services were completed following Resident #4's last fall. She stated that CNA's were in-serviced on how to use the lift and to always have another staff member with them. She was asked if staff were in-serviced on the proper use of a lift but were not using the lift when care planned if that was effective. S2DON stated, "No, that is a problem."

Based on observation, interview, and record review, the facility failed to ensure that nurses and CNA's (Certified Nursing Assistant) were able to demonstrate competency in skills when necessary to care for 1 (#4) of 5 (#1, #2, #3, #4, #5) residents needs when Resident #4 was not appropriately transferred as described in the resident's care plan. The facility failed to: 1) ensure the CNA followed the care plan for Resident #4. 2) use the correct mode of transfer for resident #4. 3) in-service nursing staff and CNA's (Certified Nursing Assistant) to follow approaches in Resident #4's care planned mode of transfer. This failed practice had the potential to affect 35 residents who required a lift for transfers when the facility failed to use a lift that was care planned for transferring Resident #4 which resulted in a fall with fractures to her right radius and fourth metacarpal. Resident #4 had a history of [REDACTED]. The resident was care planned for fall risk due to her unsteady gait and right sided [MEDICAL CONDITION]/paresis, and [MEDICAL CONDITION]. She was care planned on 04/23/10 to be transferred with a stand lift prior to her fall on 03/22/13. Resident #4 was placed in immediate jeopardy on 03/22/13 when S6CNA failed to use the care planned lift when she transferred Resident #4 from her wheelchair to her bed which resulted in a fall with a fracture to her right radius and right fourth metacarpal. The resident remained in immediate jeopardy on 04/09/13 when a surveyor observed S7CNA manually transferring Resident #4 from her wheelchair to her bed and not using the care planned lift. The immediate jeopardy was lifted on 04/10/13 when the S1ADM submitted a plan to ensure all nursing staff and CNA's use a lift for Resident #4 by providing around the clock in-service training and surveyors confirmed the plan had been implemented. The in-service included "per Resident #4's care plan two employees will be present for all transfers; a total lift will be used for transfers between the bed and the chair and the chair and the bed; the CNA will notify the charge nurse each time Resident #4 needs to be transferred; the charge nurse will supervise and/or assist the CNA with the transfer of Resident #4; the charge nurse will document the events of the transfer; noncompliance with the above will result in disciplinary action at the discretion of the DON and Administrator " The deficient practice remains at an actual harm "G" for Resident #4 and at an "E" for those 35 residents who required the use of a lift for transfers. Findings: A review of the clinical record revealed Resident #4 was admitted to the facility initially on 05/04/00 with [DIAGNOSES REDACTED]. A review of the care plan revealed problems/goals including Falls and ADL's as follows: Falls - Updated on 03/22/13 (following fall on 03/22/13 with fracture to right arm and finger) - new approaches included an In-service to CNA on proper transfer technique and Transfer x 2 assist. ADL's - Onset 05/08/12 and current approaches included "stand lift for transfer." This care plan was copied and verified with S4LPN who completed Resident #4's care plan. On 04/10/13 at 9:10 a.m. an interview was conducted with S4LPN who completed the MDS and care plans for Resident #4. She was asked what type of transfer is care planned for Resident #4. S4LPN stated Resident #4 should be transferred by a lift which is documented as an approach for ADL's at least since 05/08/12. On 04/09/13 at 2:05 p.m. an interview was conducted with S6CNA. S6CNA stated she was with Resident #4 in her room on 03/22/13 when she fell . She stated she was transferring Resident #4 from her wheelchair to her bed. She was asked if she used a lift while transferring Resident #4 from her wheelchair to her bed when she fell on [DATE], she stated, "No." On 04/09/13 at 12:44 p.m. an interview was conducted with S7CNA who was familiar with Resident #4 and taking care of her that day. She was asked how was Resident #4 transferred from her wheelchair to her bed. S7CNA stated she assisted resident by holding on to her paralyzed right arm and pants while resident pivots to her bed. She was asked if another staff member assisted while transferring Resident #4 and she stated, "No, I do it by myself because I know her, some people have to use the lift on her but I never have to use the lift because I know her well." On 04/09/13 at 1:05 p.m. an observation was performed of S7CNA assisting Resident #4 from her wheelchair to her bed. S7CNA removed the lap tray from the wheelchair and transferred Resident #4 without assistance from her wheelchair to the bed while resident stepped and pivoted into a seated position on her bed. S7CNA assisted the resident to a supine position in her bed with her right arm elevated on a pillow, then placed the full side rail in the up position. On 04/09/13 at 1:20 p.m.an interview was conducted with S5LPN who was familiar with Resident #4 and is was caring for her that day. She was asked how Resident #4 is transferred from her wheelchair to her bed. She stated, "I stand and support her on her weak side while (Resident #4) stands and pivots, then she sits on the bed." She was asked if staff use a lift for transferring resident from her wheelchair to her bed. She stated, "Not with me and some of the other staff like S7CNA who is caring for her today because (Resident #4) is comfortable with us and hasn't had a fall with us." She stated that some staff have to use a lift on Resident #4 and have another staff member with them after Resident #4 fell a couple of weeks ago. She was asked how staff knew which residents needed a lift for transfers. She stated it is care planned and written on a Kardex (a written communication for each resident). She stated the Kardex is used while giving verbal report to the next shift and the CNA's use this to know each residents ADL's. She provided a copy of Resident #4's Kardex which documented resident as "Lift:Assist." On 04/09/13 at 1:35 p.m. an interview was conducted with S3NM. She stated that she completes staff education and monitors staff following in-services. She was asked to provide any in-services on falls this year. She provided in-service training reports with personnel who attended an in-service dated 01/22/13 with the subject titled "Use of lifts" and an in-service dated 03/24/13 with the subject titled "(Resident #4) needs to be transferred using total lift." She was asked if all CNA's attended the in-services on these dates. She stated, "No, only the staff who work with that resident " She was asked if staff assist in other areas of the facility when staffing is needed, she stated, "Yes." The staff attending the in-service training on 03/24/13 with subject "(Resident #4) needs to be transferred using total lift," included S7CNA who was observed not using a lift for Resident #4 on 04/09/13 and an interview with S7CNA and S5LPN who stated they do not use care planned lift for Resident #4. S3NM was asked what type of monitoring following in-services is done. S3NM stated the staff demonstrated the appropriate use of a lift and take a test. S3NM showed surveyor the certificates of completion and post test following in-services. S3NM was asked to provide documented monitoring that staff were using the lift on the resident as care planned following the in-service. S3NM was not able to provide documentation that staff were actually using the lift on residents as care planned. On 04/09/13 at 12:30 p.m. an interview was conducted with S2DON. S2DON was asked how nurses and CNA's know the type of transfer required for each resident. She stated, "The residents care plan and a Kardex for easy written communication." She was asked what type of transfer Resident #4 required. She stated Resident #4 was to be transferred via lift. She stated that recent in-services were completed following Resident #4's last fall. She stated that CNA's were in-serviced on how to use the lift and to always have another staff member with them. She was asked if staff were in-serviced on the proper use of a lift but were not using the lift when care planned if that was effective. S2DON stated, "No, that is a problem."

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well being for 1 (#4) of 5 (#1, #2, #3, #4, #5) residents investigated for falls. The Administrative staff failed to: 1. Have a system in place to ensure comprehensive assessments were performed timely following Resident #4's fall on 03/22/13. 2. Have a system in place to supervise and monitor staff for implementing the resident's plan of care. Staff continued to transfer Resident #4 without 2 person assist with the lift as care planned following the resident's fall with injury. 3. Have a system in place to ensure that staff were knowledgeable of the consequences and necessity of transferring a resident with a lift when it has been care planned. 4. Have a system in place to ensure that all facility staff are inserviced when a problem/concern is identified. This failed practice had the potential to affect 35 residents who required a lift for transfers when the facility failed to use a lift that was care planned for transferring Resident #4 which resulted in a fall with fractures to her right radius and fourth metacarpal. Resident #4 had a history of [REDACTED]. The resident was care planned for fall risk due to her unsteady gait and right sided [MEDICAL CONDITION]/paresis, and [MEDICAL CONDITION]. She was care planned on 04/23/10 to be transferred with a stand lift prior to her fall on 03/22/13. Resident #4 was placed in immediate jeopardy on 03/22/13 when S6CNA failed to use the care planned lift when she transferred Resident #4 from her wheelchair to her bed which resulted in a fall with a fracture to her right radius and right fourth metacarpal. The resident remained in immediate jeopardy on 04/09/13 when a surveyor observed S7CNA manually transferring Resident #4 from her wheelchair to her bed and not using the care planned lift. The immediate jeopardy was lifted on 04/19/13 when the S1ADM submitted a plan to ensure all nursing staff and CNA's use a lift for Resident #4 by providing around the clock in-service training and surveyors confirmed the plan had been implemented. The in-service included "per Resident #4's care plan two employees will be present for all transfers; a total lift will be used for transfers between the bed and the chair and the chair and the bed; the CNA will notify the charge nurse each time Resident #4 needs to be transferred; the charge nurse will supervise and/or assist the CNA with the transfer of Resident #4; the charge nurse will document the events of the transfer; noncompliance with the above will result in disciplinary action at the discretion of the DON and Administrator." The deficient practice remains at an actual harm "G" for Resident #4 and at an "E" for those 35 residents who required the use of a lift for transfers. Findings: A review of the clinical record revealed Resident #4 was admitted to the facility initially on 05/04/00 with [DIAGNOSES REDACTED]. She had a history of [REDACTED]. The last fall on 03/22/13 resulted in a fracture to her right radius and right fourth metacarpal. A review of Resident #4's Fall Risk Assessments completed by the facility revealed the following: 11/5/12- (prior to falls on 01/27/13 and 03/22/13) score of 13 (high risk falls) 1/27/13- (post fall on 01/27/13) score of 13 (high risk falls) 3/22/13- (post fall on 03/22/13) score of 13 (high risk falls) A review of Resident #4's last Incident and Accident report completed by the facility revealed the following: 03/22/13 at 5:42 p.m. (time of fall) S6CNA called the nurse to Resident #4's room. S6CNA stated she assisted "slid" resident to floor during "bed/chair" transfer. Physician and family were notified on 3/22/12. Neuro check was within normal limits and there were no bruises noted on the initial assessment. 03/23/13 at 11:00 a.m. (17 hours following fall) Resident #4 showed the nurse her right hand with swelling and bruising and complained of pain all over. Nurses notes on Incident and Accident report at this time documented "will monitor" with no other interventions documented at this time. 03/23/13 at 6:00 p.m. (24 hours following fall) Documentation of nurses notes on Incident and Accident report "Swelling noted to right hand. Bruises to bilateral knees, small scratch under (L) eye. C/O gen. pain, relieved by pp. Will monitor." 03/24/13 "7-3" (no specific time document) Resident #4 "In w/c in DR. C/O pain to right hand. Swelling and bruising noted to wrist and fingers. Bruises noted to bilateral knees. Swelling and redness noted to right eye with small scratch. Contacted x-press ray to come take x-ray of right FA and wrist." 03/24/13 at 1:00 p.m. (43 hours following fall on 03/22/13 at 5:42 p.m. and 26 hours following resident complaining of her right hand swollen, bruised and in pain on 03/23/13 at 11:00 a.m.) an X-ray was taken. 03/24/13 at 2:00 p.m. - S5LPN received an x-ray report with urgent findings of an acute spiral [MEDICAL CONDITION] of the fourth metacarpal and suspicious for an occult intra articular [MEDICAL CONDITION] radius. The Physician was paged and Resident #4 was sent to the emergency room to see an Orthopedic doctor. At 2:45 p.m. the resident was transferred to a local acute care hospital by ambulance. Resident #4 returned to the facility at 6:15p.m. with a splint to her right arm. On 04/09/13 at 2:05 p.m. an interview was conducted with S6CNA. S6CNA stated she was with Resident #4 in her room on 03/22/13 when she fell while transferring resident from her wheelchair to her bed. She was asked if she used the lift while she transferred Resident #4 from her wheelchair to her bed on 03/22/13, she stated, "No." A review of the care plan revealed problems/goals including Falls and ADL's as follows: Falls - Updated on 03/22/13 (following fall on 03/22/13 with fracture to right arm and finger) - new approaches included an In-service to CNA on proper transfer technique and transfer by 2 person assist. ADL's - Onset 05/08/12 and current approaches included "stand lift for transfer." This care plan was copied and verified with S4LPN who completed Resident #4's care plan. On 04/10/13 at 9:10 a.m. an interview was conducted with S4LPN who completed the MDS and care plans for Resident #4. She was asked what type of transfer is care planned for Resident #4. She pointed to the care plan and stated, "transfer per lift." She was asked if Resident #4 should be transferred by lift with all transfers, she stated, "Yes." She was asked the date Resident #4 was initially care planned to transfer the resident by a lift. S4LPN stated, "As long as I can remember, but at least the date of the onset on this care plan 05/08/12." She was asked how nurses and CNA's knew what type of transfer a resident required and she stated they would look at the current care plan. S4LPN stated Resident #4 should be transferred by a lift which is documented as an approach for ADL's. She stated there were revised approaches added 03/22/13 for falls on Resident #4 that required additional staff assistance. She stated on 03/22/13 added approaches to Falls "Transfer x2 assist" required staff to always have 2 persons assisting with lift while transferring Resident #4. On 04/09/13 at 12:44 p.m. an interview was conducted with S7CNA who has worked in this facility for [AGE] years. She stated she is familiar with Resident #4 and is caring for her today. She was asked if any residents she is caring for were high risk for falls and she named Resident #4. She was asked what type of assistance Resident #4 requires on a daily basis and she stated, "to get on and off the commode, move her from her wheelchair to bed." She was asked how Resident #4 is transferred from her wheelchair to her bed and she stated, "she is paralyzed on her right side, so when I put her in the bed I hold on to her arm and pants and she uses her good side to pivot to her bed." She was asked if another staff member assisted while transferring Resident #4 and she stated, "No, I do it by myself because I know her, some people have to use the lift on her but I never have to use the lift because I know her well." On 04/09/13 at 1:05 p.m. an observation was performed of S7CNA assisting Resident #4 from her wheelchair to her bed. S7CNA removed the lap tray from the wheelchair and transferred Resident #4 without assistance from her wheelchair to the bed while resident stepped and pivoted into a seated position on her bed. S7CNA assisted the resident to a supine position in her bed with her right arm elevated on a pillow, then placed the full side rail in the up position. On 04/09/13 at 1:20 p.m. an interview was conducted with S5LPN. She stated she had worked in the facility for almost 4 years and she is familiar with Resident #4 and is caring for her today. She was asked how Resident #4 is transferred from her wheelchair to her bed. She stated, "I stand and support her on her weak side while (Resident #4) stands and pivots, then she sits on the bed." She was asked if staff use a lift for transferring resident from her wheelchair to her bed. She stated, "Not with me and some of the other staff like S7CNA who is caring for her today because (Resident #4) is comfortable with us and hasn't had a fall with us." She stated that some staff have to use a lift on Resident #4 and have another staff member with them after Resident #4 fell a couple of weeks ago. She was asked how staff knew which residents needed a lift for transfers. She stated it is care planned and written on a Kardex (a written communication for each resident). She stated the Kardex is used while giving verbal report to the next shift and the CNA's use this to know each residents ADL's. She provided a copy of Resident #4's Kardex which documented resident as "Lift: Assist." On 04/09/13 at 1:35 p.m. an interview was conducted with S3NM. She stated that she completes staff education and monitors staff following in-services. She was asked to provide any in-services on falls this year. She provided in-service training reports with personnel who attended an in-service dated 01/22/13 with the subject titled "Use of lifts" and an in-service dated 03/24/13 with the subject titled "(Resident #4) needs to be transferred using total lift." She was asked if all CNA's attended the in-services on these dates. She stated, "No, only the staff who work with that resident." She was asked if staff assist in other areas of the facility when staffing is needed, she stated, "Yes." The staff attending the in-service training on 03/24/13 with subject "(Resident #4) needs to be transferred using total lift," included S7CNA who was observed not using a lift for Resident #4 on 04/09/13 and an interview with S7CNA and S5LPN who stated they do not use care planned lift for Resident #4. S3NM was asked what type of monitoring following in-services is done. S3NM stated the staff demonstrated the appropriate use of a lift and takes a test. S3NM showed surveyor the certificates of completion and post test following in-services. S3NM was asked to provide documented monitoring that staff were using the lift on the resident as care planned following the in-service. S3NM was not able to provide documentation that staff were actually using the lift on residents as care planned. On 04/10/13 a list of CNA's employed by the facility was provided by S2DON. The list of CNA's employed by the facility was compared with the in-service training on 03/24/13 with the subject "(Resident #4) needs to be transferred using total lift." There was a total of 11 CNA's and 1 LPN who signed the in-service training on 03/24/13. There was a total of 81 CNA's employed by the facility according to the list provided by S2DON. On 04/09/13 at 12:30pm an interview was conducted with S2DON. S2DON was asked how nurses and CNA's know what type of transfer is required for each resident. She stated, "The residents care plan and a Kardex for easy written communication." She was asked what type of transfer Resident #4 required. She stated Resident #4 was to be transferred via lift. She stated that recent in-services were completed following Resident #4's last fall. She stated that CNA's were in-serviced on how to use the lift and to always have another staff member with them. She was asked if staff were in-serviced on the proper use of a lift but were not using the lift when care planned if that was effective. S2DON stated, "No, that is a problem."

Based on observation, interview, and record review, the facility failed to ensure residents' environment remained as free of accident hazards as was possible. The facility failed to ensure residents who required a lift for transfers received adequate supervision to prevent avoidable accidents for 1 (#4) of 5 (#1, #2, #3, #4, #5) residents investigated for falls. This failed practice had the potential to affect 35 residents who required a lift for transfers when the facility failed to use a lift that was care planned for transferring Resident #4 which resulted in a fall with fractures to her right radius and fourth metacarpal. The facility failed to: 1. Ensure Resident #4's safety during transfers from her wheelchair to her bed which resulted in a fall with fractures. 2. Identify that transferring Resident #4 from her wheelchair to her bed without using the care planned lift would result in a fall. 3. Implement interventions care planned to transfer Resident #4 with a lift which resulted in a fall. 4. Implement interventions care planned to transfer with a lift to prevent future falls by continuing to transfer Resident #4 without a lift following a fall. 5. Supervise and monitor staff practices to ensure Resident #4 was transferred as care planned prior to and following a fall. 6. In-service nursing staff and CNA's (Certified Nursing Assistant) to follow approaches in Resident #4's care planned mode of transfer. 7. Ensure that all staff who provided care to Resident #4 were in-serviced to always transfer Resident #4 using a total lift. 8. Monitor and audit staff to ensure that staff followed resident specific care planned interventions. 9. Ensure an assessment was completed in a timely manner following a fall on 03/22/13. The resident complained of pain on 03/23/13 at 11:00 a.m. to her right swollen and bruised hand. An X-ray was performed on 03/24/13 at 1:00 p.m. (26 hours following complaints of pain). Resident #4 had a history of [REDACTED]. The resident was care planned for fall risk due to her unsteady gait and right sided [DIAGNOSES REDACTED]/paresis, and Parkinson's. She was care planned on 04/23/10 to be transferred with a stand lift prior to her fall on 03/22/13. Resident #4 was placed in immediate jeopardy on 03/22/13 when S6CNA failed to use the care planned lift when she transferred Resident #4 from her wheelchair to her bed which resulted in a fall with a fracture to her right radius and right fourth metacarpal. The resident remained in immediate jeopardy on 04/09/13 when a surveyor observed S7CNA manually transferring Resident #4 from her wheelchair to her bed and not using the care planned lift. The immediate jeopardy was lifted on 04/10/13 when the S1ADM submitted a plan to ensure all nursing staff and CNA's use a lift for Resident #4 by providing around the clock in-service training and the surveyors confirmed the plan had been implemented. The in-service included "per Resident #4's care plan two employees will be present for all transfers; a total lift will be used for transfers between the bed and the chair and the chair and the bed; the CNA will notify the charge nurse each time Resident #4 needs to be transferred; the charge nurse will supervise and/or assist the CNA with the transfer of Resident #4; the charge nurse will document the events of the transfer; noncompliance with the above will result in disciplinary action at the discretion of the DON and Administrator." The deficient practice remains at an actual harm "G" for Resident #4 and at an "E" for those 35 residents who required the use of a lift for transfers. Findings: A review of the clinical record revealed Resident #4 was admitted to the facility initially on 05/04/00 with [DIAGNOSES REDACTED]. Resident #4 had a CVA (Cebrovascular Accident) with right sided [DIAGNOSES REDACTED] prior to her admission on 05/04/00. She had a history of [REDACTED]. The last fall on 03/22/13 resulted in a fracture to her right radius and right fourth metacarpal. A review of the resident's cognitive status documented by the facility revealed that Resident #4's BIMS (Brief Interview for Mental Status) score on 11/06/12 was 13 (this score indicated that resident was cognitively intact) and her score on 02/05/13 was 6 (severe impairment). During an interview with Resident #4, she was asked probing questions including how long she had been in the facility, dates of her recent falls, and how the food was in the facility and she answered all of these questions appropriately. An interview with staff caring for Resident #4 stated that she understands everything she is asked but she is slow in her response. On 04/09/13 at 9:30 a.m. an interview was conducted with Resident #4 in her room. She was alert and oriented to time, place and person. She was able to answer probing questions appropriately. She had a splint device and bandage wrapped around her right arm from her hand to her forearm. She was asked what happened to her right hand and arm. Resident #4 stated. "A couple weeks ago the nurse was helping me to my bed from my wheelchair. When I turned and started to sit on the bed I fell on the floor. She was asked if following her fall on 03/22/13 staff transfer her with a lift. She stated, "At night they do sometimes." A review of Resident #4's Fall Risk Assessments completed by the facility revealed the following: 11/5/12- (prior to falls on 01/27/13 and 03/22/13) score of 13 (high risk falls) 1/27/13- (post fall on 01/27/13) score of 13 (high risk falls) 3/22/13- (post fall on 03/22/13) score of 13 (high risk falls) A review of Resident #4's Incident and Accident reports completed by the facility revealed the following: 01/27/13 at 7:00 p.m. (time of fall) - Resident #4 called staff to her room where she was found on the floor. Resident stated she was reaching for something. There were no injuries. Physician and family were notified. 03/22/13 at 5:42 p.m. (time of fall) S6CNA called the nurse to Resident #4's room. S6CNA stated she assisted "slid " resident to floor during " bed/chair " transfer. Physician and family were notified on 3/22/12. Neuro check was within normal limits and there were no bruises noted on the initial assessment. 03/23/13 at 11:00 a.m. (17 hours following fall) Resident #4 showed the nurse her right hand with swelling and bruising and complained of pain all over. Nurses notes on Incident and Accident report at this time documented "will monitor " with no other interventions documented at this time. 03/23/13 at 6:00 p.m. (24 hours following fall) Documentation of nurses notes on Incident and Accident report "Swelling noted to right hand. Bruises to bilateral knees, small scratch under (L) eye. C/O gen. pain, relieved by pp. Will monitor." 03/24/13 "7-3" (no specific time document) Resident #4 "In w/c in DR. C/O pain to right hand. Swelling and bruising noted to wrist and fingers. Bruises noted to bilateral knees. Swelling and redness noted to right eye with small scratch. Contacted x-press ray to come take x-ray of right FA and wrist." 03/24/13 at 1:00 p.m.(43 hours following fall on 03/22/13 at 5:42 p.m. and 26 hours following resident complaining of her right hand swollen, bruised and in pain on 03/23/13 at 11:00 a.m.) an X-ray was taken. 03/24/13 at 2:00 p.m. - S5LPN received an x-ray report with urgent findings of an acute spiral fracture of the shaft of the fourth metacarpal and suspicious for an occult intra articular fracture of the distal radius. The Physician was paged and Resident #4 was sent to the emergency room to see an Orthopedic doctor. At 2:45 pm the resident was transferred to a local acute care hospital by ambulance. Resident #4 returned to the facility at 6:15pm with a splint to her right arm. On 04/09/13 at 2:05 p.m. an interview was conducted with S6CNA. S6CNA stated she was with Resident #4 in her room on 03/22/13 when she fell . She was asked how Resident #4 fell . S6 CNA stated she was the only staff in the residents room while she was assisting Resident #4 from her wheelchair to her bed. S6CNA stated she was standing between the right side of the residents wheelchair and the bed. She stated the resident stood and pivoted as she assisted Resident #4 to her bed to sit down. S6CNA was asked where on the bed and how far was the resident seated. CNA demonstrated that Resident #4 was seated in the middle of the bed and on the edge of the bed (less than six inches onto the bed) and stated, "I didn't have time to help her lay down in her bed yet." S6CNA stated she was trying to move the resident's wheelchair away from the bed when the resident yelled, "No" and the resident "slipped" I tried to tell (Resident #4) to hold on while I tried to help her but she was falling to the floor on her right side." She stated "I immediately called for the nurse." She was asked if she used the lift while she transferred Resident #4 from her wheelchair to her bed on 03/22/13, she stated, "No." A review of the care plan revealed problems/goals including Falls and ADL's as follows: Falls - Updated on 01/27/13 (following fall on 01/27/13 with no injury)- new approaches included therapy screened and "keep needed items within reach " . Updated on 03/22/13 (following fall on 03/22/13 with fracture to right arm and finger) - new approaches included an In-service to CNA on proper transfer technique and Transfer x 2 assist. ADL 's - Onset 05/08/12 and current approaches included "stand lift for transfer." This care plan was copied and verified with S4LPN who completed Resident #4's care plan. On 04/10/13 at 9:10 a.m. an interview was conducted with S4LPN who completed the MDS and care plans for Resident #4. She was asked what type of transfer is care planned for Resident #4. She pointed to the care plan and stated, "transfer per lift." She was asked if Resident #4 should be transferred by lift with all transfers, she stated, "Yes " She was asked the date Resident #4 was initially care planned to transfer the resident by a lift. S4LPN stated, "As long as I can remember, but at least the date of the onset on this care plan 05/08/12 " She was asked how nurses and CNA's knew what type of transfer a resident required and she stated they would look at the current care plan. She was asked what problem area in the care plan is the resident's type of transfer documented as an approach. She stated that the type of transfers a resident requires is documented under the ADL's/ Functional Status since this is the area completed on the MDS. S4LPN stated that if a resident had a fall, additional approaches are added to the care plan under the problem Falls. S4LPN was asked to review Resident #4's current care plan and to explain the approaches documented for Resident #4's type of transfer. S4LPN stated Resident #4 should be transferred by a lift which is documented as an approach for ADL's. She stated there were revised approaches added 03/22/13 for falls on Resident #4 that required additional staff assistance. She stated on 03/22/13 added approaches to Falls " Transfer x2 assist " required staff to always have 2 persons assisting with lift while transferring Resident #4. On 04/11/13 at 10:45 a.m.(during the survey) a review of the clinical record revealed changes were made to the care plan including a line drawn through an approach for ADL's , "stand lift for transfer," and was not signed or dated. The care plan was reviewed and copied on 04/09/13 with ADL approach "stand lift for transfer" without a line drawn through. An interview with S4LPN and DON revealed that resident was care planned to transfer via lift on 04/09/13 and 04/11/13. On 04/11/13 at 12:30 p.m. an interview was conducted with S2DON regarding the findings of lines drawn through areas of the care plan that were not previously marked and this finding was not dated or timed . She stated, "All resident charts were reviewed last night and some of them may have been changed without dates and times, I will make sure they date and time it " On 04/09/13 at 12:44 p.m. an interview was conducted with S7CNA who has worked in this facility for [AGE] years. She stated she is familiar with Resident #4 and is caring for her today. She was asked if any residents she is caring for were high risk for falls and she named Resident #4. She was asked what type of assistance Resident #4 requires on a daily basis and she stated "to get on and off the commode, move her from her wheelchair to bed " She was asked how Resident #4 is transferred from her wheelchair to her bed and she stated, "she is paralyzed on her right side, so when I put her in the bed I hold on to her arm and pants and she uses her good side to pivot to her bed." She was asked if another staff member assisted while transferring Resident #4 and she stated, "No, I do it by myself because I know her, some people have to use the lift on her but I never have to use the lift because I know her well." On 04/09/13 at 1:05 p.m. an observation was performed of S7CNA assisting Resident #4 from her wheelchair to her bed. S7CNA removed the lap tray from the wheelchair and transferred Resident #4 without assistance from her wheelchair to the bed while resident stepped and pivoted into a seated position on her bed. S7CNA assisted the resident to a supine position in her bed with her right arm elevated on a pillow, then placed the full side rail in the up position. On 04/09/13 at 1:20 p.m. an interview was conducted with S5LPN. She stated she had worked in the facility for almost 4 years and she is familiar with Resident #4 and is caring for her today. She was asked how Resident #4 is transferred from her wheelchair to her bed. She stated, " I stand and support her on her weak side while (Resident #4) stands and pivots, then she sits on the bed." She was asked if staff use a lift for transferring resident from her wheelchair to her bed. She stated, " Not with me and some of the other staff like S7CNA who is caring for her today because (Resident #4) is comfortable with us and hasn't had a fall with us." She stated that some staff have to use a lift on Resident #4 and have another staff member with them after Resident #4 fell a couple of weeks ago. She was asked how staff knew which residents needed a lift for transfers. She stated it is care planned and written on a Kardex (a written communication for each resident). She stated the Kardex is used while giving verbal report to the next shift and the CNA's use this to know each residents ADL's. She provided a copy of Resident #4's Kardex which documented resident as "Lift:Assist." On 04/09/13 at 1:35 p.m. an interview was conducted with S3NM. She stated that she completes staff education and monitors staff following in-services. She was asked to provide any in-services on falls this year. She provided in-service training reports with personnel who attended an in-service dated 01/22/13 with the subject titled "Use of lifts" and an in-service dated 03/24/13 with the subject titled "(Resident #4) needs to be transferred using total lift." She was asked if all CNA's attended the in-services on these dates. She stated, "No, only the staff who work with that resident." She was asked if staff assist in other areas of the facility when staffing is needed, she stated, "Yes." The staff attending the in-service training on 03/24/13 with subject " (Resident #4) needs to be transferred using total lift," included S7CNA who was observed not using a lift for Resident #4 on 04/09/13 and an interview with S7CNA and S5LPN who stated they do not use care planned lift for Resident #4. S3NM was asked what type of monitoring following in-services is done. S3NM stated the staff demonstrated the appropriate use of a lift and take a test. S3NM showed surveyor the certificates of completion and post test following in-services. S3NM was asked to provide documented monitoring that staff were using the lift on the resident as care planned following the in-service. S3NM was not able to provide documentation that staff were actually using the lift on residents as care planned. On 04/09/13 at 12:30pm an interview was conducted with S2DON. S2DON was asked how nurses and CNA's know the type of transfer required for each resident. She stated, "The residents care plan and a Kardex for easy written communication." She was asked what type of transfer Resident #4 required. She stated Resident #4 was to be transferred via lift. She stated that recent in-services were completed following Resident #4's last fall. She stated that CNA's were in-serviced on how to use the lift and to always have another staff member with them. She was asked if staff were in-serviced on the proper use of a lift but were not using the lift when care planned if that was effective. S2DON stated, "No, that is a problem."

Based on observation, clinical record review, and interviews, the facility failed to ensure that a resident received necessary treatment and services to prevent pressure sores for 1 (Resident #11) of 6 residents reviewed for pressure sores (#3, #4, #5,#9, #10 and #12) out of 13 Phase 1 sampled residents. The facility: 1) Failed to have a system in place to ensure skin condition of residents were monitored and breakdowns reported to appropriate nursing personnel. 2) Failed to follow their wound Prevention Protocol for residents at High Risk to develop Skin Breakdown 3) Failed to accurately assess and document the skin condition of resident #11 after a change in the skin condition on the MAR. No skin conditions were documented on resident #11's MAR indicated [REDACTED]. 4. Failed to ensure CNA's reported changes in skin to nursing staff; 5. After the Stage III pressure sore was discovered on 04/04/11, the facility failed to follow their Wound care protocol by not ensuring the resident wore heelbo's while in bed. This resulted in a harm to Resident #11 when he developed an avoidable pressure sore to the left heel that was not discovered and treated until Stage III severity on 04/04/22. The resident also developed an Stage 2 avoidable pressure sore to the right and left buttock that was not discovered until 04/25/11 during an observation of a skin assessment. Findings: Review of the Facility's policy on Wound Prevention Protocol revealed in part: PURPOSE To provide interventions for resident who are assessed to be at risk for skin breakdown PROCEDURE Upon admission the Risk for Pressure Ulcer Assessment will be completed. At quarterly review and on significant changes of resident a Braden Scale Assessment will be done to ensure all preventive care is being provided to our resident to minimize the risk of pressure areas. BRADEN SCALE RESULTS AND INTERVENTIONS... HIGH RISK 11 OR BELOW Reposition every 1-2 hours Provide passive range of motion to increase mobility Keep skin clean and dry. Provide moisture barrier ointment after each incontinent episode Keep lines free of moisture and wrinkle Provide pressure relieving surface for bed and chair Use draw sheet and head of bed to minimize risk of shearing Total Protein and serum [MEDICATION NAME] Lab If abnormal notify M.D. and registered dietician for consult Keep individual off trochanter (hip) Float heels with pillows. Prevent skin to skin contact Provide heel protectors Provide pressure relieving /pressure reduction surface to bed and chair DO NOT MASSAGE BONY PROMINENCES Provide weekly skin assessments Review of the Providers Policy and Procedure for Weekly Skin Integrity Check revealed (in part) Purpose: To assure that all potential or actual skin conditions are quickly detected. 1. All resident in the facility are to have their body checked by a Licensed Nurse. 2. Documentation is to be done on the medication administration sheet on a weekly basis. 3. If a condition is found, "skin care alert" form is to be marked. The area is to be adequately assessed with [REDACTED]. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to admission MDS dated [DATE] she required extensive assistance with ADL's. Her mode of transportation was by wheelchair. (Left Heel Pressure Ulcer) Documentation of the resident's Admission Resident (MDS) data set [DATE] revealed under P. skin, a surgical wound to the left hip, and bruises/ecchymosis. Pressure ulcers/sores was not checked. According to Part V. Risk for Pressure Ulcers, she had slightly limited sensory perception, her skin was occasionally moist, her activity was chair fast, her mobility was very limited and she was coded with potential problems with friction and sheering; therefore scoring a 15. Documentation revealed a total score of 16 or below deemed a resident at risk for pressure sore. Review of the resident's record revealed no documentation that a Braden Scale Assessment for Skin was done. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]= unchanged. 2=Problem Noted, see nurses notes. Documentation were as followed" 03/25/11: 2 (3-11 shift), 2 (11-7 shift) 03/26/11: 2 (7-3 shift), blank (3-11 shift), 2 (11-7 shift) 03/27/11: 2 (7-3 shift), blank (3-11 shift), 2 (11-7 shift) 03/28/11: 2 (7-3 shift), blank (3-11 shift), 1 (11-7 shift) 03/29/11: 2 (7-3 shift, blank (3-11 and 11-7 shifts) 03/30/11: (7-3, 3-11 and 11-7 shifts) blank 03/31/11: (7-3, 3-11 and 11-7 shifts) blank 04/01/11: blank (7-3 and 3-11) , 1 (11-7) shift 04/02/11: 1(7-3 shift), blank (3-11 shift), 1 (11-7 shift) 04/03/11: 1(7-3 shift), blank (3-11 shift), 1 (11-7 shift) 04/04/11: 1(7-3 shift), blank (3-11 shift), 1 (11-7 shift) 04/05/11: blank (7-3 shift), 1 (3-11 shift), blank (11-7 shift) 04/06/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/07/11: 1 (7-3 shift), blank (3-11 shift), 1 (11-7 shift) 04/08/11: blank (7-3, 3-11 and 11-7 shifts) 04/09/11: blank (7-3 and 3-11) , 1 (11-7) shift 04/10/11: (7-3, 3-11 and 11-7 shifts) blank 04/11/11: (7-3, 3-11 and 11-7 shifts) blank 04/12/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/13/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/14/11: 1 (7-3 and 11-7) , blank (3-11 shift) 04/15/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/16/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/17/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/18/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/19/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/20/11: blank (7-3, 3-11 and 11-7 shift) 04/21/11: 1 (7-3 shift) and 1 (3-11 and 11-7 shift) 04/22/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/23/11: blank (7-3 and 3-11 shift), 1 (11-7 shift) 04/24/11: 1 ( 7-3 shift) and blank (3-11 and 11-7 shifts) Review of the nurses notes for March 2011 revealed no documentation of changes in skin condition that were noted on the MAR. Review of April 1-4 2011 nurses notes revealed no documentation of changes noted the residents' heel. Documentation of a Skin Alert Form dated 04/04/11 and signed by S3LPN revealed: L Heel. There was a picture of a person with the left heel circled. Review of a form entitled Wound Assessment and, dated 04/04/11 revealed: Wound Etiology- pressure ulcer Location of Wound: Left posterior heel Wound Dimensions: 3.0 centimeters (cm) (length), 4.0 cm ( width), 0.1 cm (depth) Wound stage: Unable to stage r/t (related to deep tissue injury Wound Present on Admission/Readmission_ No Description of Wound Tissue: 90% [MEDICATION NAME] 10% granulation Periwound- Bruised Exudate: light serous Odor- none Pain 0-10- None Skin and Ulcer Treatment: (checked) -Pressure reducing device for chair/bed, nutrition & Hydration to manage skin problems, Turing/ repositioning Program/Ulcer The form was signed and dated by S4LPN wound care nurse and S1DON. Review of wound care notes revealed a wound care note that the resident had a left hip wound. Further documentation by S2LPN, Wound Care Nurse, date 04/04/11, revealed the resident had a (blank) to left heel. The document did not describe the area to the left heel. Documentation revealed the resident had increase [MEDICAL CONDITION] to LLE ( left lower leg). an order for [REDACTED]. Review of documentation from Dr. ___ from ___ wound care clinic signed and dated 04/04/11 revealed: a wound to the left posterior heel: Stage: a DTI ( Deep Tissue Injury) Size: 3.0 cm x 4.0 cm x 0.1 cm Exudate: light Color: serous Exposed Bone. Granulation: 90% Epithelium:10% Periwound Condition: Bruised Procedure: After the wound was cleansed and measured, it was then anesthetized with HurriCane Topical Anesthetic Spray. After an appropriate time interval the wound was sharply curetted with a 3 mm Derma Curette and /or 15 blade scalpel. Callus, eschar, necrotic material, biofilm, and/or slough were removed until the wound base was seen. The wound was then treated as outlined in the treatment section. No wound is staged unless its base is fully seen. Checked is; follow facility protocol. A wound care note dated 04/11/11, revealed the left posterior heel wound staged at a Stage 2. Dated 04/14/11, an additional Wound care note from dr. ___ revealed the left posterior heel wound as a Stage 3 pressure wound. Review of Lab work dated 03/29/11 for Resident #11 revealed Total Protein level as 5.6 (low), within normal limits: 6.4 to 8.2 G/Dil and an [MEDICATION NAME] level as 2.6 (low),within normal limits: 3.4 to 5.0 G/Dil) Review of a US (ultra sound) of the left lower exterior artery revealed no well-defined, focal areas of increased velocity that would indicate hemodynamically significant stenosis. An interview was conducted with S3LPN on 04/25/11 at 1:30 p.m. She stated she had cared for Resident #11. She stated she did not recall the pressure ulcer on the resident's heel until it was pointed out by the wound care nurse. An interview was conducted with S5CNA on 04/25/11 at 1:30 p.m. She stated she did not recall any breakdowns on resident #11's heel until the wound care nurse found it. She stated she had never applied heelbo's to the resident's heels. An interview was conducted on 04/26/11 at 8:30 a.m. with S4LPN. She stated she provided care to Resident #11 on the 7-3 shift. She did the Initial Assessment on Resident #11 when she was admitted on [DATE]. She did not recall assessing any skin breakdown over the resident's heels on admission. When asked when a body skin assessment was made by the nurse, she stated weekly. Some nurses wrote daily notes concerning skin condition but a written skin assessment was required only weekly). Body skin assessments on the residents were not assigned to any specific nurse or shift. She stated the CNA's checked the resident's skin with their bathes. If they saw anything abnormal, they would go and check it. Also, if S4LPN would be passing in the hall, and saw the CNA changing the resident, then she would take a look at their skin. She wrote it on the MAR indicated [REDACTED]. She stated the change in the skin condition should be described in the nurses notes. In a later interview held on 04/27/11 at 9:30 a.m., S4LPN stated she stated she was aware of the wound on resident #11 heel but she was not aware that S2LPN Wound Care nurse did not know about it until talking to her on 04/04/11. She thought she was following the wound. An interview was conducted with S2LPN wound care nurse on 04/25/11 at 3 p.m. She stated that Resident #11's left heel wound was acquired at the facility. Someone came and told her, she could not recall who, that Resident #11 had a pressure area on her heel. Resident #11 had been complaining of pain to her leg and having some swelling, so when they called the order about the pressure ulcer, they obtained an order for [REDACTED]. An interview was conducted on 04/27/11 at 2:46 p.m. with S7CNA. She stated she worked with resident #11 on the 3-11 shift. She stated she had not noticed that Resident #11's heel were discolored. She stated that she did float her heel while she was bed, but the resident did not have heelbo's. An interview was conducted with S1DON on 04/26/11 at 1:30 p.m. She stated that the facility should have been more aggressive on the front end of treating Resident #11. On the Admission Data Set the Skin Assessment section rated the resident at 16, which put her at high risk. A Braden scale was done on everyone in the facility. She stated she did not see that one was done for Resident #11. After reviewing Resident #11's MAR for March 2011, she verified, the nurse marked under Skin Condition an 2, for a change in skin condition, then it should have been noted in the nurses notes. She verified an hand entry was made on the Care Plan on 04/02/11 to float heels while in bed. She did not know why that was made at that time, with no explanation of it in the nurses notes. The facility failed to ensure that a Resident #11 received necessary treatment and services to prevent pressure sores Resident #11 developed a pressure sore to the left heel that was not discovered and treated until Stage III severity on 04/04/22. The facility failed to follow they Wound Protocol for Resident's at High Risk for Skin Breakdown, accurately assess and document, communicate to needed staff changes in the skin condition and follow and update the residents plan of care for Impaired skin Integrity. (Stage 2 Pressure Ulcers on the Right and Left Buttock) An observation of a skin assessment on Resident #11 was made on 04/25/11 at 1:00 p.m. with S2LPN Wound Care Nurse in attendance. On her right buttock was an area approximately 1 cm in size with red granulating tissue. On her left buttock area was an area approximately .5 cm in size with red granulating tissue. During the observation, S2LPN stated the wound was new, she was not aware of it, she would have the DON stage it. An interview was conducted with S5CNA on 04/25/11 at 1:30 p.m. She stated she cared for Resident #11. She stated she was not aware that Resident #11 had any breakdowns on her buttock until today. The resident was continent of urine and wiped herself when she went to the bathroom. If she had a BM, she would assist her in wiping her buttock but had not assisted her today. An interview was conducted with S4LPN on 04/26/11 at 8:30 a.m. She stated she was the nurse for Resident #11. She was not aware of any other wounds on Resident #11 except on her left heel. She had not been told that she had new breakdown to her buttock. An interview was conducted with S1DON on 04/26/11 at 1:30 p.m. She verified that she assessed the new Stage 2 Pressure ulcers that were found on Resident #11 buttock during 04/25/11 skin assessment. She stated she had checked with her staff and they were not aware of new changes in her skin condition.