Every finding on record at Carriage Hill Health & Rehab Center

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for the treatment of a pressure injury for one of four residents in the survey sample, Resident #2. The findings include:For Resident #2 (R2), the facility staff failed to thoroughly assess a sacral pressure injury upon admission and failed to provide treatment for the sacral pressure injury 5/3/25 through 5/5/25. A review of R2's clinical record revealed a nursing admission assessment dated [DATE] that documented the resident presented with an open wound on the sacrum. No further descriptors were documented. A physician's order dated 5/2/25 documented, Sacrum - cleanse wound with NS (Normal Saline), pat dry, and apply foam dressing. A review of R2's May 2025 MAR (medication administration record) and TAR (treatment administration record) failed to reveal the physician's order. Further review of R2's clinical record (including the May 2025 MAR, TAR, nurses' notes, and assessments) failed to reveal treatment was provided for R2's sacral pressure injury on 5/3/25, 5/4/25, and 5/5/25. Daily skilled assessments dated 5/3/25, 5/4/25, and 5/5/25 documented, 12. Does the resident have impaired skin and/or a wound that is being monitored or treated? 2. No. A body audit dated 5/5/25 documented R2 presented with a stage three (pressure injury) (1) on the sacrum measuring 3.9 (centimeters in length) by 2.2 (centimeters in width). On 11/19/25 at 11:07 a.m., ASM (Administrative Staff Member) #2 (the Director of Nursing) stated the nurse who entered the 5/2/25 physician's order for R2's treatment into the computer system did not click a schedule for the order so the order did not carry over to the TAR. On 11/19/25 at 11:09 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated pressure injuries should be assessed on the same day as a resident's admission and the assessment should consist of a measurement, and a description of the color, smell, and drainage. On 11/19/25 at 12:10 p.m., an interview was conducted with LPN #2. LPN #2 stated dressing treatments that need to be done are communicated to nurses via the TAR and nurses evidence treatments are done by signing them off on the TAR. On 11/19/25 at 3:19 p.m. ASM #1 (the Administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Documentation of Wound Treatments documented, 2. The following elements are documented as part of a complete wound assessment in tandem with the skin/wound app: a. Type of wound (pressure injury, surgical, etc.) and anatomical location. b. Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue pressure injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness). c. Measurements: height, width, depth, undermining, tunneling. d. Description of wound characteristics: i. Color of the wound bed, ii. Type of tissue in the wound bed (i.e., granulation, slough, eschar, epithelium), iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated), iv. Presence, amount, and characteristics of wound drainage/exudate, v. Presence or absence of odor, and vi. Presence or absence of pain. No further information was presented prior to exit. Reference:(1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device .Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead skin tissue) may be visible. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for one of four residents in the survey sample, Resident #2. The findings include:For Resident #2 (R2), the facility staff failed to transcribe a physician's order for a treatment to the administration record. A review of R2's clinical record revealed a physician's order dated 5/2/25 that documented, Sacrum - cleanse wound with NS (Normal Saline), pat dry, and apply foam dressing. A review of R2's May 2025 MAR (medication administration record) and TAR (treatment administration record) failed to reveal the physician's order. On 11/19/25 at 11:07 a.m., ASM (Administrative Staff Member) #2 (the Director of Nursing) stated the nurse who entered the 5/2/25 physician's order for R2's treatment into the computer system did not click a schedule for the order so the order did not carry over to the TAR. On 11/19/25 at 12:10 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #2. LPN #2 stated that when entering a physician's order into the computer system, nurses must click whether the order is a verbal order or telephone order, type in the doctor's name, type in the order, select if the order should transcribe onto the MAR or TAR, then select a schedule for the ordered treatment to be completed. LPN #2 stated if a schedule is not selected, the order will just sit in the system and not transcribe to the MAR or TAR. On 11/19/25 at 3:19 p.m. ASM #1 (the Administrator) and ASM #2 were made aware of the above concern. The facility policy titled, GUIDELINES FOR MEDICATION ORDERS documented, 4. Documentation of the Medication Order. a. If a physician or a nurse practitioner/physician assistant (prescriber) writes an order in the Facility, a nurse in the Facility transcribes or enters the complete order onto the medication or treatment administration record or electronic medical records system. No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to promote the highest level of well-being for five of eleven residents in the survey sample, Residents #10, #4, #5, #6, and #2. The findings include: 1. For Resident #10 (R10), the facility staff failed to assess a resident identified as having a change in status on 7/31/24. A review of R10's clinical record revealed the following: 7/29/24 6:15 p.m. New Order O2 (oxygen) at 2 liters/min (per minute) via NC (nasal canula) prn (as needed) for SOB (shortness of breath). The resident received oxygen as ordered for her shortness of breath. 7/31/24 8:38 a.m .Pt (patient) noted to be quieter on this shift and appeared lethargic. Vitals wnl (within normal limits). Pt denies any discomfort but verbalized that she does not feel good. Pls (please) assess. The nurse who wrote this note was not available during the survey. Further review of R10's clinical record failed to reveal further physical assessment by another nurse or provider for more than 29 hours. On 8/1/24 at 1:25 p.m., R10 tested positive for COVID-19. On 12/12/24 at 12:01 a.m., ASM (administrative staff member) #3, a nurse practitioner, was interviewed. When asked her how often she is physically present in the facility, she stated either she or another NP (nurse practitioner) or physician is in the facility five days a week, and extending over most business hours. She stated she was unaware of any request to assess R10 until after the resident was diagnosed with COVID-19. She stated she assessed the resident in the afternoon on 8/2/24. On 12/12/24 at 1:59 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated if she felt a resident needed to be assessed for a physical status change, she would document it in a progress note, and document which provider she notified about the need. She stated she would also document the provider's response to her request. On 12/12/24 at 4:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were informed of these concerns. On 12/12/24 at 4:25 p.m., ASM #1 stated there was no facility policy regarding notifying a provider for the need of a physical assessment for a resident. No additional information was provided prior to exit. 2. For Resident #4 (R4), the facility staff failed to follow physician's orders to administer medications in a timely manner. A review of R4's medication administration records for August 2024 revealed she received the following medications late, resulting in a failure to follow the physician's orders: Mupirocin (an antibacterial ointment) ordered 8/8/24 at 8:00 a.m., given at 10:23 a.m.; ordered 8/9/24 at 12:00 noon, given at 2:03 p.m.; ordered 8/10/24 at 12:00 noon, given at 1:58 p.m.; ordered 8/9/24 at 8:00 p.m., given at 5:48 p.m. Apixaban (anticoagulant) ordered 8/0/24 at 4:00 p.m., given at 5:48 p.m. Tylenol ordered 8/9/24 at 9:00 p.m., given at 11:38 p.m. Cefdinir (antibiotic) ordered 8/9/24 at 4:00 p.m., given at 5:48 p.m.; ordered 8/10/24 at 4:00 a.m., given at 5:43 a.m. On 12/12/24 at 10:21 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated to comply with a physician's order, a medication should be administered within 60 minutes before or after it is listed as due. She stated if a medication is given late, the nurse is not following the physician's order. On 12/12/24 at 1:56 p.m., LPN #2 was interviewed. She stated all medications should be given within an hour before or after the medication is due. She stated the physician's orders are not followed if the nurse is later than hour after the due time administering the medication. On 12/12/24 at 4:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were informed of these concerns. A review of the facility policy, Medication Administration, failed to reveal information about the timing of medication administration. No additional information was provided prior to exit. 3. For Resident #5 (R5), the facility staff failed to follow physician's orders to administer medications in a timely manner. A review of R5's medication administration records for August and November 2024 revealed she received the following medications late, resulting in a failure to follow the physician's orders: Sevelamer (kidney function supplement) ordered 8/20/24 at 8:00 a.m., given at 9:22 a.m.; ordered 11/30/24 at 12:00 noon, given at 2:13 p.m. Carvedilol (for high blood pressure) ordered 8/20/24 at 8:00 a.m., given at 9:21 a.m. Cromolyn (eyedrops) ordered 8/20/24 at 8:00 a.m., given at 9:21 a.m. Augmentin (antibiotic) ordered 8/20/24 at 8:00 a.m., given at 9:20 a.m. Risperidone (antipsychotic) ordered 8/20/24 at 8:00 a.m., given at 9:22 a.m. Aspirin ordered 8/20/24 at 8:00 a.m., given at 9:20 a.m. Sodium Bicarbonate (kidney function supplement) ordered 8/20/24 at 8:00 a.m., given at 9:23 a.m. On 12/12/24 at 10:21 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated to comply with a physician's order, a medication should be administered within 60 minutes before or after it is listed as due. She stated if a medication is given late, the nurse is not following the physician's order. On 12/12/24 at 1:56 p.m., LPN #2 was interviewed. She stated all medications should be given within an hour before or after the medication is due. She stated the physician's orders are not followed if the nurse is later than hour after the due time administering the medication. On 12/12/24 at 4:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were informed of these concerns. No additional information was provided prior to exit. 4. For Resident #6 (R6), the facility staff failed to follow physician's orders to administer medications in a timely manner. A review of R6's medication administration records for 9/28/24 revealed he received the following medication late, resulting in a failure to follow the physician's orders: Lidocaine Patch (for pain) ordered 9/28/24 at 8:00 a.m., given at 10:46 a.m. On 12/12/24 at 10:21 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated to comply with a physician's order, a medication should be administered within 60 minutes before or after it is listed as due. She stated if a medication is given late, the nurse is not following the physician's order. On 12/12/24 at 1:56 p.m., LPN #2 was interviewed. She stated all medications should be given within an hour before or after the medication is due. She stated the physician's orders are not followed if the nurse is later than hour after the due time administering the medication. On 12/12/24 at 4:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were informed of these concerns. No additional information was provided prior to exit. 5. For Resident #2 (R2), the facility staff failed to follow physician's orders to administer medications in a timely manner. A review of R2's medication administration records for August and September 2024 revealed she received the following medications late, resulting in a failure to follow the physician's orders: Tramadol (for pain) ordered 8/10/24 at 8:00 a.m., given at 9:12 a.m.; ordered 9/22/24 at 8:00 a.m., given at 12:19 p.m. Memantine (for dementia) ordered 8/10/24 at 8:00 a.m., given at 11:25 a.m.; ordered 9/22/24 at 8:00 a.m., given at 12:16 p.m. Hiprex (to prevent urinary tract infections) ordered 8/10/24 at 8:00 a.m., given at 11:25 a.m.; ordered 9/22/24 at 8:00 a.m., given at 12:17 p.m. Sennosides (stool softener) ordered 8/10/24 at 8:00 a.m., given at 11:25 a.m.; ordered 9/22/24 at 8:00 a.m., given at 12:17 p.m. On 12/12/24 at 10:21 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated to comply with a physician's order, a medication should be administered within 60 minutes before or after it is listed as due. She stated if a medication is given late, the nurse is not following the physician's order. On 12/12/24 at 1:56 p.m., LPN #2 was interviewed. She stated all medications should be given within an hour before or after the medication is due. She stated the physician's orders are not followed if the nurse is later than hour after the due time administering the medication. On 12/12/24 at 4:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were informed of these concerns. No additional information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain resident safety equipment in working order for one of 11 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to maintain the resident's pacemaker monitor in working order at the resident's bedside. On the following dates and times, R2's room was observed. At each observation, the resident's pacemaker monitor was positioned on her bedside table, and the green light was illuminated, indicating proper functioning: [DATE] at 9:35 a.m. and 4:12 p.m.; [DATE] at 8:18 a.m. A review of R2's provider's orders revealed the following order dated [DATE]: Check pacemaker monitor for function q shift every shift. On [DATE] at 10:21 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated on Monday, [DATE], she returned to work after a week's vacation. She stated R2's daughter was visiting the resident and approached her with questions about R2's pacemaker monitor. The daughter told LPN #3 that the monitor was not on the resident's bedside table, and had not been for some time. LPN #3 stated she could not verify how long the monitor had not been at the resident's bedside, but LPN #3 discovered the monitor in her office when she first entered her office after vacation. She stated that usually the cardiology office calls the facility immediately if they detect that the monitor is not functioning properly. She stated she asked staff if anyone knew how the monitor came to be located in her office, but no one had any information to provide. On [DATE] at 1:59 p.m., LPN #1 was interviewed. She stated she regularly cared for R2 and her roommate. R2's roommate died while LPN #1 was on vacation, and the staff moved items in the room around before and after the resident's death. She stated a day after she returned to work from her vacation in [DATE], she noticed R2's pacemaker monitor was missing from the room. She stated LPN #3 was just returning from vacation that day, and they located the pacemaker monitor in LPN #3's office. The immediately returned the machine to R2's bedside, plugged it in, and the light turned green, indicating the device was functioning correctly. She stated she did not understand why the cardiology office had not called the facility to alert the staff that there was a problem with the pacemaker monitor's functioning. On [DATE] at 4:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were informed of these concerns. A review of the facility policy, Physical Environment: Electrical Equipment, revealed, in part: The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the provider of a need to assess a resident for one of eleven residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to notify the provider of a assess a resident identified as having a change in status on 7/31/24. A review of R10's clinical record revealed the following: 7/29/24 6:15 p.m. New Order O2 (oxygen) at 2 liters/min (per minute) via NC (nasal canula) prn (as needed) for SOB (shortness of breath). The resident received oxygen as ordered for her shortness of breath. 7/31/24 8:38 a.m .Pt (patient) noted to be quieter on this shift and appeared lethargic. Vitals wnl (within normal limits). Pt denies any discomfort but verbalized that she does not feel good. Pls (please) assess. The nurse who wrote this note was not available during the survey. A review of R10's clinical record failed to reveal notification of a provider of the need for an assessment of the resident, or reveal further physical assessment by another nurse or provider for more than 29 hours. On 8/1/24 at 1:25 p.m., R10 tested positive for COVID-19. On 12/12/24 at 12:01 a.m., ASM (administrative staff member) #3, a nurse practitioner, was interviewed. When asked her how often she is physically present in the facility, she stated either she or another NP (nurse practitioner) or physician is in the facility five days a week, and extending over most business hours. She stated she was unaware of any request to assess R10 until after the resident was diagnosed with COVID-19. She stated she assessed the resident in the afternoon on 8/2/24. She stated if she had been requested to assess the resident on 7/29/24, she would have done so. She stated sometimes nurses will verbally report this request, or will put the resident's name on a list to be seen by a provider. She stated she checks this list regularly throughout the day. On 12/12/24 at 1:59 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated if she felt a resident needed to be assessed for a physical status change, she would document it in a progress note, and document which provider she notified about the need. She stated she would also document the provider's response to her request. On 12/12/24 at 4:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director of clinical services were informed of these concerns. A review of the facility policy, Notification of Changes, revealed, in part: The purpose of this policy is to ensure the Center promptly informs the patient, consults the patient's physician/physician extender; and notifies .the patient's legal representative when there is a change requiring notification. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to identify and prevent pressure ulcers/injuries, resulting in harm for two of 41 residents in the survey sample, Residents #47 and #15. The findings include: 1. For Resident #47 (R47), the facility staff failed to identify and prevent pressure injuries until stage three pressure injuries (1) developed on the resident's right buttock and sacrum on 4/12/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/10/23, the resident's cognitive skills for daily decision making were coded as severely impaired. Section G coded R47 as requiring extensive assistance of two or more staff with bed mobility and as being totally dependent on two or more staff with transfers. A review of R47's clinical record revealed a Braden scale for predicting pressure sore risk dated 1/19/23 that documented the resident was at very high risk for developing a pressure injury. R47's comprehensive care plan dated 1/15/20 documented, (R47) has the potential for alteration in skin integrity d/t (due to) impaired mobility, urinary and bowel incontinence. Multiple interventions including barrier cream, keeping the skin clean and dry, a pressure reduction support surface and turning and repositioning frequently were documented. A review of R47's clinical record revealed a Braden scale for predicting pressure sore risk dated 1/19/23 that documented the resident was at very high risk for developing a pressure injury. A review of R47's clinical record revealed a body audit dated 4/6/23 that documented redness to the groin but no other skin impairments. Further review of R47's clinical record failed to reveal documentation regarding the resident's skin until 4/12/23. A nurse's note dated 4/12/23 documented, redness noted to buttock and intergluteal cleft. N.O. (New Order) Apply Thera Calazinc Body Shield to buttock as needed for Altered skin integrity AND every shift for Altered skin integrity. RP (Responsible Party) aware. MD (Medical Doctor) notified. A wound care physician note dated 4/12/23 documented, Wound #1 Right Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.3cm (centimeters) length x (times) 1cm width x 0.1 cm depth, with an area of 2.3 sq cm (square centimeters) and a volume of 0.23 cubic cm. There is a Light amount of serous drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100%, granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. Wound #2 Sacral is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.5cm length x 0.5 cm width x 0.1 cm depth, with an area of 0.75 sq cm and a volume of 0.075 cubic cm. There is a Light amount of serous drainage noted which has no odor. The wound margin is flat and intact. Wound bed has 76-100%, granulation. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. On 6/7/23 at 1:09 p.m., an interview was conducted with LPN (licensed practical nurse) #2 (the wound care nurse) and ASM (administrative staff member) #2 (the director of nursing). LPN #2 stated that it was accurate that there was no documentation of skin impairment to R47's right buttock or sacrum until the stage three pressure injuries were identified on 4/12/23. LPN #2 stated Braden assessments are completed on admission, quarterly and when skin issues are identified. ASM #2 stated weekly body audits are completed by nurses and residents' skin is observed daily during care provided by the CNAs (certified nursing assistants). ASM #2 stated CNAs should alert nurses of any skin issues then nurses should speak with the doctor and obtain a treatment order. On 6/7/23 at 2:14 p.m., an interview was conducted with LPN #2, ASM #2 and ASM #3 (the clinical services specialist). LPN #2 stated she had no additional information regarding the development of R47's pressure injuries on 4/12/23. ASM #3 stated an action plan was created and nurses were educated. ASM #3 stated that during the development of the plan, they learned that nurses were not communicating excoriation, incontinence associated dermatitis, redness, or even open skin areas that may have been a stage two pressure injury. ASM #3 stated that if barrier cream was in place, then the nurses did not communicate those skin impairments. (Note: an action plan was created on 12/13/22 with an allegation of compliance date of 3/20/23 and another action plan was created on 5/22/23 with an allegation of compliance date of 6/6/23. R47's stage three pressure injuries were identified on 4/12/23). On 6/7/23 at 3:19 p.m., an interview was conducted with ASM #4 (the wound care physician). ASM #4 stated he tells all staff to tell him or management if they see any skin alterations. ASM #4 stated he only sees a wound when he is told about a wound. ASM #4 stated R47 is at high risk for developing pressuring injuries because the resident requires maximum assistance and is bed bound. ASM #4 stated he could not provide additional information about R47's pressure injuries before he first saw them. On 6/7/23 at 3:34 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the concern for harm. The facility policy titled Body Audit documented, Policy: It is our policy to perform a full body audit as part of the systematic approach to pressure injury prevention and management. Policy Explanation: 1. A full body, or head to toe, body audit will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The body audit may also be performed after a change of condition or after any newly identified pressure injury. 2. Documentation of the body audit in the EHR (electronic health record) includes but it not limited to: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the patient tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if patient refused assessment and why. f. Document other information as indicated or appropriate. Reference: (1) A stage three pressure injury Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf 27660 2. For Resident #15 (R15), the facility staff failed to identify a pressure injury to the sacrum prior to it being an unstageable pressure injury (1) with eschar (black necrotic [dead] tissue). On the MDS (minimum data set) assessment, prior to the discovery of the pressure injury, a quarterly/significant change assessment, with an assessment reference date of 1/17/2023, the resident was coded as having both short- and long-term memory difficulties. In Section G - Functional Status, R15 was coded as requiring extensive assistance of two or more staff members for moving in the bed. In Section H - Bladder and Bowel, the resident was coded as always being incontinent of both bowel and bladder. In Section M - Skin Conditions, the resident was not coded as having any pressure injuries. The nurse's note dated, 2/14/2023 at 5:30 a.m. documented Staff reports to this writer that when provided care this morning, observed resident scratching her buttocks causing an open area on right buttock. Open area clean [sic] with wound cleanser and Medihoney applied and covered with foam dressing. Resident tolerated well and denies pain. Resident refusing to allow this nurse to clip fingernails. Resident in bed at this time, MD/NP (medical doctor/nurse practitioner) notified. The physician orders, dated 2/15/2023, documented, Clean open area to right buttock with wound cleanser, apply TAO (topical antibiotic ointment) and cover with foam dressing every day shift for altered skin integrity. The February 2023 MAR (medication administration record) documented the above over. The treatment was documented as performed on 2/15/23 through 2/17/2023. The physician order dated, 2/18/2023, documented, Cleanse right buttock with wound cleanser, pat dry, apply betadine topically BID (twice a day), til resolved, two times a day. The February 2023 MAR documented the above over. The treatment was documented as performed on 2/18/2023 through 2/21/2023. The Body Audit form on 2/11/2023 at 2:14 p.m. documented, Skin integrity intact? no. Right heel - Discoloration/blister, TX (treatment) in place. The Body Audit form for 2/19/2023 at 4:23 a.m. documented, Skin integrity intact? no. Right buttock - wound on upper right buttock, dressing intact. A second Body Audit form for 2/19/2023 at 6:50 a.m. documented, Skin integrity intact? no. Right buttock, tx (treatment) initiated. The nurse's note dated 2/22/2023 at 10:00 a.m. documented, New pressure injury noted to sacrum. Unable to stage due to slough/eschar coverage of wound bed. Length 6/1 cm (centimeters) X width 3.9 cm, with surface area of 13.8cm2. No measurement of depth noted. No pain/discomfort. Air mattress ordered to be placed on bed, heels were elevated, pillow between knew and ankles for pressure relief. Dietician noted significant weight loss this month. Contractures prevention full ROM (range of motion) and making positioning in bed and chair difficult. Therapy screen request ordered. Wound MD (doctor) to assess on next round date. The Skin & Wound Evaluation dated, 2/22/2023, documented in part, Describe: pressure. Stage: unstageable - obscured full-thickness skin and tissue loss. Due to: Slough and/or eschar. Location: Sacrum. Acquired: In-house acquired. How long has wound been present? New. Wound measurements: Area - 13.8 cm2. Length: 6.1.cm. Width: 3.9 cm. Wound bed: eschar. % of eschar: 100% of wound filled. Surrounding tissue: Excoriated: superficial loss of tissue. The Therapy Screening Request dated, 2/22/2023, documented in part, A. Resident has had a change in status or function and may benefit from therapy services .Other: Difficulty with or maintaining positioning in bed or chair. Loss of joint mobility/contracture risk. Skin integrity issues .Additional Information: New Pressure Injury to sacrum, has contractures, difficult to maintain position in bed/chair. Ordered air mattress for bed. The comprehensive care plan dated, 10/14/2023 and last revised on 3/23/2023, documented in part, Focus: (R15) is at risk for skin breakdown r/t (related to) fragile skin, actual impaired skin to bilateral arms, blister to right heel, discolored areas to left foot (resolved) area to sacrum, discolored area to chest. Stage 4 pressure injury to sacrum. The Interventions documented in part, 6/6/2023 - air mattress. 10/17/2022 - assess skin thoroughly and implement precautions and/or treatment as indicated. Encourage frequent position changes for pressure relief. Observe for moisture and incontinence issues that affect skin. Report for further assessment, if noted. Provide pressure reduction surfaces as ordered/indicated. Report changes in skin integrity or condition for further assessment and treatment. 3/13/2023 - Reposition resident often while in bed. An interview was conducted with ASM (administrative staff member) #2, the director of nursing and ASM #3, the clinical services specialist, on 6/7/2023 at 8:33 a.m. When asked to clarify the right buttock wound and the sacral wound, ASM #2 stated the facility has recently had education on anatomical positioning as the floor nurses were incorrect in their description of body part. ASM #3 stated the open area on the right buttock was cause by a scratch that was self-inflicted by the resident. Treatment was put in place. Then the sacral pressure injury was noted on 2/22/2023. An interview was conducted with LPN (licensed practical nurse) #2, the wound nurse, ASM #2 and ASM #3, on 6/7/2023 at 11:14 a.m. When asked to clarify the location of the scratch wound and the sacral wound, LPN #2 stated the right buttock wound was on the right upper outer quadrant of the buttock. When asked, if a nurse is applying a treatment to the right buttock, how did they miss a large sacral wound, ASM #3 stated, they would have expected someone to notify someone about a new area. LPN #2 stated that as soon as she was made aware of the area, she went and assessed it and put treatment orders in place. She further stated the resident was noted to be having a decline and they spoke with the family. ASM #2 stated they recognized that they had a process with skin and they have been aggressively working on skin since 5/24/2023. When stated that this happened prior to 5/24/2023, ASM #2 stated they had a previous action plan in place for skin assessments. The action plan dated, 12/31/2022, documented in part, Area of Concern: Body audit and Treatment in place. Corrective Action: 1. Licensed nursing staff failed to complete timely wound assessment and initiate treatment on admission for (other resident initials) 2. Any resident is at risk for not having a complete and accurate body audit on admission. Any resident that has a wound is at risk for not have treatment in place on admission. Date of Compliance: 3/20/2023. The plan was reviewed with ASM #2 and ASM #3 and it was verified that R15 did not appear on any audit forms. An interview was conducted with LPN #6 on 6/7/2023 at 12:57 p.m. LPN #6 stated that she had observed the resident's skin on 2/20/2023 and the sacral wound was not there. An interview was conducted with CNA (certified nursing assistant) #1 on 6/7/2023 at 1:07 p.m. When asked when she looks at a resident's skin, CNA #1 stated she checks it when she is changing them, showers, baths or providing any care to them. CNA #1 was asked what she does when she finds any new breakdown on the resident's skin, CNA #1 stated she goes to the nurse and tells them. When asked if she documents skin assessments/observations anywhere, CNA #1 stated she documents in the computer program. An interview was conducted with ASM #4, the wound doctor, on 6/7/2023. When asked what he found when he saw R15 on 2/22/2023. ASM #4 reviewed his progress notes then stated, it was an unstageable due to necrosis wound on the sacrum, it had hard eschar. When asked if a pressure injury like that could develop overnight, ASM #4 stated, with what he saw, it couldn't have developed overnight. ASM #4 stated he was surprised that the wound didn't take the resident's condition in a decline as the wound had done remarkedly well. ASM #1, the administrator, ASM #2 and ASM #3 were made aware of the concern for harm for R15 on 6/7/2023 at 3:33 p.m. No further information was provided prior to exit. Reference: (1) Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf

Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services per the comprehensive care plan, for one of 41 residents in the survey sample, Resident #29. The findings include: The facility failed to provide communication to the dialysis facility for 4 out of 20 dialysis center visits in April and May 2023. Resident #29 was admitted to the facility on [DATE] with a diagnosis that included but was not limited to, end stage renal disease (ESRD) with dialysis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/23/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 4/22/23, which revealed, FOCUS: Resident has renal disease requiring dialysis. INTERVENTIONS: Coordinate with Dialysis center for dialysis treatments as ordered. Communicate with dialysis provider regularly via pre/post treatment notes. A review of the physician orders dated 4/24/23 revealed, Resident receives Dialysis as follows: Tuesday, Thursday and Saturday with a 5:00 AM chair time. Diagnosis ESRD. An interview was conducted on 6/7/23 at 9:30 AM with Resident #29. When asked if he takes his dialysis communication book to the dialysis center, Resident #29 stated, Yes, the book goes with me. It is in the bag in my room. A review of Resident #29's dialysis communication book revealed missing communication to the dialysis facility on 4/25/23, 4/27/23, 5/6/23, and 5/9/23. An interview was conducted on 6/7/23 at 10:50 AM with RN (registered nurse) #1. When asked the purpose of the dialysis communication sheets, RN #1 stated, to provide communication about the resident's current condition, vital signs and maybe labs or medications. When asked if there is missing documentation, is the facility communicating with the dialysis center, RN #1 stated, No, we would not be communicating on those days. On 6/7/23 at approximately 1:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the clinical services specialist was made aware of the findings. A review of the dialysis contract dated 2012, revealed, The nursing facility shall ensure that all appropriate medical and administrative information accompanies all ESRD residents at the time of transfer or referral to the ESRD Dialysis unit. This information, shall include, but is not limited to, where appropriate, the following: appropriate medical records, including history of ESRD resident's illness, laboratory and x-ray findings. Collaboration of care: The nursing facility shall ensure that there is documented evidence of collaboration of care and communication between the nursing facility and ESRD dialysis unit. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for five of 41 residents in the survey sample; Residents #121, #4, #76, #29, #130. The findings include: 1. For Resident #121 the facility staff failed to follow the comprehensive care plan for indwelling catheter care. On 6/6/23 at 8:38 AM, Resident #121 was observed sitting on the side of the bed awaiting his breakfast tray. The catheter drainage bag was noted on the floor under the edge of the bed with the tubing also laying on the floor and the resident stepping on the tubing. A review of the comprehensive care plan revealed one dated 5/21/23 for the use of a Foley catheter which included the intervention, Provide catheter care per order and protocol and PRN (as-needed). A review of the physician's orders revealed one dated 5/20/23 for catheter care every shift. On 6/7/23 at 10:37 AM, an interview was conducted with LPN (Licensed Practical Nurse) #6 on. When asked the purpose of the care plan, LPN #6 stated it's to be able to look at it to see what care is to be provided to the resident and the care plan should always be followed; that's the purpose of the care plan. On 6/7/23 at 11:50 AM an interview was conducted with CNA (Certified Nursing Assistant) #2. She stated that the catheter bag should be hanging on the side of the bed and neither the bag nor the tubing should be on the floor. On 6/7/23 at 11:52 AM an interview was conducted with LPN (Licensed Practical Nurse) #4. She also stated that neither the bag nor the tubing should be on the floor and the bag should be hanging on the side of the bed. On 6/7/23 at 2:03 PM in a follow up interview with LPN #4 when asked if the care plan documented to provide Foley care per protocol and the bag and tubing was on the floor, was the care plan being followed, she stated it was not. When asked what was the purpose of the care plan was, she stated it is to guide care to meet the resident's goals. On 6/7/23 at 2:00 PM the facility policy, Urinary Catheterization/Irrigation was provided and reviewed. This policy documented, The plan of care will address the use of an indwelling/external urinary catheter, including strategies to prevent complications Indwelling urinary catheters will be secured with use of an anchor to prevent excessive tension on the catheter, prevent accidental dislodgement, prevent kinks in the tubing and facilitate adequate flow of urine . The policy did not specify the need for the bag and tubing to be maintained off the floor to prevent infections. On 6/7/23 at 2:10 PM, after a review of the above policy ASM #2 (Administrative Staff Member) the Director of Nursing and ASM #3, Clinical Services Specialist, were made aware of the findings. When asked what complication is the resident at risk for with the Foley catheter and bag being on the floor, ASM #2 stated, Infections. No further information was provided by the end of the survey. 27660 2. For Resident #4 (R4), the facility staff failed to implement fall mats when the resident was in bed per the care plan. The comprehensive care plan dated, 8/23/2022, documented in part, Focus: (R4) has had actual fall with injury. Cognitive impairment impacting ability to understand own physical limitations. Poor balance, unsteady gain. Resident has had an unwitnessed fall from the bed to the floor with no injury. (R4) fell after attempting to self-ambulate with no injuries, injured when transferring self. The Interventions dated 8/23/2022, documented in part, Fall Mat. Observations were made of R4 on 6/6/2023 at 9:41 a.m. and at 9:54 a.m. R4 was lying in their bed, on their side, and appeared to be asleep. Two fall mats were located behind the headboard against the wall. The physician orders dated, 6/2/2023, documented, Fall mats on both sides of the bed while in bed. The Kardex for R4 documented in part, Fall mat on left side of bed while in bed every shift. May have bed side on mats on each side of bed. An interview was conducted with LPN (licensed practical nurse) #6 on 6/7/2023. When asked the purpose of the care plan, LPN #6 stated it's to be able to look at it to see what care is to be provided to the resident, and stated the care plan should always be followed, since that's the purpose of the care plan. ASM #1, the administrator, ASM #2, and ASM # 3, the clinical services specialist, were made aware of the above concern on 6/7/2023 at 3:33 p.m. No further information was obtained prior to exit. 42183 3. For Resident #76, the facility staff failed to develop the comprehensive care plan for CPAP (continuous positive airway pressure) use. Resident #76 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). A review of the comprehensive care plan dated 11/30/22 revealed, FOCUS: Resident has respiratory problems (COPD) related to acute illness or chronic condition. INTERVENTIONS: Provide oxygen as ordered. Report changes in breathing patterns or difficulty breathing including wheezing, shortness of breath, rales, rhonchi, note on observation and/or auscultation for further assessment by nurse or physician/physician assistant/nurse practitioner. A review of the physician orders dated 11/29/22, revealed, Oxygen at 2 liters/minute via Nasal cannula every shift. CPAP with oxygen at 2L. Apply at HS (bedtime), remove in AM (morning) every shift. An interview was conducted on 6/7/23 at 10:50 AM with RN (registered nurse) #1. Asked to describe the purpose of the care plan, RN #1 stated, the purpose is to outline the specific care and interventions for a resident. Asked if CPAP (continuous positive airway pressure) should be on the care plan, RN #1 stated, yes, it should be. On 6/7/23 at approximately 1:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the clinical services specialist was made aware of the findings. No further information was provided prior to exit. 4. For Resident #29, the facility staff failed to implement the comprehensive care plan for dialysis communication. Resident #29 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: end stage renal disease (ESRD) with dialysis. A review of the comprehensive care plan dated 4/22/23 revealed, FOCUS: Resident has renal disease requiring dialysis. INTERVENTIONS: Coordinate with Dialysis center for dialysis treatments as ordered. Communicate with dialysis provider regularly via pre/post treatment notes. A review of the physician orders dated 4/24/23, revealed, Resident receives Dialysis as follows: Tuesday, Thursday and Saturday with a 5:00 AM chair time. Diagnosis ESRD. The facility failed to provide communication to the dialysis facility for 4 out of 20 visits in April and May 2023 specifically on 4/25/23, 4/27/23, 5/6/23 and 5/9/23. An interview was conducted on 6/6/23 at 3:00 PM with LPN (licensed practical nurse) #1. When asked to describe the purpose of the care plan, LPN #1 stated, the purpose is to outline the specific care and interventions for a resident. When asked if the care plan was being followed when the dialysis communication forms are not completed for each dialysis treatment, LPN #1 stated, no, the care plan is not being followed. On 6/7/23 at approximately 1:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the clinical services specialist was made aware of the findings. No further information was provided prior to exit. 31753 5. For Resident #130 (R130), the facility staff failed to implement the resident's comprehensive care plan for a Hoyer lift transfer on 3/8/23. R130's comprehensive care plan revised on 3/2/23 documented, (R130) demonstrates the need for ADL (activities of daily living) assistance r/t (related to) weakness d/t (due to) cerebral infarction (stroke), Stage IV breast cancer, medication, and medical deficit. Interventions/Tasks: Resident Hoyer lift/two person assist with transfers . R130's CNA (certified nursing assistant) kardex dated 3/8/23 documented, Transferring 2 person/Hoyer . On 6/6/23 at 10:22 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that on 3/8/23, she entered R130's room and two CNAs were attempting to transfer the resident (without a Hoyer lift) from the bed to a shower chair. LPN #3 stated the CNAs were struggling, so she assisted with the transfer. LPN #3 stated that at the time, she and the CNAs were not aware that they were supposed to use a Hoyer lift. LPN #3 stated R130's transfer status must have recently changed prior to 3/8/23. LPN #3 stated R130's son, who was present in the room, complained after R130's transfer to the shower chair. LPN #3 stated that after R130's son complained, she looked at R130's kardex and saw that the transfer without a Hoyer lift was an error on her and the CNAs part. (A review of nurses' notes for 3/8/23 failed to reveal documentation regarding the transfer). The CNAs who transferred R130 to the shower chair on 3/8/23 were not available for interview during the survey. On 6/6/23 at 2:47 p.m., an interview was conducted with CNA #1. CNA #1 stated CNAs are made aware of residents' need for a Hoyer lift via the kardex, dialog with therapy staff, dialog with the unit manager, and in the CNA verbal report. On 6/7/23 at 1:05 p.m., an interview was conducted with LPN #6 regarding the implementation of care plans. LPN #6 stated the CNAs can look up information on the kardex and go to their nurses for clarification, and nurses can look at the care plan. On 6/7/23 at 1:48 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to offer information related to developing an advance directive for one of 41 residents in the survey sample, Resident #123. The findings include: For Resident #123 (R123), the facility staff failed to evidence that information related to developing an advance directive was offered to the resident. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 5/26/2023, the resident score a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The Social Services Admission Assessment, dated 5/25/2023, documented in part, Advance Directive and Code Status documented the resident did not have an advance directive, or durable DNR (do not resuscitate). The form further documented, If no Advanced Directives exist, information and assistance to complete Advance Directives has been offer. This part of the form was blank. Nothing was documented in the answers of Yes, No or Not offered due to cognitive status of resident. On 6/7/2023 at 2:10 p.m. an interview was conducted with OSM (other staff member) #3, the social services case coordinator, who stated the process for determining if the resident has an advance directive upon admission is it is discussed during the safe transition meeting. OSM #3 was asked where it was documented, OSM #3 stated on the social services admission assessment. The above social services admission assessment was reviewed with OSM #3. OSM #3 stated she must have missed that question and cannot recall if she offered information about advance directives to R123. The facility policy, Advance Directives documented in part, If an Advance Directive does not exist, the Resident or legal representative will be informed of and given the opportunity to formulate an Advance Directive. ASM #1, the administrator, ASM #2, and ASM # 3, the clinical services specialist, were made aware of the above concern on 6/7/2023 at 1:46 p.m. No further information was obtained prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence the required documents were sent to the receiving facility, upon transfer to the hospital for 2 of 41 residents in the survey sample, Residents #51 and #83. The findings include: 1. For Resident #51, the facility staff failed to evidence the documents sent with the resident upon transfer to the hospital on 5/15/2023. The nurse's note dated, 5/15/2023 at 2:50 p.m. documented in part, Fall at 1426 (2:46 p.m.), resident landed on head with a hard thump. Blood noted to resident left elbow, skin tear. NP (nurse practitioner) notified at 1428 (2:28 p.m.), verbal order to send resident out . The SNF/NF to Hospital Transfer Form dated, 5/15/2023, failed to evidence what documents were sent with the resident to the hospital. The section, Acute Care Transfer Document Checklist was blank. An interview was conducted with LPN (licensed practical nurse) #6 on 6/7/2023 at 10:37 a.m. When asked what documents are sent to the hospital with the resident for an acute change in condition, LPN #6 stated, they should send the face sheet, labs (laboratory tests) if related to why going out, doctor notes, and medication list. When asked if they send the care plan goals with the resident, LPN #6 stated she would have to check on that. She stated they send the eInteract transfer form that collects information and send that with the resident. When asked where what documents you send, are documented in the clinical record, LPN #6 stated in the nurse's notes. The facility policy, Emergency Transfer to Acute Care Hospital documented in part, 3. The Transfer Envelope and designated EHR copies (current labs/consults/progress notes, e-Interact Transfer Form, face sheet, etc.) are completed and should accompany the patient to the hospital. 4. Medical records pertinent to the acute episode should be included with Emergency Transfer packet to aide in medical history information for the receiving health care center to review. 5. The transfer process may include but it not limited to: a. Obtain an order to transfer the patient, when possible and obtaining the order does not delay lifesaving interventions at a higher level of care. b. Call ambulance for emergency (911). c. Notify the patient and/or legal representative of reason for transfer and document in the HER. d. Complete the Emergency Transfer/e-Interact Transfer Form from the EMR. e. The e-Interact Transfer form should accompany the patient to the Acute Care Hospital. f. The patient's DDNR (Advanced Directive) must accompany the patient if one has been executed. 6. A PRE-PRINTED Transfer envelope with the Transfer and Treatment Checklist and Bed Hold Policy attached should accompany the patient to any outside transfers with completed contents inside which coincide with the listed components on the checklist. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical services specialist, were made aware of the above findings on 6/7/2023 at 1:46 p.m. No further information was provided prior to exit. 2. For Resident #83, the facility staff failed to document what documents were sent with the resident upon transfer on 2/25/2023. The nurse's notes dated 2/24/2023 at 4:33 p.m. documented, This nurse witnessed resident walking across the common area. As writer was approaching resident, to guide (them) back to the chair, (they) fell and landed on (their) left side . The nurse's note dated, 2/24/2023 at 11:45 p.m. documented, X-ray is - intertrochanteric fracture without shortening. (Name of Doctor). order received to send to ED (emergency department) . On 6/7/2023 at 10:00 a.m., ASM (administrative staff member) #3, the clinical services specialist, stated they have no evidence of documents sent with the resident upon transfer to the hospital. An interview was conducted with LPN (licensed practical nurse) #6 on 6/7/2023 at 10:37 a.m. When asked what documents are sent to the hospital with the resident for an acute change in condition, LPN #6 stated, they should send the face sheet, labs (laboratory tests) if related to why going out, doctor notes, and medication list. When asked if they send the care plan goals with the resident, LPN #6 stated she would have to check on that. She stated they send the eInteract transfer form that collects information and send that with the resident. When asked where what documents you send, are documented in the clinical record, LPN #6 stated in the nurse's notes. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical services specialist, were made aware of the above findings on 6/7/2023 at 1:46 p.m. The facility policy, Emergency Transfer to Acute Care Hospital documented in part, 3. The Transfer Envelope and designated EHR copies (current labs/consults/progress notes, e-Interact Transfer Form, face sheet, etc.) are completed and should accompany the patient to the hospital. 4. Medical records pertinent to the acute episode should be included with Emergency Transfer packet to aide in medical history information for the receiving health care center to review. 5. The transfer process may include but it not limited to: a. Obtain an order to transfer the patient, when possible and obtaining the order does not delay lifesaving interventions at a higher level of care. b. Call ambulance for emergency (911). c. Notify the patient and/or legal representative of reason for transfer and document in the HER. d. Complete the Emergency Transfer/e-Interact Transfer Form from the EMR. e. The e-Interact Transfer form should accompany the patient to the Acute Care Hospital. f. The patient's DDNR (Advanced Directive) must accompany the patient if one has been executed. 6. A PRE-PRINTED Transfer envelope with the Transfer and Treatment Checklist and Bed Hold Policy attached should accompany the patient to any outside transfers with completed contents inside which coincide with the listed components on the checklist. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a bed hold notice upon transfer to the hospital, for three of 41 residents in the survey sample, Residents #51, #83 and #23. The findings include: 1. For Resident #51, the facility staff failed to provide a bed hold notice/policy to the resident and/or responsible party, upon transfer to the hospital on 5/15/2023. The nurse's note dated, 5/15/2023 at 2:50 p.m. documented in part, Fall at 1426 (2:46 p.m.), resident landed on head with a hard thump. Blood noted to resident left elbow, skin tear. NP (nurse practitioner) notified at 1428 (2:28 p.m.), verbal order to send resident out . The SNF/NF to Hospital Transfer Form dated, 5/15/2023, failed to evidence what documents were sent with the resident to the hospital. The section, Acute Care Transfer Document Checklist was blank. An interview was conducted with LPN (licensed practical nurse) #6 on 6/7/2023 at 10:37 a.m. When asked what documents are sent to the hospital with the resident for an acute change in condition, LPN #6 stated, they should send the face sheet, labs (laboratory tests) if related to why going out, doctor notes, and medication list. LPN #6 was asked if they send the care plan goals with the resident, LPN #6 stated she would have to check on that. LPN #6 stated they send the EInteract transfer form that collects information and send that with them. When asked where what documents are sent are documented in the clinical record, LPN #6 stated in the nurse's notes. LPN #6 was asked if a bed hold notice is provided to the resident upon transfer, LPN #6 stated, the eInteract transfer form collects information and send with them, however she didn't think there was a section for the bed hold. The facility policy, Bed Hold Prior to Transfer documented in part, It is the policy of this Center to provide written information to the patient and/or the patient's legal representative regarding bed hold policies prior to transferring a patient to the hospital or the patient goes on therapeutic leave. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical services specialist, were made aware of the above findings on 6/7/2023 at 1:46 p.m. No further information was provided prior to exit. 2. For Resident #83, the facility staff failed to provide a bed hold notice/policy to the resident and/or responsible party, upon transfer to the hospital on 2/25/2023. The nurse's notes dated 2/24/2023 at 4:33 p.m. documented, This nurse witnessed resident walking across the common area. As writer was approaching resident, to guide (them) back to the chair, (they) fell and landed on (their) left side . The nurse's note dated, 2/24/2023 at 11:45 p.m. documented, X-ray is - intertrochanteric fracture without shortening. (Name of Doctor). order received to send to ED (emergency department), RP (responsible party) notified. 911 called. An interview was conducted with LPN (licensed practical nurse) #6 on 672023 at 10:37 a.m. When asked what documents are sent to the hospital with the resident for an acute change in condition, LPN #6 stated, they should send the face sheet, labs (laboratory tests) if related to why going out, doctor notes, and medication list. LPN #6 was asked if they send the care plan goals with the resident, LPN #6 stated she would have to check on that. LPN #6 stated they send the eInteract transfer form that collects information and send that with them. When asked where what documents you send, are documented in the clinical record, LPN #6 stated in the nurse's notes. LPN #6 was asked if a bed hold notice is provided to the resident upon transfer, LPN #6 stated, the eInteract transfer form collects information and send with them, however she didn't think there was a section for the bed hold. On 6/7/2023 at 10:00 a.m., ASM (administrative staff member) #3, the clinical services specialist, stated they have no evidence of documents sent with the resident or a bed hold notice provided. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above findings on 6/7/2023 at 1:46 p.m. No further information was provided prior to exit. 3. For Resident #23, the facility staff failed to provide the resident and/or responsible party, with a bed hold notice upon transfer to the hospital on 3/26/2023. The nurse's note dated, 3/26/2023 at 12:06 a.m. documented in part, Reason for transfer and requires higher level of care: Resident having increased episodes of emesis and decreased BP (blood pressure), last taken was 67/40 .Bed Hold Provided: No, left with rescue squad. ASM #3, the clinical services specialist, stated on 6/7/2023 at 12:57 p.m., the facility did not have any documentation of a bed hold notice when sent to the hospital on 3/26/2023. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above findings on 6/7/2023 at 1:46 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, the facility staff failed to review and revise the comprehensive care for two of 41 residents in the survey sample, Residents #23 and #83. The findings include: 1. For Resident #23 (R23), the facility staff failed to review and review the comprehensive care plan after the resident was hospitalized with a small bowel obstruction. The resident's diagnoses included but was not limited to: personal history of malignant carcinoid tumor of large intestine. The nurse's note dated, 3/26/2023 at 12:06 a.m. documented in part, Reason for transfer and requires higher level of care: Resident having increased episodes of emesis and decreased BP (blood pressure), last taken was 67/40 .left with rescue squad. The comprehensive care plan dated, 3/30/2023, failed to evidence documentation related to the resident's bowel conditions. An interview was conducted with 6/7/2023 at 10:37 a.m. with LPN (licensed practical nurse) #6. When asked who updates the care plans, LPN #6 stated she does on her unit, each department does their section and the MDS (minimum data set) nurse reviews the care plans with each assessment. When asked if a resident returns from the hospital after suffering a small bowel obstruction and having a history of colon cancer, would she expect to see a care plan to address bowel regimen, LPN #6 stated, since it was a new change in condition for the resident, it should be addressed on the care plan to monitor her bowels, and make sure medications are in place, if needed. The facility policy, Comprehensive Care Planning Process documented in part, Additionally, the care plan is a fluid document and shall be reviewed and updated at any time the resident, family or representative or member of the ID team determines a need for additional interventions or care areas to be addressed. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical services specialist, were made aware of the above findings on 6/7/2023 at 1:46 p.m. No further information was provided prior to exit. 2. For Resident #83 (R83), the facility staff failed to review and revise the comprehensive care plan after the resident suffered a fall with a broken hip. The nurse's notes dated 2/24/2023 at 4:33 p.m. documented, This nurse witnessed resident walking across the common area. As writer was approaching resident, to guide (them) back to the chair, (they) fell and landed on (their) left side. Resident did not hit (their) head . The nurse's note dated, 2/24/2023 at 11:45 p.m. documented, X-ray is - intertrochanteric fracture without shortening. (Name of Doctor). order received to send to ED (emergency department), RP (responsible party) notified. 911 called. Review of the comprehensive care plan, revised on 2/27/2023, documented in part, Focus: (R83) had actual falls and continues to be at risk for further falls r/t (related to) unsteady gait, impaired cognition and muscle weakness, fell while attempting to transfer self, fall when ambulating self. The Interventions documented in part, dated 2/24/2023, ER (emergency room ). X-ray. The Fall Analysis/Investigation dated 2/24/2023, documented at the bottom of the first page there was a section, Care Plan/Individualized Service Plan Review: NEW Recommendations to minimize recurrent fall. Change/modify Care Plan. Care plan Remains Effective, No change Indicated. There were boxes to check off next to each of those statements, however there were no check [NAME]. An interview was conducted with LPN (licensed practical nurse) #6 on 6/7/2023 at 10:37 a.m. When asked who updates the care plans, LPN #6 stated she did on her unit. When asked if ER and X-ray are interventions to prevent further falls, LPN #6 stated it's an intervention of what is being done at that moment in time. LPN #6 concurred that the care plan should be an reviewed and updated after a resident has suffered a fall with a broken hip, after they return to the facility. On 6/7/2023 at 11:13 a.m. ASM (administrative staff member) #2, the director of nursing, stated there was no review or update to the care plan after (R83's) fall. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical services specialist, were made aware of the above findings on 6/7/2023 at 1:46 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to perform blood sugar checks per the physician order for one of 41 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4) the facility staff failed to obtain weekly fingerstick blood sugar on two out of four Wednesdays in the month of May 2023. The physician order dated, 3/15/2023 documented, Check BS (blood sugar) at HS (bedtime) on Wednesdays (Wed) at bedtime every Wed for DM (diabetes mellitus). Notify MD (medical doctor) if BS greater than 250 or less than 60. The May 2023 Medication Administration Record (MAR) documented the above order. On 5/24/2023 and 5/31/2023, there was no documented blood sugar, just the nurse's initials with a check mark. Review of the Blood Sugar Summary, failed to evidence the blood sugar reading for 5/24/2023 and 5/31/2023. Review of the nurse's notes failed to evidence documentation of the blood sugar readings on 5/24/2023 and 5/31/2023. An interview was conducted with LPN (licensed practical nurse) #6 on 6/7/2023 at 4:08 p.m. When asked if its not documented on the MAR, where would the blood sugar be documented, LPN #6 stated maybe in the nurse's notes. All the above documents were reviewed with LPN #6. LPN #6 was asked how you could tell the blood sugar was completed on those days; LPN #6 stated I don't know how the nurses bypassed the scheduled blocks to document the blood sugar. We can't tell what the readings were for those days. The facility policy, Blood Glucose Monitoring, documented in part, It is the policy of this Center to perform blood glucose monitoring per physician/physician extender's orders. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the clinical services specialist, were made aware of the above findings on 6/7/2023 at 4:35 p.m. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to implement safety interventions and/or maintain a safe environment for three of 41 residents in the survey sample, Residents #130, #278 and #4. The findings include: 1. For Resident #130 (R130), the facility staff failed to transfer the resident with a Hoyer lift, per the resident's plan of care on 3/8/23. R130's comprehensive care plan revised on 3/2/23 documented, (R130) demonstrates the need for ADL (activities of daily living) assistance r/t (related to) weakness d/t (due to) cerebral infarction (stroke), Stage IV breast cancer, medication, and medical deficit. Interventions/Tasks: Resident Hoyer lift/two person assist with transfers . R130's CNA (certified nursing assistant) kardex dated 3/8/23 documented, Transferring 2 person/Hoyer . On 6/6/23 at 10:22 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that on 3/8/23, she entered R130's room and two CNAs were attempting to transfer the resident [without a Hoyer lift] from the bed to a shower chair. LPN #3 stated the CNAs were struggling, so she assisted with the transfer. LPN #3 stated that at the time, she and the CNAs were not aware that they were supposed to use a Hoyer lift. LPN #3 stated R130's transfer status must have recently changed prior to 3/8/23. LPN #3 stated R130's [family member], who was present in the room, complained after R130's transfer to the shower chair. LPN #3 stated that after R130's [family member] complained, she looked at R130's Kardex (a document that gives a brief overview of the resident) and saw that the transfer without a Hoyer lift was an error on her and the CNAs part. (A review of nurses' notes for 3/8/23 failed to reveal documentation regarding the transfer). The CNAs who transferred R130 to the shower chair on 3/8/23 were not available for interview during the survey. On 6/6/23 at 2:47 p.m., an interview was conducted with CNA #1. CNA #1 stated CNAs are made aware of residents' need for a Hoyer lift via the Kardex, dialog with therapy staff, dialog with the unit manager, and in the CNA verbal report. On 6/7/23 at 1:48 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility did not have a policy regarding resident transfers. 2. For Resident #278, the facility staff failed to ensure disinfectant wipes were not out in the open in the resident's room. A nurse's note dated 6/4/23 documented, Resident confused this shift. Resident knows how old she is but states that her mother is 91 and that she has three babies to take care of, 2 girls and a boy. She was concerned about her mother taking care of the babies and that she stated that she needed to get home. Multiple attempts of reality orientation . On 6/5/23 at 12:49 p.m., R278 was lying on the bed and stated she needed to get out to check on the her mother and she needed to get a babysitter for her children. At that time, a container of disinfectant wipes was observed on R278's windowsill. A nurse's note dated 6/6/23 documented R278's preliminary urinalysis results were indicative of a urinary tract infection and antibiotic therapy was started. It was documented that R278 required extensive assistance with bed mobility and transfers and did not ambulate. On 6/6/23 at 9:34 a.m., R278 and an employee was observed in the resident's room. The container of disinfectant wipes remained on the windowsill. On 6/6/23 at 3:57 p.m., an interview as conducted with RN (registered nurse) #3. RN #3 stated disinfectant wipes cannot be kept in residents' rooms because, It has some kind of chemical component to it. RN #3 stated that usually the nurses have access to disinfectant wipes and can get them if they need them for a resident. On 6/7/23 at 1:48 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility did not have a policy regarding disinfectant wipes. 27660 3. For Resident #4 (R4), the facility staff failed to have fall mats on the floor when the resident was in bed. Observation was made of R4 on 6/6/2023 at 9:41 a.m. and at 9:54 a.m. R4 was lying in their bed, on their side, and appeared to be asleep. Two fall mats were located behind the headboard against the wall. The physician orders dated 6/2/2023, documented, Fall mats on both sides of the bed while in bed. The comprehensive care plan dated, 8/23/2022, documented in part, Focus: (R4) has had actual fall with injury. Cognitive impairment impacting ability to understand own physical limitations. Poor balance, unsteady gain. Resident has had an unwitnessed fall from the bed to the floor with no injury. (R4) fell after attempting to self-ambulate with no injuries, injured when transferring self. The Interventions dated 8/23/2022, documented in part, Fall Mat. An interview was conducted with CNA (certified nursing assistant) #4 on 672023 at 2:04 p.m. When asked where she can look to see what safety interventions a resident needs, CNA #4 stated, it is in the Kardex. The Kardex for R4 documented in part, Fall mat on left side of bed while in bed every shift. May have bed side on mats on each side of bed. On 6/7/2023 at 3:53 p.m. ASM (administrative staff member) #2, the director of nursing, was asked should interventions for the prevention of falls be put in place, ASM #2 stated, yes. The facility policy, Fall Prevention Program documented in part, 5. High Risk Protocols: a. The patient will be evaluated by the IDT (interdisciplinary team) for intervention management. b. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. 6. Each patient's risk factors, and environmental hazards will be evaluated when developing the patient's comprehensive plan of care. a. Interventions will be monitored for effectiveness. ASM #1, the administrator, ASM #2, and ASM # 3, the clinical services specialist, were made aware of the above concern on 6/7/2023 at 3:33 p.m. No further information was obtained prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide appropriate care and services for an indwelling urinary catheter, for one of 41 residents in the survey sample; Resident #121. The findings include: For Resident #121 the facility staff failed to ensure the Foley catheter was maintained off the floor to prevent infections. A Foley catheter is a common type of indwelling catheter. It has soft, plastic or rubber tube that is inserted into the bladder to drain the urine (1). On 6/6/23 at 8:38 AM, Resident #121 was observed sitting on the side of the bed awaiting his breakfast tray. The Foley catheter bag was noted on the floor under the edge of the bed, the tubing was laying on the floor and the resident was stepping on the tubing. A review of the physician's orders revealed one dated 5/20/23 for catheter care every shift. On 6/7/23 at 11:50 AM an interview was conducted with CNA (Certified Nursing Assistant) #2 who stated that the catheter bag should be hanging on the side of the bed and the bag and the tubing should not be on the floor. On 6/7/23 at 11:52 AM an interview was conducted with LPN (Licensed Practical Nurse) #4 who stated that neither the bag nor the tubing should be on the floor and the bag should be hanging on the side of the bed. A review of the comprehensive care plan dated 5/21/23 for the use of a Foley catheter included the intervention dated 5/21/23 for Provide catheter care per order and protocol and PRN (as-needed). On 6/7/23 at 1:45 PM ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing and ASM #3 Clinical Services Specialist, were made aware of the findings. On 6/7/23 at 2:00 PM the facility policy, Urinary Catheterization/Irrigation was provided and reviewed. This policy documented, .Indwelling urinary catheters will be secured with use of an anchor to prevent excessive tension on the catheter, prevent accidental dislodgement, prevent kinks in the tubing and facilitate adequate flow of urine . The policy did not specify the need for the bag and tubing to be maintained off the floor to prevent infections. No further information was provided by the end of the survey. Reference: (1) The Foley catheter information was obtained from: https://medlineplus.gov/ency/article/003981.htm#:~:text=A%20Foley%20catheter%20is%20a,smallest%20catheter%20that%20is%20appropriate.

Based on observation, staff interview, and facility documentation review, the facility staff failed to allow all residents to receive visitors from 7:00 P.M. through 10 A.M. for an undetermined length of time. The findings included: On 01/25/2022 at 12:15 P.M. upon survey entrance, a sign was observed on the front door of the facility which read: Visiting Hours 10AM to 7PM Please wear a face mask, sanitize hands upon entry and departure, and social distance during your visit. If you have any questions or concerns, please ask the Charge Nurse. The sign was also observed on the front door on the morning and afternoon of 01/26/2022. On 01/26/2022 at 2:05 P.M., an interview with Employee G, the front desk receptionist, was conducted. Employee G verified that she worked from 11:00 A.M. through 7 P.M. When asked when visiting hours were, the receptionist stated the visiting hours were from 10:00 A.M. through 7 P.M. The receptionist also stated that the front doors get locked around 7:00-7:05 P.M. nightly. When asked why visiting was limited to that time frame, the receptionist stated she didn't know why. On 01/26/2022 at 2:20 P.M., the regional nurse consultant was interviewed. When asked about their visitation policy, the regional nurse consultant stated they go by the CMS (Centers for Medicare and Medicaid) guidance. A copy of the facility policy pertaining to visitation was requested. At 3:50 P.M., the administrator provider a copy of their policy with a review/revise date of 12/31/2021 entitled, COVID-19 Visitation. In Section 6(a), it was documented, Indoor visitation will be conducted in a manner that reduces the risk of COVID-19 transmission based on the following guidelines: (a) The facility will allow indoor visitation at all times for all residents and will not limit the frequency and length of visits, the number of visitors, or require advanced scheduling of visits. When asked about visiting hours, the administrator stated that visitation is allowed at all times. When asked about the sign on the door that states visiting hours are from 10:00 A.M.-7:00 P.M., the administrator stated that those are recommended hours but that visitors could also come before or after those times. On 01/26/2022 at 4:00 P.M., there were 3 visitors at the bedside of a resident. The Resident was identified and placed in the sample as Resident #42. The visitors identified themselves as friends of Resident #42. When asked about when visiting hours were, one of the visitors stated that visiting hours were from 10:00 A.M. through 7:00 P.M. When asked how long the visiting hours were restricted to that time frame, the visitor stated they did not know. The visitor then stated that they were in to visit around the end of December to assist their friend (Resident #42) to remove Christmas decorations and the visiting hours at that time were also 10:00 A.M. through 7:00 P.M. On 01/26/2022 at 4:45 P.M., the administrator and DON were notified of findings. At 5:00 P.M., the visitation sign was no longer on the front door. On 01/27/2022 at 4:20 P.M., the administrator and Director of Nursing were interviewed. When asked when the visitation sign was posted on the door, the administrator stated he didn't know how long the sign was there and suggested maybe since December (2021). On 01/27/2022 at 5:55 P.M., the regional nurse consultant stated they had no further information or documentation to submit.

Based on interview, clinical record review, facility documentation and in the course of a complaint investigation, the facility staff failed to report the allegation of neglect for 4 Residents (#'s 310, 311, 312, and 410) in a survey sample of 52 Residents. The findings included: For Resident #'s 310, 311, and 312 the facility staff failed to report missing [MEDICATION(S)] for three Residents, the incident of RN D overdosing at the facility on [MEDICATION(S)] and the investigation that ensued. The 3 Residents involved were all on comfort care measures and receiving [MEDICATION(S)] patches every three days to manage pain. The facility submitted 2 documents related to the diversion of narcotics by a former employee. The documents included a letter reporting the incident to the board of nursing, and a document entitled Summary of Findings in the Investigation of Suspected Diversion of [MEDICATION(S)] at [facility name redacted]. Per the above mentioned documents, it was found that the RN D admitted to diverting medications and did overdose at the facility, on [MEDICATION(S)] patches. The RN involved denied removing patches prior to the scheduled times, however there was evidence that the patches were not on the Residents' and the MD/ NP nor DON was not always documented as being notified. On 1/27/21 an interview was conducted with the DON who stated she was working at the facility at the time of the incident, however she was not in the roll of DON at the time. The Administrator was also working in facility, in the capacity of AIT (Administrator in Training) at that time. Both the Administrator and the DON remember the incident of narcotics missing and the subsequent overdose of RN D while at work. The Regional nurse consultant provided a copy of the letter notifying the Board of Nursing of the incident of drug diversion. They also provided a document entitled Summary of Findings in the investigation of suspected diversion of [MEDICATION(S)] at [facility name redacted] (see excerpt below). During an interview with [RN D] on 4/17/20, she acknowledged that she had been diverting controlled substances from the center since February 2020. [RN D] reported that she diverted medications that were pulled from the medication carts which were intended for destruction, including the 3 [MEDICATION(S)] patches she consumed on April 12th. Page 2. CDR/MAR Documentation A center wide audit was conducted of CDR's and MAR's for PRN controlled substances and revealed [Information redacted by facility] medication doses that were documented as having been pulled from the medication cart but were not documented as being administered to patients on their MAR's [Facility redacted information]. The complaint names 3 Residents that were found to have [MEDICATION(S)] patches missing prior to the scheduled removal dates. A review of the clinical records for Resident #310 revealed documentation of [MEDICATION(S)] patches missing from her body prior to scheduled date of removal on 8 occasions between 2/19/20 and 4/9/20. The progress notes revealed that on 2/19/20 at 9:29 PM that the [MEDICATION(S)] patch was not found on the Resident. On 3/23/20 at 4:21 PM again progress notes documented [MEDICATION(S)] patch was not found on the Resident and the NP was notified. On 3/24/20 again the [MEDICATION(S)] patch was not found and the MD notified. On 3/29/20 and on 3/30/20 the documentation reflects no [MEDICATION(S)] patch being found and the MD/NP notified. On 4/7/20, 4/8/20 and 4/9/20 the documentation reflects no [MEDICATION(S)] patch found on the Resident. (Please note that on 2/19/20, 4/7/20, 4/8/20 and 4/9/20 the progress notes to not indicate notification of MD / NP or DON). A review of the clinical record for Resident #311 revealed that on 2/28/20 at 4:28 AM no [MEDICATION(S)] Patch was found on the Resident's body and the supervisor was made aware. On 3/6/20 once again an entry was made in the progress notes that no [MEDICATION(S)] patch was found on the resident and the MD and RP were made aware. A review of the clinical record for Resident #312 revealed that on 3/3/20 an entry was made in the progress notes that no patch was found on the Resident and the NP was made aware. On 3/4/20 the notes indicate once again no patch was found. On 4/2/20 again an entry was made in the progress notes that no patch was found on the Resident. On 4/9/20 and 4/12/20 entries were made in the progress notes that no [MEDICATION(S)] patch was found on the Resident. (Please note on 4/2/20, 4/9/20 and 4/12/20 no documentation of notification of DON / MD / NP was present) On 1/27/22 at approximately 2:00 PM a copy of the facility policy for Controlled Substance Loss, Diversion and Impairment was reviewed and read as follows: Page 2 C -Internal Notifications 1. Supervisor will immediately notify the Unit Manager and or Director of Nursing and Center Human Resources. If not previously notified the Unit Manager will notify the DON 2. DON will immediately notify the Administrator. 3. The Administrator will immediately notify the Regional Director of Operations as well as the Compliance Officer or the Director of Legal Services. 4. The DON will immediately report the theft to the Clinical Services Specialist and the Pharmacy Vendor's Pharmacist-in-Charge. On 1/27/22 at approximately 4:15 PM an interview was conducted with the DON who was asked why the facility did not act on the missing patches prior to 4/12/20 she stated We acted as soon as we found out on 4/12/20. When asked what the expectation was for acting on Diversion of medication and she stated that it should be immediately reported to the DON and Administrator. When asked if this was done she stated that it was done on 4/12/20. When asked why it was not acted upon on several occasions when the MD / NP /and supervisor were notified of patches were missing from these 3 Residents, she stated again that the facility acted on it when they found out on the 4/12/20 after a staff member overdosed on [MEDICATION(S)] while on duty. On 1/27/22 during the end of day meeting the Administrator was made aware of this concern and no further information was provided. Complaint Deficiency For Resident #410, who reported an allegation of abuse, the facility staff failed to report the allegation or investigation results to the state survey agency (Office of Licensure and Certification), adult protective services and other officials as required. On the afternoon of 1/25/22, an interview was conducted with Resident #410. During this interview, the Resident verbalized that previously she had reported that CNA B dumped a pan of hot water on her during a bath. Review of the facility grievances revealed that a grievance form dated 12/6/21, read, Resident reported her CNA, [CNA B name redacted], threw hot water on her back while assisting her with getting cleaned up and bed bath [sic]. The facility conducted an investigation, which included a head to toe assessment of the Resident, checking the water temperature in the room and obtaining statements from staff. On 1/25/22, a request for all FRI's (facility reported incidents) was requested and received. The FRI's were reviewed with no report of Resident #410's allegation being sent to the State Agency. On 1/26/22, an interview was conducted with the facility Administrator and Corporate Clinical Consultant. The facility Administrator confirmed that neither a report nor follow-up report had been submitted to the state survey agency, adult protective services or other agencies as required. A review of the facility policy titled, Abuse Prevention was conducted. This policy read, .VII. Reporting/Response: A. Allegations of Abuse, Neglect, Misappropriation of Property, Exploitation: The Center Administrator, DON, or designee must timely report all alleged incidents of abuse, neglect, exploitation or mistreatment including injuries of unknown origin, misappropriation of property and unusual occurrences using the Virginia Office of Licensure & Certification Facility Reported Incident form to the (OLC) and to all other required agencies including Adult Protective Services (APS), and local law enforcement A final report with results of the investigation is filed with the OLC within 5 working days of the alleged incident. If the allegation involves a licensee, the Department of Health Professions should be notified only after the investigation has been completed and in accordance with section B. The Administrator should consult the [corporate company name redacted] Legal Team when reporting a licensee No further information was provided.

Based on interview, clinical record review, facility documentation and in the course of a complaint investigation, the facility staff failed to ensure Residents were free from neglect for 3 Residents (#'s 310, 311, and 312) in a survey sample of 52 Residents. The findings included: For Resident #'s 310, 311, and 312 the facility staff neglected to ensure that [MEDICATION(S)] patches remained on the Resident for the appropriate length of time. The 3 Residents involved were all on comfort care measures and receiving [MEDICATION(S)] patches every three days to manage pain. The facility submitted 2 documents related to the diversion of narcotics by a former employee (RN D). The documents included a letter reporting the incident to the board of nursing, and a document entitled Summary of Findings in the Investigation of Suspected Diversion of [MEDICATION(S)] at [name of facility redacted]. Per the above mentioned documents, it was found that the RN D admitted to diverting medications and did overdose at the facility, on [MEDICATION(S)] patches. The RN involved denied removing patches prior to the scheduled times however there was evidence that the patches were not on the Residents' and the MD/ NP nor DON was not always documented as being notified. On 1/27/21 an interview was conducted with the DON who stated she was working at the facility at the time of the incident, however she was not in the roll of DON at that time. The Administrator was also working at the facility, however he was an AIT (Administrator in Training) at that time. Both the Administrator and the DON remember the incident of narcotics missing and the subsequent overdose of RN D while at work. On 1/26/22 a review of the clinical record for Resident #310 revealed documentation of [MEDICATION(S)] patches missing from her body prior to scheduled date of removal on 8 occasions between 2/19/20 and 4/9/20. On 3/23/20 at 4:21 PM again progress notes documented [MEDICATION(S)] patch was not found on the Resident however they did document the Nurse Practitioner (NP) was notified. On 3/24/20 a [MEDICATION(S)] patch was not found and the MD notified. On 3/29/20 and on 3/30/20 the documentation reflects no [MEDICATION(S)] patch being found and the MD/NP notified. On 4/7/20, 4/8/20 and 4/9/20 the documentation reflects no [MEDICATION(S)] patch found on the Resident. (Please note that on 2/19/20, 4/7/20, 4/8/20 and 4/9/20 the progress notes do not indicate notification of MD / NP or DON.) A review of the clinical record for Resident #311 revealed that on 2/28/20 at 4:28 AM no [MEDICATION(S)] Patch was found on the Resident's body and the supervisor was made aware. On 3/6/20 once again an entry was made in the progress notes that no [MEDICATION(S)] patch was found on the resident and the MD and RP were made aware. A review of the clinical record for Resident #312 revealed that on 3/3/20 an entry was made in the progress notes that no patch was found on the Resident and the NP was made aware. On 3/4/20 the notes indicate once again no patch was found. On 4/2/20 again an entry was made in the progress notes that no patch was found on the Resident. On 4/9/20 and 4/12/20 entries were made in the progress notes that no [MEDICATION(S)] patch was found on the Resident. (Please note on 4/2/20, 4/9/20 and 4/12/20 no documentation of notification of DON / MD / NP was present) On 1/27/22 at approximately 2:00 PM a copy of the facility policy for Controlled Substance Loss, Diversion and Impairment was reviewed and read as follows: Page 2 C -Internal Notifications 1. Supervisor will Immediately notify the Unit Manager and or Director of Nursing and Center Human Resources. If not previously notified the Unit Manager will notify the DON 2. DON will Immediately notify the Administrator. 3. The Administrator will immediately notify the Regional Director of Operations as well as the Compliance Officer or the Director of Legal Services. 4. The DON will immediately report the theft to the Clinical Services Specialist and the Pharmacy Vendor's Pharmacist-in-Charge. On 1/27/22 at approximately 4:15 PM an interview was conducted with the DON who was asked why the facility did not act on the missing patches prior to 4/12/20 she stated We acted as soon as we found out on 4/12/20. When asked what the expectation was for acting on Diversion of medication and she stated that it should be immediately reported to the DON and Administrator. When asked if this was done she stated that it was done on 4/12/20. When asked why it was not acted upon on several occasions when the MD / NP /and supervisor were notified of patches were missing from these 3 Residents, she stated again that the facility acted on it when they found out on the 4/12/20 after a staff member (RN D) overdosed on [MEDICATION(S)] while on duty. On 1/27/22 during the end of day meeting the Administrator was made aware of this concern and no further information was provided. Complaint Deficiency

Based on Resident interview, staff interview and facility documentation review, the facility staff failed to implement their abuse policy for one Resident (Resident #410) in a survey sample of 52 Residents. For Resident #410, who reported an allegation of abuse to the facility staff, the facility staff failed to carry out their abuse policy with regards to protecting the Resident while an investigation was being conducted and failing to report an allegation of abuse. The findings included: On the afternoon of 1/25/22, Surveyor C conducted an interview with Resident #410. During the interview Resident #410 reported that in the past CNA B had poured a pan of hot water onto her back while bathing her. Review of the facility grievances revealed that a grievance form dated 12/6/21, read, Resident reported her CNA, [CNA B name redacted], threw hot water on her back while assisting her with getting cleaned up and bed bath [sic]. The facility conducted an investigation, which included a head to toe assessment of the Resident, checking the water temperature in the room and obtaining statements from staff. There was no indication that during the investigation process, that the facility staff removed CNA B from providing care to or having access to Resident #410, while a determination of if abuse had taken place. On 1/25/22, a request for all FRI's (facility reported incidents) was requested and received. The FRI's were reviewed with no report of Resident #410's allegation being noted being sent to the State Agency. On 1/26/22, an interview was conducted with the facility Administrator and Corporate Clinical Consultant. The facility Administrator confirmed that a neither a report nor follow-up report had been submitted to the State Agency, Adult Protective Services or other agencies as required. The Administrator and Corporate Clinical Consultant were made aware that there was no evidence of CNA B being removed from having access to Resident #410, in an effort to protect the Resident, during the course of the investigation. Both of them (Administrator and Corporate Clinical Consultant) confirmed this. A review of the facility policy titled, Abuse Prevention was conducted. This policy read, .VI. Protection: A. The Center will immediately assess the resident, notify the physician and Responsible Party, and take steps to protect the resident from further harm or incident .VII. Reporting/Response: A. Allegations of Abuse, Neglect, Misappropriation of Property, Exploitation: The Center Administrator, DON, or designee must timely report all alleged incidents of abuse, neglect, exploitation or mistreatment including injuries of unknown origin, misappropriation of property and unusual occurrences using the Virginia Office of Licensure & Certification Facility Reported Incident form to the (OLC) and to all other required agencies including Adult Protective Services (APS), and local law enforcement A final report with results of the investigation is filed with the OLC within 5 working days of the alleged incident. If the allegation involves a licensee, the Department of Health Professions should be notified only after the investigation has been completed and in accordance with section B. The Administrator should consult the [corporate company name redacted] Legal Team when reporting a licensee No further information was provided.

Based on Resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to implement measures to protect the Resident while an abuse investigation was conducted, for one Resident (Resident #410) in a survey sample of 52 Residents. For Resident #410, who reported an allegation of abuse, the facility staff failed to protect the Resident by not allowing the alleged perpetrator to have continued access to the Resident while an investigation was being conducted. The findings included: On 1/25/22, an interview was conducted with Resident #410. During this interview, the Resident verbalized that previously she had reported that CNA B dumped a pan of hot water on her during a bath. Review of the facility grievances revealed that a grievance form dated 12/6/21, read, Resident reported her CNA, [CNA B name redacted], threw hot water on her back while assisting her with getting cleaned up and bed bath [sic]. The facility conducted an investigation, which included a head to toe assessment of the Resident, checking the water temperature in the room and obtaining statements from staff. There was no indication that during the investigation process, that the facility staff removed CNA B from providing care to or having access to Resident #410, while a determination of if abuse had taken place or not. On 1/26/22, an interview was conducted with the facility Administrator and Corporate Clinical Consultant. Both, the Administrator and Corporate Clinical Consultant were made aware that there was no evidence of CNA B being removed from having access to Resident #410, in an effort to protect the Resident, during the course of the investigation. Both of them (Administrator and Corporate Clinical Consultant) confirmed this. A review of the facility policy titled, Abuse Prevention was conducted. This policy read, .VI. Protection: A. The Center will immediately assess the resident, notify the physician and Responsible Party, and take steps to protect the resident from further harm or incident . No further information was provided.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a safe environment free from hazards and adequate supervision to prevent an accident for one of three residents in the survey sample, Resident #101. The facility staff failed to ensure Resident #101 was supervised and monitored while outside of the facility in the courtyard, to prevent accidents and ensure safety in an environment free from hazards. On 9/24/17 at approximately 1:45 p.m., Resident #101 exited the facility to the courtyard in a wheelchair and was unable to reenter the facility when she began to feel ill. The facility staff failed to supervise and check on Resident #101 on 9/24/17 at 3:00 p.m. as requested by the resident. Resident #101 was outside unsupervised by staff for approximately 2 - 2 ½ hours. The temperature was report as 89 degrees Fahrenheit (F). The resident was subsequently found at 4:30 p.m. sitting in the wheelchair in the courtyard. The resident was unresponsive and had vomit coming out of her mouth and was found to have a temperature of 105 degrees. The resident was transferred to the hospital and admitted to the intensive care unit. The findings include: Resident #101 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), an admission assessment, with an ARD (assessment reference date) of 10/4/17 coded Resident #101 as having scored a 13 out of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring the assistance of one staff member for all activities of daily living except for eating which the resident coded as able to do after the meal tray was set up. Review of the 30 day MDS with an ARD of 9/20/17 coded Resident #101 as having scored a 12 out of 15 on the BIMS indicating the resident was moderately impaired cognitively. Resident #101 was coded as requiring the assistance from staff for activities of daily living except for eating which the resident could do under staff supervision, the resident was coded as requiring supervision of one staff member for locomotion on the unit which the resident accomplished by using a wheelchair. Review of the resident's care plan initiated on 8/24/17 documented, Focus. (name of resident #101) requires assistance with ADLS (activities of daily living) .Interventions. Provide assistance for locomotion as needed. An observation was made of Resident #101 on 10/4/17 at 2:55 p.m. The resident was in the therapy department using a stationary bicycle and talking to therapy staff. An observation was made of Resident #101 on 10/5/17 at 8:01 a.m. The resident was lying in bed with eyes closed. The lights were turned off. Review of the nurse's notes for 9/21/17 at 5:13 p.m. documented, Mobility and Function this shift: Transfers: Physical assist of 1 person Walking: Did not occur or was not observed this shift; Assistive Device: : (sic) Locomotion on the unit: Wheeled self in wheelchair; Locomotion off the unit: Wheeled self in wheelchair. Review of the nurse's notes for 9/22/17 at 5:13 p.m. documented, Transfers: Physical assist of 1 person Walking: Did not occur or was not observed this shift; Assistive Device: (sic) Locomotion on the unit: Wheeled self in wheelchair; Locomotion off the unit: Wheeled by staff in wheelchair. Review of the nurse's notes dated 9/24/17 at 4:14 p.m. documented, Went to check on patient outside, patient found unresponsive with vomit coming out of mouth, went and called other nurses for help with patient. Vital signs assessed. (Blood pressure) 121/71, (pulse) 143 (normal pulse is 60 to 100), (respirations) 14, (temperature) 105.0 (degrees), (oxygen saturation) 90%. This nurse and other nurses assisted patient back to bed. Review of the nurse's note dated 9/24/17 at 4:30 p.m. documented, Correction went outside to check on resident at 16:30 (4:30 p.m.). Review of the nurse's note dated 9/24/17 at 4:31 p.m. documented, Pt (patient) put back to bed, clothing removed and ice packs applied to groin and armpits, cool cloths to head and neck. Pt sat up (by staff) in bed, pt not responsive to verbal or tactile (touching) stimulus. BP 121/70, pulse 143, respirations 12-14 and labored, temp (temperature) 105.0 on temporal artery (a thermometer used on the side of the head), oxygen applied at 3L(liters)NC (nasal cannula, soft prongs that fit in the nose to deliver oxygen), O2 (oxygen) sats (saturations) 87-91% (1). 911 called, report given, pt transported via (name of EMS (emergency medical system) company) stretcher to (name of hospital). Emergency contact aware, NP (nurse practitioner) notified. Review of the resident's vital signs from 9/20/17 to 9/24/17 did not evidence documentation of any change in the resident's vital signs prior to the incident. Review of the nurse's notes for 9/20/17 through 9/23/17 did not evidence documentation of any change in the resident's status, prior to this incident. Review of the emergency room 's communication record on 9/24/17 at 5:03 p.m. from the EMS (emergency medical services) company documented, Heat Stroke -- outside 2 - 2 1/2 hr (hour). Review of the physician's admission note to the emergency roiagnom on [DATE] at 5:12 p.m. documented, Chief Complaint: UNRESPONSIVE. This started today and is still present. The patient was found unresponsive Additional history - 78 yo (year old) female brought from (name of nursing home) unresponsive. Per EMS pt went outside without staff knowing and was unable to get back inside. She was found unresponsive with a temp of 105. PHYSICAL EXAM. Vital Signs: 09/24/2017 17:14 (5:14 p.m.) BP (blood pressure): 152/72. HR (heart rate): 135. RR (respiratory rate): 40. O2 saturation: 97%. Temp: 102.8 F (Fahrenheit). CLINICAL IMPRESSION. Changed mental status. Generalized seizure. Changed mental status (sic). Urinary tract infection. Heat stroke with hyperthermia (high temperature) and stupor. The resident was admitted to the intensive care unit. Review of the discharge summary from the hospital dated 9/30/17 documented, FINAL Diagnoses: [REDACTED]. 2. Sepsis, secondary to Enterococus faecalis (3), on IV (intravenous) antibiotics, stable. 3. [DIAGNOSES REDACTED] (4) urinary tract infection, asymptomatic, afebrile (no fever). 4 .myocardial infarction (heart attack), secondary to demand ischemia (5) An observation of the courtyard was conducted on 9/24/17 at 4:20 p.m. with ASM (administrative staff member) #2, the director of nursing. ASM #2 walked to the place Resident #101 was found. The walkway was cobble stone and slightly uneven. The place the resident was found was approximately 25 feet from the door. The door opened outward into the courtyard. ASM #2 demonstrated how the resident was found and stated that if someone was looking out into the courtyard from the nurses' station they would only have been able to see the resident's back. An interview was conducted on 10/4/17 at 4:23 p.m. with LPN (licensed practical nurse) #1, the resident's nurse on 9/24/17. When asked how often staff checked on residents, LPN #1 stated, We were just doing the standard practice of every two hours then (at the time of the 9/24/17 incident). Now we check on them every 15 minutes if they're outside and every 30 minutes if they're in activities. When asked if there was anything unusual about Resident #101 on 9/24/17, LPN #1 stated she seemed fine. When asked how often Resident #101 went outside, LPN #1 stated, I saw her go outside (on 9/23/17). When asked how Resident #101 got there, LPN #1 stated, I don't know how she got outside but I saw her reading in the gazebo. I saw her opening the door to let herself in. When asked what had occurred on 9/24/17 when the resident was found unresponsive in the courtyard, LPN #1 stated, She (the resident) said she wanted me to check on her at 3:00 (p.m.). and I said okay, 3 o'clock came and I did shift change. I didn't look for her (Resident #101). Around 4:30 (p.m.) speech therapy was looking for her (Resident #101) and then I went outside to look for her and I found her (Resident #101) in her wheelchair. When asked what the normal routine was a shift change, LPN #1 stated, We didn't have one before. Now we have to do walking rounds. When asked about Resident #101's status when LPN #1 found her, LPN #1 stated, She (Resident #101) wasn't responding but she was breathing. We did vital signs. Her blood pressure was normal, it was just her pulse was fast and her temperature was 105. We put ice on her. When asked if there was anyone else in the courtyard at the time, LPN #1 stated there was not. An interview was conducted on 10/4/17 at 4:35 p.m. with CNA (certified nursing assistant) #1, the resident's 3:00 p.m. to 11:00 p.m. aide. When asked how Resident #101 got around the unit, CNA #1 stated, When I had her she didn't leave the room. When asked if many residents went outside, CNA #1 stated, No. CNA #1 was asked about the normal routine followed by staff when they come on shift. CNA #1 stated, Sometimes the resident is in the activity room. I don't worry about them. If I don't see them after dinner, then I go look for them. When asked how often she had worked with Resident #101 prior to 9/24/17, CNA #1 stated it was her second day with the resident. When asked what occurred on 9/24/17 the day Resident #101 was found in the courtyard, CNA #1 stated, This day when I came and they told me she was in the activity room. When asked if she had looked for the resident in the activities room, CNA #1 stated, No. I think that day I had a resident who needed me to change her before dinner. When I pushed her into the dining room they told me they found her (Resident #101). Now after this incident we have to check on every resident if not in their room. If they are in activities, we check on them every 30 minutes and if they are outside every 15 minutes. An interview was conducted on 10/4/17 at 4:55 p.m. with OSM (other staff member) #2, the physical therapist, regarding how Resident #101 was doing in therapy prior to 9/24/17. OSM #2 stated, She was doing what amounted to 15 steps with my hand on her. She was using a rolling walker and walked on the cobbled sidewalk outside. When asked how Resident #101 has been doing since her return on 9/30/17, OSM #2 stated, I'm not her therapist now but she has significantly declined. An interview was conducted on 10/5/17 at 8:00 a.m. with Resident #102. Resident #102 had been identified in the facility's plan of correction dated 10/2/17 as a resident who went outside. Resident #102 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, a quarterly assessment, with an ARD of 9/8/17 coded the resident as having a BIMS of 13 out of 15 indicating the resident was cognitively intact to make daily decisions. Resident #102 was coded as requiring assistance with activities of daily living. The resident was coded as requiring supervision for locomotion. Review of the resident's care plan initiated on 4/21/17 and revised on 5/9/17 documented, Focus. Demonstrates the need for ADL assistance. Interventions. Provide assistance for locomotion as needed. Resident #102 was asked if he went outside. Resident #102 stated, I sit outside when the weather's warm. When asked how he would let staff know if he needed help when he was outside, Resident #102 stated, I sit by the door. They know I'm there. An interview was conducted on 10/5/17 at 8:07 a.m. with LPN #2, the 9/24/17 day shift supervisor. When asked what she remembered about the 9/24/17 incident with Resident #101, LPN #2 stated, I was supervising that day. I picked up her breakfast tray. I left the room about 9:30 (a.m.) to 10:00 (a.m.). At 4:30 p.m. I have to go help in the dining room. I would say about 15 minutes later I was told I was needed on the C unit to (name of Resident #101's) room. That was a very busy day. There were families visiting. People coming in and out. The next nurse had come in, I'm not sure if she'd laid eyes of her (Resident #101) yet. LPN #2 was asked the usual routine followed by staff when they came on duty. LPN #2 stated, Get report, start my shift, look at my patients and make sure everyone's okay. When asked what staff did if the resident wasn't in the room, LPN #2 stated, I don't know that there was a process for that. When asked how staff would know if a resident needed help when they were outside in the courtyard, LPN #2 stated, It's kinda hard to know if you're not in your visual sight. When asked what had occurred since the incident with Resident #101 on 9/24/17, LPN #2 stated there were new changes and I think it's good. We should always know where patients are. Even if you're alert and oriented they could fall on the uneven pathway or grass. Anything can happen. When asked what the weather was like on 9/24/17, LPN #2 stated, I know it was warm outside maybe 84 (degrees). According to accuweather.com (6) the high temperature on 9/24/17 was 89 degrees. An interview was conducted on 10/5/17 at 8:20 a.m. with CNA #2, the 9/24/17 day shift aide for Resident #101. CNA #2 was asked about the routine staff followed when coming on duty. CNA #2 stated, In the morning when we first get here we go around with the aide who worked 11:00 (p.m.) to 7:00 (a.m.) and talk about how they (the residents) were the night before and we do the same thing in the evening. When asked what staff did if the resident was not in their room during the rounds at shift change, CNA #2 stated, We're supposed to go down to find our resident so we know where they are because a lot of them go to activities and therapy grabs them. When asked what happened on 9/24/17 the day Resident #101 was found outside, CNA #2 stated, On that particular day I did not see (name of resident (Resident #101)). I was on my lunch break and I came back around 2:00 (p.m.) and I thought she went down to activities because that was her usual routine. That's what I told the next person when they came in. When asked if she had seen Resident #101 after her lunch break until the time she went home, CNA #2 stated, No. When asked about Resident #101's normal routine, CNA #2 stated, She'd get up and get dressed, watch TV. She'd read her book. Therapy would get her a couple times a day. She'd go to activities. She was always around. She was alert and oriented. When asked if Resident #101 usually went outside, CNA #2 stated, No. When asked if she cared for the resident 9/23/17, CNA #2 stated she had. When asked if Resident #101 had been outside that day, CNA #2 stated, Not that I know of. The only time I heard she'd go outside was when her grandson would come. When asked if many residents went outside, CNA #2 stated, No. Not many. Most sit at the desk or in their room. She (Resident #101) was the only one who could get around by herself. When asked if there was a way staff would know if a resident outside needed help, CNA #2 stated, I'm going to say not that I'm aware of. When asked about the normal routine for checking on residents, CNA #2 stated, Now it's every fifteen minutes if outside. Before that (incident of 9/24/17 with Resident #101) I'd go around to do showers for them (the residents) and then I take them down to lunch and of course bring them back after lunch. When asked if prior to the 9/24/17 incident with Resident #101 could the residents go around on their own without being checked, CNA #2 stated, Honestly, yes. When asked what the resident was wearing on 9/24/17, CNA #2 stated, She wore a sweatshirt and some khaki pants, she always wore that. An interview was conducted on 10/5/17 at 8:40 a.m. with OSM #1, the occupational therapy assistant. When asked about Resident #101's ability to open doors from her wheelchair, OSM #1 stated, I didn't focus that much on the wheelchair. We were working to get her to use the rolling walker. The speech therapist who was looking for the resident on 9/24/17 was not available to be interviewed. An interview was conducted on 10/5/17 at 8:50 a.m. with RN (registered nurse) #1, Resident #101's 9/24/17 3:00 p.m. to 11:00 p.m. nurse. When asked about the usual routine staff followed when they came on duty, RN #1 stated, When I come here I usually make assignments out and get report from the outgoing nurse. We talk about each patient. When asked what staff did after report, RN #1 stated, I usually walk up and down and poke my head in each room. After that I hop on my med (medication) cart. When asked if she had seen Resident #101 on 9/24/17, RN #1 stated, Not in her room. That wasn't a red flag to me. She could always state her needs about what she wanted. There were a lot of families here. (Name of resident (Resident #101)) liked to go outside a lot. When asked what time she would normally have seen all of her residents, RN #1 stated, By dinner time around 5:00 (p.m.). When asked when she had seen Resident #101 that day, RN #1 stated, I did not lay eyes on her until about 4:25 p.m. (when Resident #101 was found unresponsive). When asked if the resident was capable of getting in and out of the door to the courtyard, RN #1 stated, She could always get out there but as far as I knew I think she could get in but it's hard to manage that door. When asked what she was told in report about Resident #101, RN #1 stated, I wasn't told anything. I was at my med (medication) cart and the speech therapist said 'where's (name of resident (Resident #101)). I've been looking for her for a while.' I asked (LPN #1) where she (Resident #101) was and she (LPN #1) said, 'Oh, she's outside.' LPN #1 found her and called for help. When we went over the door threshold (with Resident #101 in her wheelchair) she slid down and the girls helped her onto the floor. We put her back in the wheelchair and ran her back to her room. Her temp (temperature) was high about 105 or a little higher. When asked if there was anyone else in the courtyard when the resident was found, RN #1 stated, I don't think so. When asked what condition Resident #101 was in when she was found, RN #1 stated, Her respirations were somewhat labored because she was so hot. The cooler she got the more her respirations became steady and slower. When asked if Resident #101 was responsive before leaving for the hospital, RN #1 shook her head no. When asked what had changed since the incident, RN #1 stated the nurses did walking rounds and if the residents weren't in their rooms they had to find them. When asked what she thought of the new process, RN #1 stated, I think it's probably something we should have been doing all along. An interview was conducted on 10/5/17 at 9:10 a.m. with RN #2, the assistant director of nursing. When asked what process the aides followed for checking on residents, RN #2 stated, That would be every two hours they would check on the residents. When asked if this started at the beginning of the shift, RN #2 stated, Yes, ma'am. When asked if there was a different process on the weekend, RN #2 stated, No. When asked what staff were expected to do if the resident wasn't in their room at the beginning of the shift, RN #2 stated, The expectation is that they (the staff) go and find the resident. When asked what process the nurses followed, RN #2 stated, The nurses do report on their patients and start their shifts. When asked when the nurses were expected to see their residents, RN #2 stated, The expectation is that before they get into med (medication) pass they would have eyeballed all of their residents. When asked what nurses were supposed to do if the resident was not in their room, RN #2 stated they were to find the resident. When asked about the process staff were to follow to monitor the residents when they were outside, RN #2 stated, Honestly we did not have a process. It would have been the standard checking on your patients every two hours. When asked how a nurse would know if a resident outside needed help, RN #2 stated, That would have been on their standard two hour checks. When asked when Resident #101 would have been found if speech therapy hadn't been looking for her, RN #2 stated that the staff would have looked for the resident about that time. When asked what occurred on 9/24/17 when Resident #101 was found, RN #2 stated, I was notified of (name of resident (Resident #101)) it was about 4:30 (p.m.) I was going to open the Rose room for dinner. The housekeeper called me to come to the living room. (Name of resident (Resident #101)) was in the wheelchair in the living room. She was unresponsive. I went to get the paperwork started because I knew she was going to the emergency room . I went to her room and (name of RN #1) told me her temp was 105 and they were putting ice on her. The next morning, we started getting statements (from staff). We were trying to estimate a timeline for how long she was outside. When asked when the process changed for nurses doing walking rounds at change of shift and being expected to see each resident before med pass occurred, RN #2 stated, The immediate change would have been on 9/25 (17). When asked what the result of the investigation was, RN #2 stated, Obviously what we were doing was not effective as it might have been. RN #2 stated, Our concern was that our nurses are making walking rounds and laying eyes on our residents. If they're not in their room, then they (the nurses) are now checking on them in activities or outside. An interview was conducted on 10/5/17 at 10:35 a.m. with Resident #101. The resident was sitting in a wheelchair. She was wearing a tee shirt and a pair of pants. The resident was very alert. When asked what she remembered about 9/24/17, Resident #101 stated, I was sitting out there (in the courtyard) reading and I had an arrangement at 3 o'clock (p.m.) but she forgot. When asked what time she went outside, Resident #101 stated, About 1:45 (p.m.). When asked what happened next, Resident #101 stated, It's not easy getting over those bricks. I started screaming and yelling and no one came. I guess even with me screaming with the noise from the traffic outside and the noise inside combined, nobody could hear me. And then I knew I was slumped over in the chair and I knew I was going to faint. When asked how she felt when she was calling for help, Resident #101 stated, Panicked. I suffer from panic attacks anyway. When asked how often she went outside prior to that day, Resident #101 stated, I was out about four times when I lived here then. I was stronger then and I could wheel my wheelchair easier. When asked how she had been feeling that day before she went outside, Resident #101 stated, I was feeling a little weak. When asked if she was able to open the door to get in and out of the courtyard, Resident #101 stated, No, someone had to let me out and let me in and I told the girl (who let her out) someone was going to come get me at 3 o'clock. When asked if it was warm that day, Resident #101 stated, Yes, it was very hot. It was 90 degrees. When asked if she had been outside since she came back to the facility, Resident #101 stated, No. I've been in rehab (rehabilitation) and have to have the voya (sic.) (Hoyer lift - a mechanical lift to get a resident out of bed) to get me up. An interview was conducted on 10/5/17 at 10:50 a.m. with Resident #103. The resident had been identified as a resident who went outside on the facility's 10/2/17 plan of corrections. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, a quarterly assessment, with an ARD of 9/1/17 coded the resident as having a 12 out of 15 on the BIMS indicating the resident was moderately impaired cognitively. The resident was coded as requiring supervision from staff for activities of day living including locomotion. Review of the resident's care plan initiated on 12/15/15 and revised on 12/12/16 documented, Focus. (name of resident) has some activity preferences that seem to continue to offer her some positive feeling of self, identity, purpose, meaning despite assessed cognitive loss .going for exercise walks in the facility. Interventions. Provide one-on-one assistance as needed to provide resident success. Resident #103 was asked if she went outside, Resident #103 stated, Yes. It only takes me a full ten to 15 minutes to do my walk. Sometimes I stay out and watch them (the construction workers) working on that building (indicating across the street). When asked if staff ever checked on her when she was outside, Resident #103 stated, I've never seen that happen. When asked how she would get help if she needed it when outside, Resident #103 stated, I don't know. An interview was conducted on 10/5/17 at 11:00 a.m. with LPN #3, Resident #103's nurse. On the A and B units there was a small outside porch with wooden benches outside the door diagonally to the nurses' station. When asked how residents got back inside LPN #3 stated, They can ring the bell when they want to come in. When asked what staff did when a resident went outside, LPN #3 stated, We have residents out walking. (Name of Resident #103) likes her exercise. She goes out a couple times a day for five minutes. We are aware of it. When asked how staff would know if a resident fell or needed help when outside, LPN #3 stated, Good question. That's why we're trying to get them to sign out so we know who's outside. When asked if residents were checked when they were outside, LPN #3 stated, Now we have to check them every fifteen minutes. When asked what the process was before the change LPN #3 didn't have an answer. An interview was conducted on 10/5/17 at 12:55 p.m. with ASM #1, the administrator and ASM #2, the director of nursing. When asked when they had been made aware of Resident #101's incident, ASM #2 stated, The Monday morning (the day after the incident) when I read the 24-hour report. ASM #2 stated, I asked for them to give me the hospital admission stuff. It looked like they were working her up for sepsis. ASM #1 stated, I asked for a timeline and a statement to try to understand the circumstances from the staff statements. When asked what they did next, ASM #2 stated, It was obvious from talking to staff they did not make rounds and lay eyes on their patients. When asked what the process was for staff to check on residents, ASM #2 stated, I don't know if there's any process. Their standard was to check every two hours. When asked why they did education on 9/25/17 and then did not start education again until 10/2/17, ASM #2 stated, We started with the charge nurses and set a firm expectation that report was to be walking down the hall if (the resident) was not in their room then they needed to find them and look at them. ASM #1 stated, I think we were still trying to understand (what the issues were). When asked what the process for aides were for checking on their residents, ASM #2 stated, They do walking rounds. I've not seen them go hunting for anybody. ASM #2 stated that education for nursing staff started on 10/2/17 to put into place the new process of walking rounds for the nurses with the expectation that every resident will be seen. Residents in activities would be checked every 30 minutes and residents outside would be checked every 15 minutes. ASM #1 and ASM #2 were made aware of the concern of harm for Resident #101 at that time. ASM #1 stated, She was septic that's why she was hospitalized it wasn't heat stroke. ASM #1 and ASM #2 were informed of the concern Resident #101 was unsupervised and not monitored while outside of the facility in the courtyard, to prevent accidents and ensure safety in an environment. Resident #101 was outside unsupervised for 2 2 ½ hours and was unable to reenter the facility when she began to feel ill. The facility staff failed to supervise and check on Resident #101 on 9/24/17 at 3:00 p.m. as requested by the resident. The temperature was report as 89 degrees Fahrenheit (F). The resident was subsequently found at 4:30 p.m. and the resident was transferred to the hospital and admitted to the intensive care unit. A request for a policy on resident rounding was requested of ASM #2. At 3:45 p.m. ASM #2 stated they did not have a policy on resident rounding. Review of the facility's five-point plan of corrections dated 10/2/17 documented: 1.Area of Concern: Supervision of Residents (while off of dedicated unit and/or participating in outside leisure activities. 2. Identified Area. Resident number (resident's number) returned to center on 9/30 (17). She was educated on allowing staff members to assist her needs as needed (including going outside to enjoy leisure activities) Target Completion Date: (MONTH) 3, (YEAR). How other residents at risk for related non-compliance will be identified & what corrective action will be taken. An audit of all residents will be completed to identify those who enjoy outside leisure activities .Those identified will be educated on notifying their charge nurse and safe practices while outside .Target Completion Date: (MONTH) 3, (YEAR). 3. System Changes to maintain compliance. Charge Nurses will be educated on: center practice of walking rounds and visibly locating all patients at change of shifts; communication with resident who wish to go outside the center for outdoor leisure activities and the requirements to check on those residents every 15 minutes. Nursing Assistants will be educated on: assisting residents to activities and checking on them every thirty minutes by visibly locating them in the center. assisting residents back to the units upon completion of their activities and provide assistance as needed . 4. Monitoring for effectiveness of New Systems & Compliance. Unit Managers and/or designees will observe shift change practices to ensure walking rounds are being completed. (Daily times five for four weeks, weekly times four weeks and monthly time one month). Unit manager or designees will randomly observe nursing assistants to ensure supervision and checks are provided to those residents attending activities off the unit. 5. Results of these audits will be reviewed and discussed for further recommendations during the center's monthly quality assurance program Review of the plan of corrections documented that 14 residents went outside to enjoy leisure activities. Each resident's care plan was updated as needed to reflect their desire to go outside and education about taking safety precautions when outside. Further review of the plan of corrections evidenced education was given for each resident who went outside. The plan evidenced education was completed for 88 out of 101 nursing staff for a total of 87% completion. ASM #2 stated they did not expect to obtain 100% of the staff. Review of the audits documented that the audits had been completed on 10/3/17 and 10/4/17. Observations were made of the courtyard and on 10/4/17 at 4:45 p.m. and on 10/5/17 at 9:20 a.m., 12:15 p.m. and 2:25 p.m. there were no residents observed at those times. As a result, this writer was not able to monitor staff's monitoring. An observation of the sitting area outside unit A and B was made on 10/5/17 at 10:55 a.m. A resident was sitting by the door in a wheelchair. At 11:05 a.m. the resident was inside. Based on the review of the plan of corrections and interviews with staff the facility is past non-compliance. COMPLAINT DEFICIENCY -- PAST NON-COMPLIANCE. (1) Oxygen saturation - Though the pulse oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. This (TRUNCATED)

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide supervision and safety devices to prevent accidents for three of 28 residents in the survey sample, Residents #5, #13 and #3. 1. CNA (certified nursing assistant) #1 failed to provide supervision during a transfer from the wheelchair to the toilet. Resident #5 fell and sustained a hip fracture requiring hospitalization and surgery. 2. The facility staff failed to apply Resident #13's alarm (the alarm included a string and clip attached by a magnet to an alarm box. If the resident attempted to exit the bed or chair the string and clip section would separate from the alarm section setting off an alarm to alert the staff). 3. The facility staff failed to apply the physician ordered arm protectors to prevent skin tears for Resident #3. The findings include: 1. Resident #5 was admitted to the facility on [DATE] with a readmission of 12/24/12. [DIAGNOSES REDACTED]. The most recent comprehensive MDS (minimum data set) assessment, prior to Resident #5's fall with injury, was an annual assessment, with an ARD (assessment reference date) of 10/6/12. Resident # 5 was coded as being cognitively impaired for making daily decisions. The resident was coded as requiring extensive assistance of one staff member for all of her activities of daily living and was coded as requiring extensive assistance of one staff member for transfers. Resident # 5 was coded as being occasionally incontinent bowel and bladder. In Section G0300 "Balance During Transitions and Walking" of the MDS, Resident #5 was coded as "Not steady, only able to stabilize with staff assistance" for "Moving on and off toilet." Review of Resident #5's MDS (minimum data set) assessment, a "Discharge assessment-return anticipated," with an ARD (assessment reference date) of 12/20/12, coded the resident as requiring limited assistance for transfers. Resident # 5 was coded as being occasionally incontinent of bladder and always continent of bowel. Review of the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/25/13, coded the resident as being cognitively impaired for making daily decisions. The resident was coded as requiring limited to extensive assistance of one staff member for all of her activities of daily living and requiring extensive assistance of one staff member for transfers. Resident # 5 was coded as being frequently incontinent bowel and bladder. In Section G0300 "Balance During Transitions and Walking" of the MDS, Resident #5 was coded as "Not steady, only able to stabilize with staff assistance" for "Moving on and off toilet." Review of Resident #5's care plan dated 10/12/2012 documented, "Focus: (Resident #5) requires extensive staff assistance with ADL's r/t (related to) Dementia diagnosis." Under the heading "Interventions" documented, "Supervision with transfers." Further review of Resident #5's clinical record documented: "Fall Risk Assessment" dated 4/10/12 with a score of 14.0. It documented Resident #5 as "Moderate risk" for falls. "Fall Risk Assessment" dated 12/26/12 with a score of 17.0. It documented Resident #5 as "High risk" for falls. No other "Fall Risk Assessments" were located in the clinical record for Resident #5 (Note: according to the facility policy documented below this should have been completed quarterly). Review of Resident #5's clinical record documented a "Fall Incident" dated 8/2/12. Under the heading "Description" it documented, "Writer heard resident screaming, write (sic) and CNA (certified nursing assistant) went into the room and noted resident on the floor. Observed in corner of the room near wheelchair and trash can at 6:30 p.m. Alert with confusion at the time. Noted with tremors on her hands. Noted with hematoma behind head approximately 6.0 cm (centimeters). No bleeding or injury. No bruises noted. Resident stated, 'I got up and fell .' She c/o (complained of) slight pain to her head on scale of 5/10 (five out of 10). Immediate action taken: Neurological assessment initiated, responded, MD notified immediately. New orders received to send out to ER (emergency room ) for evaluation. Injury type: No injuries observed post incident." Review of Resident #5's clinical record revealed a "Incident Note" dated 12/20/12. The note documented, "Type/Nature of Incident: Fall. 12/20/2012 Resident had a fall at 7:15 a.m., skin tear to right thumb; dressing applied; call put in to MD (medical doctor); awaiting for call back; unable to reach RP (responsible party); phone not answered." It further documented, "12/21/2012 no time, Resident toilets self with only supervision and requires no set up help." Review of the "(Name of Hospital) History and Physical" dated 12/20/12 documented, "History of Present Illness: ...according to the records, ...she fell today and started complaining. This happened around 7 o'clock in the morning, when she fell . An x-ray was done, and she was found to have a left femur neck fracture, and she was sent to the hospital for further evaluation ..." Further review of the "(Name of Hospital) History and Physical" dated 12/20/12 documented, "EXAM: CAT (computed tomography) LOWER EXTREM (extremity) w/o (without) contrast - LEFT. Impression: Nondisplaced minimally impacted left femoral neck fracture confirmed. Plan: We will admit her to the fracture care order set. Her case was discussed with orthopedic surgeon (Name of Surgeon). The plan is for the OR (operating room) in the morning. We will keep her n.p.o (nothing by mouth) after midnight ... " Review of the facility's fall investigation for Resident #5's fall on 12/20/12 revealed a facility "Associate Counseling Form" dated 12/20/12 that documented the following: ? "Name: (CNA #1)" ? "Department: Nursing" ? "Detailed Description of Incident: Failed to assist pt (patient) to bathroom resulting in resident fall." ? "Action Taken: education provided on alarms and fall risk pt. Make sure all pt have supervision with transfer to commode." ? "Associate comments: When I entered Resident's room (Name of Nurse) was assisting resident to w/c (wheelchair) and stated that resident needed to use the bathroom. I replied resident always uses bathroom herself, that's when I assisted resident to bathroom until she locked the wheels & (and) I left." An interview was conducted on 6/20/13 at approximately 10:40 a.m. with CNA #1. When asked if the statement written next to "Associate comments" on the "Associate Counseling Form" dated 12/20/12 were hers, CNA #1 stated, "Yes." When asked about Resident #5's ability to transfer for toileting, she stated, "The resident always transferred herself from the wheelchair to the toilet independently, when she finished she would pull the call bell cord and I would assist resident from the toilet to the wheelchair." When asked what she meant by assistance, CNA #1 stated, "Assistance was cleaning the resident, providing and putting a brief on her, pulled her pants up while she held onto the grab bar next to the toilet, then resident would sit herself down in the wheelchair." When asked how she knew what the procedure was for transferring resident #5, CNA #1 stated, "I was told by another aid and observations of other staff working with her." CNA #1 stated she had been working on (Name of the Unit) since September 2012. She further stated, "I know the routine for (Resident #5), I always worked with her." Review of Resident #5's ADL (activities of daily living) sheets dated December 2012 for transfers that were completed on all shifts documented: ? Four instances of Independence - No help or oversight. ? 30 instances of Supervision - Oversight, encouragement or cueing. ? 22 instances of Limited Assistance - Resident highly involved in activity; received physical help in guided maneuvering of limbs or other nonweight bearing assistance. ? Two instances of Extensive Assistance - Resident performed part of activity, weight bearing support. ? Two instances of Total dependence - Full staff performance. An interview was conducted on 6/20/13 at approximately 4:55 p.m. with CNA #3. When asked what it meant to transfer a resident with supervision, CNA #3 stated, "Cueing." An interview was conducted on 6/21/13 at approximately 9:30 a.m. with RN (registered nurse) #5, MDS Coordinator. When asked about the discrepancy in Resident #5's MDS dated [DATE] that coded the resident as requiring extensive assistance of one staff member for transfers and the care plan, reviewed six days later, dated 10/12/2012 that documented Resident # 5 required supervision with transfers, RN #5 stated, "It was an over site. Policy is to update the care plan as needed, it should have been updated." When asked what procedure is followed for updating care plans, she stated, "We follow the RAI manual." An interview was conducted on 6/21/13 at approximately 10:50 a.m. with the Director of Nursing (DON) regarding Resident #5's fall on 12/20/12. When asked what type of support Resident #5 required for transfers, the DON stated, "She required supervision." When asked what was meant by supervision, she stated, "Oversight and you would be able to leave the room and check occasionally." An interview was conducted on 6/21/13 at approximately 12:50 p.m. with OSM (other staff member) #5, Therapy Program Manager, regarding types of transfers. When asked what is meant by supervision during a resident transfer, OSM #5 stated, "Eyes only, no touching, verbal cueing." An interview was conducted on 6/21/13 at approximately 1:00 p.m. with CNA #1. When asked who locked Resident #5's wheelchair after she took the resident into the bathroom, CNA #1 stated, "I did." When asked if she assisted resident #5 to the toilet, she stated, "No." When asked if she saw Resident #5 transfer herself to the toilet from the wheelchair, CNA #1 stated, "No, when I left the bathroom I saw (Resident #5) start to pull herself up using the grab bar on the wall." When asked if she saw Resident #5 stand up from the wheelchair, CNA #1 stated, "No." On 6/20/13 at approximately 1:15 p.m., in an interview with the DON, she stated that fall assessments should be done on admission, quarterly, and as needed or after every fall. An interview was conducted on 6/21/13 at approximately 2:30 p.m. in the presence of the administrator and DON regarding fall assessment for Resident #5 from July 2012 through October 2012. The administrator stated, "We're unable to locate any." Review of the facility's policy "Falling Leaves Program" documented "1. A fall risk assessment will be completed by the admitting nurse on admission, quarterly and as needed, and will be addressed on the care plan." In "Fundamentals of Nursing" 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5. "Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Clients fall due to many factors, such as improper transfer techniques, client age, side effects of medications, impaired mobility, or confusion. Learn your agency's fall prevention program for reducing client falls. Programs that use a multidimensional approach in designing fall prevention strategies have the greatest reduction in fall rates." The Administrator and DON were made aware of the concern for harm regarding Resident #5 on 6/20/12 at approximately 6:20 p.m. No further information was provided prior to exit. 2. Clinical record review revealed, Resident #13 was a [AGE] year old female admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident as able to make herself understood and able to understand others. Her score on the Brief Interview for Mental Status was 3 out of 15, indicating she had severe cognitive impairment. She was totally dependent on staff assistance for all activities of daily living except eating and personal hygiene for which she needed extensive assistance. She had no falls since her last assessment. Resident # 13's annual MDS assessment dated [DATE] was reviewed and documented she had no falls since her last assessment. Her care plan dated 6/5/13 identified risk for falls due to unaware of safety needs, decreased functional mobility and inability to transfer independently as a focus. There were several interventions including bed and chair alarm. Resident #13 was observed on 6/18/13 at 3:45 PM, and on 6/19/13 at 8:45 AM, 10:30 AM and 2:20 PM. She was observed in bed and in a chair. There was no alarm on her bed or chair. A physician's orders [REDACTED]. There were no nurse's notes explaining why the alarm was discontinued. On 6/20/13 at 8:15 AM, the unit manager Licensed Practical Nurse (LPN) #1 stated the resident should have an alarm on her chair and bed. LPN #1 stated the alarm was discontinued from the physician's orders [REDACTED]. She said the alarm was included as an intervention on the resident's care plan. On 6/20/13 at 11:25 AM, Certified Nursing Assistant (CNA) #12 stated the resident did not use an alarm. She said the interventions which were in place for Resident #13 were on the care card taped to her closet door. An alarm was not listed on the card as an intervention. The care card was last updated on 1/4/12. CNA #12 stated it should be updated because her transfer needs had changed. On 6/20/13 the assistant director of nursing observed resident #13 and stated she did not have an alarm on her chair. She said the alarms were being discontinued from the physician's orders [REDACTED]. She said she would check if the alarm intervention was documented in the resident's care plan. On 6/20/13 at 1:10 PM, LPN #1 stated Resident #13 needed an alarm. She stated she saw that the resident did not have an alarm applied to her chair. LPN #1 stated the care cards were no longer used. On 6/20/13 at 6:55 PM, this concern was shared with the administrator, the director of nursing, the assistant director and the assistant administrator. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, dated 4/19/13 coded the resident as having both short and long term memory problems. The resident was coded as being severely impaired to make cognitive daily decisions. Resident #3 was coded as requiring extensive assistance of one to two staff members for bed mobility, dressing and eating. She was totally dependent on the staff for transfers from one surface to another, toileting needs, personal hygiene and bathing. The resident was incontinent of both bowel and bladder. In Section B - Hearing, Speech and Vision, Resident #3 was coded as being highly impaired to see in adequate light. The resident was observed in her room on 6/19/13 at 8:40 a.m. Resident #3 was in her bed with pads on the side rails, both floor mats were down on either side of the bed. The resident had on a long sleeve shirt. There were no arm protectors visible. The resident was observed at 9:10 a.m. being fed by a staff member, there were no arm protectors visible. Resident #3 was again observed at 10:30 a.m. in bed with the head of the bed elevated, no arm protectors were visible. Incontinence care was observed at 11:10 a.m. Resident #3 had leg protectors on but no arm protectors on. Resident #3 was observed at 2:20 p.m. in bed, asleep on her back, her sleeves were observed halfway up her arm, no arm protectors were on. On 6/20/13 at 8:38 a.m., Resident #3 was observed in bed, floor mats down, alarm on, with her call bell in reach. The resident had on a short sleeve shirt with no arm protectors on. On 6/20/13 at 11:15 a.m. Resident #3 was observed in her chair by the nurse's station with her arm protectors on. The physician orders, signed by the physician on 6/11/13, documented, "Geri sleeves (arm protectors) to bilateral arms, remove for bathing, every shift, every day." The comprehensive care plan dated, 2/21/12 and revised on 2/19/13, documented, "(Resident #3) is a skin tear on her Rt (right) outer ankle and Lt (left) elbow with potential for impairment to skin integrity r/t (related to) decreased mobility, poor safety awareness, fragile skin, fungal rash to Rt breast, rash under both breast." The "Interventions" documented, "Skin observations." Review of the Resident "Kardex" in the computer, documented, "Dressing: geri sleeves to arms and geri legs to BLE (bilateral lower extremities); remove for bathing." An interview was conducted with CNA (certified nursing assistant) #8 on 6/20/13 at 8:56 a.m. When asked how a CNA finds out how to care for a resident, CNA #8 stated, "The nurse or the therapy department let us know what to do. Therapy will give us an in-service on any equipment that the resident might need or special transfer techniques for that resident." When asked if she gets pulled to another unit, how does she find out how to care for residents, CNA #8 stated, "The CNAs or nurses tell us what they need." CNA #8 returned five minutes later and stated, "There's a sheet of paper inside the closet door and it's on the kiosk." An interview was conducted with CNA #9 on 6/20/13 at 9:05 a.m. When asked how she finds out how to take care of a resident, CNA #9 stated, "I believe it's in the care card book." When asked about inside the closet, CNA #9 stated, "No, we don't do that anymore." CNA #9 could not locate a care card book on the unit. An interview was conducted with LPN (licensed practical nurse) #2 on 6/20/13 at 9:08 a.m. When asked if the facility uses a care card system that informs the staff how to care for a resident, LPN #2 stated, "I've not seen anything here for that." An interview was conducted with CNA #2 on 6/20/13 at 9:10 a.m. When asked how she finds out how to take care of a resident, CNA #2 stated, "On the sheet of paper in the back of the closet door." An interview was conducted with CNA #9 on 6/20/13 at 9:14 a.m. When asked how a staff member finds out how to take care of a resident, CNA #9 stated, "On the kiosk (computer screen on wall) and we get report from the other CNAs." An interview was conducted with the unit manager, LPN # 8 on 6/20/13 at 9:18 a.m. When asked how the CNAs learn how to care for a resident, LPN #8 stated, "It's in (name of computer program) in the Point of Care section. The Kardex directly linked to the care plan." When asked if there are any other ways the staff determine how to care for a resident, LPN #8 stated, "They get report from the nurses and other CNAs." The administrative team was made aware of these findings at the end of the day meeting on 6/20/13 at 6:35 p.m. A copy of the facility policy for following physician orders [REDACTED]. An interview was conducted with the director of nursing, administrative staff member (ASM) #2, on 6/21/13 at 8:12 a.m. When asked how the staff knows how to care for a resident, ASM #2 stated, "They are verbally told by the nurses and other CNAs. It's in the care plan." When asked if the CNAs have access to the care plan, ASM #2 stated, "No." ASM #2 stated, "They are instructed during report." When asked if the CNAs receive report every day, ASM #2 stated, "Only if there is a change in condition." When asked where it is documented for the staff to know how to care for a resident, ASM #2 stated, "I will get back with you." On 6/21/13 at 9:55 a.m. registered nurse (RN) #7, the assistant director of nursing, informed this surveyor that the "CNAs have access to the Kardex through point of care." In "Fundamentals of Nursing" 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 419. "The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]."

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure one of 18 residents, (Resident #210), received the proper care and services to prevent the development of pressure ulcer. For Resident #210, the facility staff failed to assess and implement interventions to prevent the development of a pressure ulcer. On 7-23-12, 3 days after her admission to the facility, Resident #210 was identified as having a Stage II pressure ulcer on the left lateral heel. The National Pressure Ulcer Advisory Panel defines a pressure ulcer, stage II, as follows: Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. The findings included: Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record was initiated on 7-26-12. The admission MDS (minimum data set) was in progress and not available for review. The Nursing Admission Assessment was not completed upon the resident's admission to the facility and was also unavailable for review. Review of the hospital documentation contained in the clinical record revealed the resident was hospitalized from 7-14-12 until her admission to the facility on [DATE]. Review of Resident #210's clinical record revealed a history and physical completed on 7-23-12 and signed by the physician which documented the following information: "C/C (chief complaint): admitted for skilled care. HPI (history of present illness): 85 yr (year) old lady lady (sic) PMHx (past medical history) listed admitted /c (with) AMS, worsening of dementia, exhibiting worsening her ADL (activities of daily living), CT (computerized tomography) of brain no acute change, X-ray of wrist has fracture of L hand (radio-ulnar)/scaphoid s/p immobilization, U/A + (positive) glycosuria, s/p IV hydration, empiric antibiotic Rx (treatment) for pneumonia although doesn't show obvious infiltration considering hypoxemia-atelectasis. Past Medical History: [MEDICAL CONDITION](hypertension) CAD ([MEDICAL CONDITION]) OA ([MEDICAL CONDITION]) of knee s/p TKR (total knee replacement) Medications: see POS (physician's order sheet) Physical Findings: ...Integumentary (skin): pulses ++; Musculoskeletal: L hand thumb spica... Assessment & Plan: 1-Worsening Dementia, 2-Metabolic [MEDICAL CONDITION], 3-HTN, 4-CAD OP: -PT (physical therapy)/OT; CBC, CMP, TSH, HgBA1c; B12 (laboratory tests); X-ray of L wrist in 2 wks (weeks); pain mgt (management) if needed" On 7-26-12 at approximately 2:30 p.m. this surveyor observed wound care provided to Resident #210 by LPN #2, the wound nurse. LPN #2 stated, "She (the resident) came in (to the facility) with an intact blister on the left lateral heel." LPN #2 identified the blister as a Stage II pressure ulcer. The blister was observed on the heel of the left foot and extending to the lateral side of the heel. The blister was observed filled with fluid, the skin was intact and no drainage was present. The ulcer on the heel itself was observed to have a centrally located area, slightly smaller than the size of a dime, which had a pale whitish pink center surrounded by a slightly darker pink border. The lateral edge of the ulcer was observed to have a small darker area which appeared more purple in nature than the rest of the wound. LPN #2 measured the wound to be 4.0 cm (centimeters) x 4.5 cm and stated, "The fluid has spread a little more toward the back of the heel...more lateral." LPN #2 was observed to provide wound care in accordance with a telephone order dated 7-23-12, not yet signed by the physician. A review of the hospital records contained in Resident #210's clinical record failed to reveal any documentation of a pressure ulcer or blister on the left heel. A hospital discharge summary was not located in the clinical record. On 7-26-12 at approximately 10:52 a.m. a copy of Resident #210's admission assessment and interim care plan was requested from ASM (administrative staff member) #1, the administrator. The interim care plan was not available and could not be provided. However, a care plan was provided at 12:10 p.m. and reviewed. A review of Resident #210's care plan revealed a focus area with the following documentation: "Actual Decline in Skin Integrity d/t (due to) decreased mobility, fluid filled blister to (L) (left) lateral heel..." The following interventions were documented: "float heels on pillows while in bed intermittently, skin prep to (L) lateral heel." The date initiated for both the focus area and the interventions was documented as 7-23-12. On 7-26-12 at 3:10 p.m. ASM #2, the director of nursing was interviewed regarding completion of the admission assessment. ASM #2 indicated it was her expectation that the admission assessment would be completed upon a resident's arrival on the unit. ASM #1 elaborated further, "Especially the critical assessments like vital signs, level of cognition, skin assessment..." ASM #2 stated, "Before you can provide care you need to know." A copy of Resident #210's admission assessment was again requested. On 7-26-12 at 3:30 p.m., LPN #2 provided this surveyor with a copy her wound progress note from observations earlier the same day. LPN #2 was asked to confirm that she had indicated Resident #210 was admitted to the facility with the left lateral heel pressure ulcer, LPN #2 indicated this was correct. LPN #2 was then asked what the facility did for the pressure ulcer between the time the resident was admitted on [DATE] and the time she completed her body audit and implemented treatment on 7-23-12. LPN #2 stated, "I need to look at the nursing admission assessment." LPN #2 was asked to get back with this surveyor. LPN #2 did not get back to this surveyor with a response. On 7-26-12 at 4:00 p.m., ASM #1 advised this surveyor, "There was no nursing admission assessment completed on admission." On 7-26-12 at 4:35 p.m. an interview was conducted with LPN #5. LPN #5 indicated she had admitted Resident #210 to the unit on 7-20-12. When asked about the admission assessment for Resident #210, LPN #5 stated, "I did a progress note...No, I didn't complete the admission assessment." LPN #5 indicated she was presently working on completing all the assessments for Resident #210's admission. When asked how she could recall that information, LPN #5 stated, "My Notes." After reviewing her notes, LPN #5 was asked to recall if Resident #210 had areas of concern regarding Resident #210 feet or heels, LPN #5 indicated the feet were "scaly" but did not identify any areas of concern. On the morning of 7-27-12, a request was made of ASM #1 to provide this surveyor with any documentation that the pressure ulcer on the left lateral heel of Resident #210 was present upon her admission to the facility. On 7-27-12 at approximately 11:40 a.m. ASM #1 provided this surveyor with a copy of the information received from the hospital upon the resident's admission to the facility. It was shared at that time this appeared to be the same documentation contained in the clinical record and had been previously reviewed by this surveyor. ASM #1 was advised that no documentation could be located in these records referencing a heel wound or pressure ulcer. Further review of Resident #210's clinical record revealed the following information: Resident #210's clinical record contained a "Progress Note" dated 7-21-12 at 02:49 (2:49 a.m.) which documented the following information: Pt. (patient) arrived via stretcher from (Name of Hospital)...Pt. arrived at 6pm..." This information was documented by LPN (licensed practical nurse) #5, the admitting nurse. The "Skilled Progress Note" also completed by LPN #5 dated 7-21-12 at 02:59 (2:59 a.m.) documented the following information in Section T, "Additional Nurses Notes": "Patient...with no c/o (complaints of) pain...nursing staff turned and repositioned & completed adl (activities of daily living) care throughout the shif (sic) (shift)." Section G of the skilled progress note, "Skin Condition", contained the following words noted with a box beside each word(s), "1. Skin intact; 2. Skin Tear; 3. Abrasion; 4. Surgical Wound; 5. Stasis ulcer; 6. Laceration; 7. Rash; 8. Bruise; 9. Pressure ulcer; 10. Non-pressure ulcer; 11a. Not assessed 11. Other." Section G of this skilled progress note was noted without any "check" marks to indicate the skin assessment was completed or any areas of concern were identified. Resident #210's clinical record contained a "Braden Scale for Predicting Pressure Ulcer Risk" form which was completed on 7-21-12 at 07:09. Resident #210 was coded as scoring a 13, indicating a moderate risk for pressure ulcer development. This assessment was completed by LPN #6. The Skilled Progress Note dated 7-21-12 at 10:39 a.m., did not document any information in Section G, "Skin Condition"; this section was without any "check" marks to indicate a skin assessment was completed or any concerns were identified. The Skilled Progress Note dated 7-22-12 at 04:44 (4:44 a.m.) documented in Section G "Skin Condition", "11. Other: left wrist fracture." There were no additional "check" marks to indicate any other areas of concern relating to the condition of Resident #210's skin. The Skilled Progress Note dated 7-22-12 at 13:26 (1:26 p.m.) did not document any information in Section G, "Skin Condition"; this section was without any "check" marks to indicate a skin assessment was completed or any concerns were identified. A "Body Audit" was completed by LPN #2, the wound nurse, on 7-23-12 at 15:13 (3:13 p.m.). The following information was documented on the Body Audit form: "Identify areas of wounds, brusing (sic) (bruising), skin tears, redness, spongy areas: Site: 50) Left heel; Description: Intact fluid filled blister to (L) lateral heel, measures 2.5 cm (centimeters) x 4 cm. Onset of Areas: C2. Identify which areas are new by #: treatment implemented. admitted [DATE]." A corresponding progress note was also located in the clinical record dated 7-23-12 at 15:23 (3:23 p.m.). The progress note documented the following statements: "Resident s/p (status [REDACTED]. Skin assessment as follows: ...Stage II pressure ulcer, fluid filled blister, to L lateral heel, measures 2.5 cm x 4 cm. Treatment implemented. Heels floated on pillows..." Resident #210's clinical record contained a telephone order sheet dated 7-23-12 and completed by LPN #2 documented the following order: "...Skin prep to (L) lateral heel, blister, q shift; float heels on pillows while in bed intermittently." On 7-27-12 at approximately 4:30 p.m., the concern was shared with the administrator that no documentation had been provided to indicate that Resident #210 was admitted to the facility with a pressure ulcer on the left heel. The concern was also shared that the pressure ulcer on the left heel was first identified as a Stage II on 7-23-12, three days after the resident was admitted to the facility, after a body audit was completed by the wound nurse. ASM #1 was asked to provide any additional information regarding this concern. A copy of the facility policy entitled "Admission Procedures: Professional Staff Duties" was provided on 7-27-12. The policy documented the following information: "Procedure: 6. Do a complete head-to-toe assessment and document findings on the Nursing Admissions Assessment form.; Documentation: A. Complete the Nursing Admission Assessment in EMR (electronic medical record). Do not leave anything blank! B. Contact the attending physician and obtain admission orders [REDACTED]." A review of the facility policy entitled "Braden Scale and Skin Risk Factors & Interventions Form, Use of" documented the following information: "2. After completing the Braden Scale at admission...the Skin Risk Factors & Interventions form will be completed by the licensed nurse and serve as a part of the interim plan of care." A review of the policy entitled "Pressure Ulcer Committee" revealed the following information: "Policy: This facility is committed to providing care to our residents in order to prevent development of or worsening of pressure ulcers if at all possible. Procedure: Responsibilities: To assure that all measures are taken to prevent pressure sores, that pressure sores are reported early, that proper evaluation of pressure sores occurs and that proper treatment modalities...are occurring as indicated." No additional information was provided prior to the end of the survey.

Based on observation, resident interview, staff interview, clinical record review, facility document review, and during the course of a complaint investigation, the facility staff failed to ensure two of 40 residents of the survey sample (Resident #'s 28 and #15 were provided supervision to prevent injury and potential injury from unsupervised smoking. The facility failed to ensure they consistently implemented their own no smoking policy. Resident # 28 was smoking unsupervised at the facility and sustained third-degree burns to his lower extremities and hand after dropping a lit cigarette on himself. Resident #15 was observed during the survey outside the facility smoking in an obscured area without staff supervision. Resident # 15 was status left below the knee amputation, was coded as requiring extensive assistance for transfers and supervision for propelling in her wheelchair. The clinical record documented the resident's non compliant smoking behaviors but did not evidence Resident # 15 had been assessed as safe to smoke unsupervised. The findings included: 1. On 6/3/11 A "Facility Reported Incident" (FRI) was received at the office of Licensure and Certification that documented the following information regarding Resident #1: " Resident was attempting to smoke outside (unattended) and dropped a lit cigarette on his pants. His pants caught fire and caused burns to his lower extremities. Resident sent to emergency room for evaluation. " Resident #28 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most current minimum data set (MDS) was an initial/admission assessment dated [DATE] which coded Resident #28 as having no cognitive impairment (cognitive score of 15). Resident #28 was coded as requiring extensive assistance with the physical help of one staff member for transfers, dressing, and hygiene. Resident #28 was coded as having range of motion impairment on one side in both the upper and lower extremities (Section G0400 Functional Limitation in Range of Motion). Resident #28 was non-ambulatory. Further documentation on the MDS revealed Resident #28 was coded under "Other Health Conditions" Section J1300 Current Tobacco Use as #1, indicating "Yes". Under " Section G 0300- Balance During Transitions and Walking " Resident #28 was coded as A. Moving from seated to standing position- (2) Not steady, only able to stabilize with human assistance, B. Walking (2) Not steady-Only able to stabilize with human assistance, C. Turning around (2) Not steady- only able to stabilize with human assistance, D. Moving on and off toilet (2) Not steady- only able to stabilize with human assistance, and E. Surface to surface transfer (2) Not steady- only able to stabilize with human assistance. Resident #28 no longer resided in the facility. The Resident was discharged to an acute care hospital on [DATE]. The facility "Tobacco-Free" policy was reviewed. This policy evidenced the following: "(name of corporation and facility) are committed to promoting good health to our employees, residents/patients and to the communities which we serve. In support of this commitment, we are now tobacco-free inside all Centers and outside premises including surrounding grounds, sidewalks, and parking lots, both owned and leased. This also includes all company vehicles. Tobacco products are defined as: cigarettes, cigars, pipe tobacco, all smokeless tobacco products, such as chewing tobacco and snuff, other devices i.e. electronic vapor kits. This policy applies to employees, volunteers, vendors, physicians, students, residents/patients, visitors. Failure of any resident/patient to abide by this policy may result in being discharged as a safety hazard to others. Adherence to this policy is a condition of employment for all staff. Employees should not trespass on any surrounding properties, but especially for the purpose of using tobacco products. Employees who choose to use tobacco products during their assigned workday must do so on their own time and leave the premises to do. Employees who are in violation are subject to corrective action. Every effort will be made to assist employees with resource materials and guidance toward smoking cessation during the correction action process. It is everyone's responsibility to promote the tobacco-free environment and encourage follow employees, visitors and residents/patients in this health issue." On 6/15/11 at 11:35 a.m., the facility administrator stated the smoking policy had been in effect since the corporation had purchased the property which was over two years ago. The residents closed record was reviewed. Documentation in the record evidenced when Resident #28 was admitted to the facility originally on 1/21/11, the following was documented: Nurses Notes entry dated 1/22/11: ..."Patient requested to go have a smoke outside but offered to give patient a nicotine patch since facility was smoke free campus and patient refused saying "I have tried all that before and it made me get bad thoughts I even shot myself a couple of times. When I was admitted I was told that I could smoke." Supervisor notified and goes in to speak with patient. Some minutes after patient was allowed to go out to smoke...at 9:15 p.m. patient requested to go out for another smoke. Supervisor notified again and says will address..." On 1/24/11 9:00 p.m. "...Patient was found outside smoking at about 5:10 p.m. Smoking alone without any staffs knowledge. Patients nurse went out to talk to patient with reinforcement on facility's policy on smoking being prohibited. Patient stated "I was told before getting admitted and when I got here that I could smoke and now everyone is flip-flopping me." Nurse assists patient back into facility after patient finishes smoking since patient became verbally abusive and uncooperative saying "I am going to finish this smoke anyway." Nurse notifies supervisor who goes into room to talk to patient. Patient agrees to try a nicotine patch that is of the highest dose..."On 1/23/11 at 9:30 p.m., "...Patient requested for a smoke time. Supervisor notified and says will take care of issue. Patient continues to be monitored after having been allowed to go and smoke..."On 1/25/11 12:05 p.m., "...Resident states, "If I go out the side door and smoke could you stop me". Resident informed of facility non-smoking policy, and encouraged not to leave the unit..." On 2/10/11 at 5:30 a.m. "Patient asked nurse "Where do you go to smoke?" Nurse informed patient he cannot go outside or smoke. Patient was non-compliant, put on jacket and exited facility via ambulance doors, smoked and returned to facility /p (after) cigarette was finished. Facility management notified at 6:00 a.m...." There was no "care plan" found in the record from this admission that addressed these issues, behaviors of compliance or smoking. There was no smoking assessment found which evaluated the residents ability to smoke unsupervised safely. The resident was discharged home from the facility on 2/19/11 after completing therapy as a result of sustaining a hip fracture. There was no documentation evidenced in the clinical record the facility held any care plan meetings with the resident regarding his non compliant smoking behaviors nor was there any documentation a 30 day discharge notice was issued for the repeated violations of the facility smoking policy. Documentation contained in the closed clinical record revealed Resident #28 was readmitted on [DATE] and the admission Nurse's Note documented, in part: "...Patient re-oriented to smoking policy and verbalize understanding..." The "Nursing Admission Assessment also dated 5/18/11 at 6:45 p.m. evidenced "Personal Habits: Smokes- Yes". On 5/19/11 it was documented, "...Resident reminded of facility smoking policy...", and on 5/22/11, "...Resident given facility smoking policy reinforcement, nicotine patch in place at this time..." On 5/27/11 at 9:00 a.m. was documented "Educated pt (patient) on safe smoking and facility policy that he could not smoke. Pt verbalized understanding. New order to D/C (discontinue) nicotine patch. RP (responsible party) made aware. This entry was signed by Licensed Practical Nurse (LPN) #5. On 5/31/11 the "Nurse's Notes" documented, "9:00 a.m. Educate pt (patient) on safe smoking that at this facility he cannot smoke. Pt states understanding and will not smoke." Entry signed by LPN #5. The "Care Plan" for Resident #28 was reviewed. The "care plan" evidenced , "5/19/11- Self Care Deficit- Requires assistance R/T (related to): High risk for falling R/T poor safety awareness- is capable of performing few ADL (activities of daily living) tasks, combing hair, brushing teeth, washing face." On 5/20/11 there was a "Safe Smoking- Cessation of Smoking care plan" which documented, "5/20/11- Resident desires to stop smoking with MD and staff assistance." On 5/27/11 another entry documented, "Non-Compliant /c (with) smoking- Resident will follow smoking policy through next 90 days- Educate risk of smoking with patch, D/C patch 5/27/11, 5/31/11 re-educate on smoking policy, 6/1/11 educated on smoking policy." The surveyor was unable to locate any assessment in the clinical record as to whether Resident #28 was safe to smoke independently and unsupervised. A document "Area of Concern" dated 6/1/11 documented, "non-compliant with smoking- Recommendation/Interventions: Educate on policy". On 5/20/11, the "Social Service Progress Notes" documented, "...Resident has a history of smoking a pack a day at home. He is prescribed a nicotine patch and has been educated on smoking policy..." And on 6/2/11, "...He continues to be educated on smoking policy. Resident in agreement with policy however continues to be non-compliant. Will set up family meeting with resident and family..." A "Nurse's Note" on 6/3/11 read as follows: " 6/3/11 at 5:20 a.m., Resident outside smoking. Dropped lighted cigarette on clothing-burn to both knees and areas around knees- Call to 911- page to MD (physician)." Entry signed by Registered Nurse (RN) # 3. Further "Nurse's Notes" documented that at 5:30 a.m. the Responsible Party was made aware and at 6:00 a.m., "Resident transferred to (name of hospital) by stretcher..." Signed by RN #3. Records obtained from the local acute care hospital which treated Resident #28 evidenced an "emergency room Physician's Report" dated 6/3/11 which documented, "...Burn- left foot- degree of burn 2nd and 3rd degrees, burn- left lower leg- degree of burn 2nd and 3rd degrees, right third finger- degree of burn 2nd degree, right fourth finger- degree of burn 2nd degree, right index finger- degree of burn- 2nd degree, right knee- degree of burn 2nd and 3rd degrees." The "History and Physical" dated 6/3/11 documented, "...He is a resident at (name of facility). Was out smoking a cigarette, caught his sweat pants on fire, was able to get himself out of his wheelchair and roll on the ground. Personnel at (name of facility) also came to assist and were able to put out the fire. He presents with second and third degree burns to most of the left leg, a little bit to the right knee area and a little bit on the tips of the 2nd and 3rd fingers on the right hand..." The history and physical also documented, "...He has left facial weakness, left arm weakness with paralysis and contracture of the left arm and has had a preexisting left leg weakness and paralysis secondary to both a stroke but also prior to that due to a gunshot injury...At this point in time approximately 10% of total body surface area burn to the left leg, right knee and right tips of fingers mostly second and third degree. Would recommend at this point in time, transfer to the _____ Burn Center. I have discussed this with (name of hospital burn center) and he will be transferred directly to their step-down unit..." On 6/15/11 the surveyor obtained documents from the "burn center" at which Resident #28 was treated after transfer from the acute care hospital. These documents evidenced, "Burn Surgery Admission H&P (History and physical): ...He sustained third degree burns to his left leg and right knee when his clothing ignited from a dropped cigarette...He required excision of his burns in the operating room to prevent [DIAGNOSES REDACTED] (compression of nerves, circulation and tissue in an enclosed space that can result in tissue death- Tabers Cyclopedic Medical Dictionary 2007 page C6) and infection...wheelchair dependent was smoking while on a wheel chair at a nursing home in (Virginia) this morning and dropped a lit cigarette in his sweat pants unknowingly catching his sweat pants on fire. According to the patient his pants were in flames and took a while before it was extinguished..." On 6/16/11 at 9:35 a.m., LPN #5 stated, "We were aware he was going out to smoke. We had educated him several times on the smoking policy that we were smoke-free, but he continued to violate the policy. We discontinued the nicotine patch because he continued to smoke and it was hazardous for him to wear the patch and smoke. He had expressed his understanding of the policy on numerous occasions, but continued to be non compliant. We think his family was providing the smoking materials. When he was caught, we would confiscate the smoking materials....I documented reeducating him on the policy when he was caught smoking..." On 6/16/10 at 9:30 a.m., Certified Nursing Assistant (CNA) # 10 stated, "I really never was assigned to care for him (Resident #28) but I knew he was going outside to smoke..." The CNA who was assigned to Resident #28 on the date the burns occurred was unavailable for interview, however a written statement dated 6/3/11 documented the following, "This morning resident (name of Resident #28) asked if I would help him into his chair and push him to the double doors...he asked me to give him 10 (ten) minutes I said okay that I would. Between 5-7 minutes I went to return (name of Resident #28) to his room, When I got to the door I smelled smoke I opened the doors and the resident was on the ground...when I got to him his pants were still smoldering. As I reached the resident he asked me to 'just get me up and let me finish my cigarette'. I explained to the resident that I couldn't that I needed to go and get help...this incident occurred between 5-5:30 a.m. today..." Signed by CNA # 2. On 6/16/11 at 11:15 a.m., LPN # 6 was interviewed. LPN #6 was on duty the morning of 6/3/11 when the incident with Resident #28 occurred. LPN #6 stated, "I was getting ready to do my med-pass and the CNA yelled for me to come real quick. I followed her out and the resident was laying on the ground. He had come out to smoke and burned himself. I at first thought the places on his knees was where he had fallen from the chair, but after assessing him I realized they were burns...I was aware that he smoked, I had been told. You would know because he smelled like smoke when he would come in from outside. He had problems here in the past over smoking..." On 6/16/11 at the end of day meeting with the facility interim administrator, Director of Nursing and Corporate personnel (Administrative Corporate staff #'s 1, 2, 3,4 and 5) at 5:00 p.m., the surveyor discussed the findings and the concern of harm sustained by Resident #28 as a result of the unsupervised smoking. When interviewed regarding why the facility readmitted Resident # 28 given his non compliance with the facility smoking policy during the previous admission, the DON and interim administrator simply stated he had agreed to abide by the non-smoking policy and signed the papers on admission. On 6/17/11 at 7:00 a.m. RN # 3 stated, "He (Resident #28) had these behaviors (smoking) prior and it was kind-of a "notice me" attention thing. We had to remind him not only about smoking but other things as well. When he was caught smoking we would take his smoking materials and search his room, but he would get more, I think from his family. The day this happened I was in a room drawing blood and I heard the nurse yelling for me, she was literally shaking telling me he (Resident #28) was outside burned. By the time I got there they already had him back in the wheelchair and he was smoking another cigarette! The nurse took it from him...He acted like he didn't care and said for me to go to his room and get him some clothes that he was staying out and smoking...he had told the CNA he wanted fresh air and she let him out...he had a "Bic" lighter and he said he stole them from his mother...from the time he was readmitted he was doing these behaviors...he said it was his fault and that he was sorry..." The surveyor inquired as to what the documentation meant, when in the nurse's notes it referred to "educating" the resident regarding the smoking policy. RN #3 stated, "That means he was smoking...when he would come back in you could smell it...he was offered smoking cessation and patches and even counseling which I talked to him about and the nicotine gum...he refused..." On 6/17/11 at 10:20 a.m., Other Staff #2 (facility social worker) was interviewed. OS #2 stated, "We were aware he was smoking unsupervised. It came to our attention and we went over the smoking policy with him several times and he said he wouldn't do it again and said he was agreeable to following our policy. We offered the patch but it was discontinued because he was smoking while using and it was hazardous for him. I was going to set up a meeting with him and his (RP) to discuss the issues but never got the chance because the incident occurred...he was observed several times by staff smoking unsupervised and we would confiscate the smoking materials and search his room...we were not sure where he was getting his smoking materials...I was personally aware of his smoking on two occasions and was going to have a meeting with him and his family..." According to information provided by the facility interim administrator and director of nursing on 6/17/11 at 12:10 p.m., immediately after the incident the facility met with the Fire Marshall, reviewed the resident's chart, reviewed the admissions policy and discussed the situation in the Interdisciplinary team meeting to identify other residents. The Resident #28 was interviewed over the phone and employees involved were interviewed and statements were taken. The incident was referred to the corporate risk management and the facility submitted the FRI. The staff were inserviced again regarding the smoking policy. The facility Director of Nursing and administrator stated that the facility was non-smoking and that when residents were admitted they or the RP signed an agreement that they would abide by the facility rules, one of them being the non-smoking policy. When asked about the readmission of the resident after the repeated non compliance with the smoking policy during the first admission, the DON stated that he had agreed to comply with the non-smoking policy on the readmission. The administrator stated that there was no audit done at that time for other residents who may have these non-compliant smoking behaviors. On 6/17/11 at 2:50 p.m. the issues were again reviewed with the Administrative/Corporate staff #1 and 2 and the concern of harm for Resident #28 was discussed. COMPLAINT DEFICIENCY 2. Resident # 15 was status left below the knee amputation, was coded as requiring extensive assistance for transfers and supervision for propelling in her wheelchair. The clinical record documented the resident's non compliant smoking behaviors but did not evidence Resident # 15 had been assessed as safe to smoke unsupervised. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. amputation and peripheral vascular disease. The most current minimum data set (MDS) was a quarterly dated 5/23/11 which coded Resident #15 as having no cognitive impairment (score of 15). Under "Section E- Behavior E0200 Behavioral Symptoms and Frequency", Resident #15 was coded as displaying B. Verbal behavioral symptoms directed toward others (3) Behavior of this type occurred daily". Resident #15 was coded as requiring extensive assistance with one staff physical help for bed mobility and two staff physical assistance for transfers. Resident #15 was coded as needing supervision with one person physical assistance for dressing, eating, and personal hygiene. Resident #15 was non-ambulatory but was able to propel self in wheelchair with supervision. "Section G- Functional Status- G0300 Balance During Transitions and Walking" revealed the resident was: A. Moving from seated to standing position (2) Not steady only able to stabilize with human assistance, B. Walking (8) Activity did not occur, C. Turning around (8) Activity did not occur, D. Moving and off toilet (2) Not steady only able to stabilize with human assistance, and E. Surface to surface transfer (2) Not steady only able to stabilize with human assistance. "Section G0400 Functional Limitation in Range of Motion" revealed: B. Lower extremity (1) Impairment on one side." According to the "care plan" for Resident #15 dated 2/16/11 and reviewed 6/2/11, the Resident was " High Risk for falls d/t (due to) unsteady gait, R/t (related to) decreased cognition and other high risk factors: S/P (status [REDACTED]. Further review of the "care plan" revealed, "Inappropriate behavior: Verbal insinuations- continues to be rude to staff and disruptive on unit: very manipulative, yells at other residents, continues to refuse care .... " On 6/14/11 at 8:00 p.m. the surveyor observed Resident #15 sitting in her wheelchair outside the double doors of the 100 unit adjacent to the nurse's station. Licensed Practical Nurse # 2 (LPN #2) noticed the surveyor looking out the door and then observed Resident #15 outside. LPN #2 went out the door and was observed talking with Resident #15. The surveyor heard a bed alarm sounding down the hall and walked down to investigate. On the way back up the hallway, the surveyor was met by LPN #2 and Certified Nursing Assistant # 1 (CNA #1) who were also responding to the alarm. The surveyor continued walking up the hallway toward the nurse's station and at approximately 8:20 p.m., again looked out the double doors and could no longer see Resident #15 outside. The surveyor looked down both hallways of the unit and did not see Resident #15, so the surveyor proceeded out the double doors to the outside of the building. Resident #15 was not seen immediately outside the building; however, as the surveyor walked toward the corner of the facility building on the right, around the corner, obscured from view (near the dumpsters) sat Resident #15 in her wheelchair. The surveyor observed Resident #15 had a lit cigarette in her right hand and was reaching with her left hand placing a pack of what appeared to be cigarettes into a back pouch on the wheelchair. The surveyor observed Resident #15 to inhale three times on the cigarette. There were no facility staff present with Resident #15. The surveyor immediately (8:21 p.m.) proceeded back into the facility through the double doors and was met by LPN # 2 who stated, "I was talking to (Resident #15) and she said she wanted to get some fresh air." The surveyor asked LPN #2 to repeat what he had said and LPN #2 stated, "She (Resident #15) was just sitting outside to get some fresh air." The surveyor informed LPN #2 that Resident #15 was around the right side of the building with a lighted cigarette smoking unsupervised. LPN #2 called for CNA #1 as he was exiting the building toward the location of Resident #15. At approximately 8:40 p.m., CNA #1 stated, "She (Resident #15) was smoking. She had a cigarette in her hand when I got to her. I have never caught her smoking. She (Resident #15) tried to tell me she was no longer skilled and that she was care-planned for it. She (Resident #15) said she knew the facility was smoke-free but needed a cigarette every now and then..." At this time, the surveyor met with a team member and informed the other surveyor of the observation and concern. Upon review of the clinical record for Resident #15 it was evidenced that on 6/8/11 in the "Patient Social Progress Notes" the following: "Spoke with Resident regarding smoking policy. Some staff have witnessed resident smoking outside. She is alert and oriented and is aware that the facility is a smoke free facility but still continues to smoke at her leisure...she was encouraged to stop smoking but she stated that this facility drove her to smoking. DON and EO (executive Officer- Administrator) made aware." Signed by Other Staff Member (OS # 1) There was no documentation in the clinical record the facility staff asked Resident #15 to surrender or to look for smoking materials in her possession. Further documentation in the "Patient Social Progress Notes" revealed: 6/9/11 "Spoke with resident regarding smoking policy along with the DON and the SSD. Resident became reluctant to having the meeting and denied ever smoking on the facility grounds. After the DON reminded her of the policy and that staff has witnessed her smoking outside on the grounds she stated that she has smoked one cigarette a day and hasn't done it lately and doesn't plan to do it again because she cannot stand everyone in her business...she seemed agitated with the fact that she was being told she couldn't smoke because during the entire conversation which lasted approximately 15-20 minutes she was yelling and was oppositional without redirection. Resident was informed that if she did not comply to the smoking policy that she would be issued a 30-day notice..." Signed by OS #1. The surveyor was unable to locate any revision or documentation on the care-plan for Resident #15 regarding the smoking and non-compliant behaviors regarding smoking. At 9:45 p.m., the facility Interim Administrator stated that Resident #15 had been placed on 1:1 supervision and the smoking materials had been confiscated. A search of the room was being conducted and all parties were being notified. The survey team informed the facility of the safety and supervision of not only Resident #15 but of all residents of the facility and their responsibility to ensure their safety. On 6/15/11 at 10:00 a.m., the surveyor interviewed OS #1 (social services director). Os #1 stated, "On 6/8, I spoke with (Resident #15) regarding the smoking policy. I made the DON aware and the next day we spoke to her (Resident #15) again. She got upset because she said we were all in her business and she denied smoking. She then agreed that she was smoking and promised not to do it again. She said she had went off the grounds but we knew that was not true. She was told then that if she continued that we would have to issue a 30-day discharge notice... It was discussed in the morning meeting." When interviewed as to the care plan-for the behaviors for Resident #15, OS #1 stated, "We do not have a smoking care plan because we are a non-smoking facility. I spoke to her and she was alert and oriented and promised not to do it again. I was told to document it in the notes. We do not care plan for smoking because we are one-hundred percent smoke free. There is no smoking care plan... " When asked as to why there was no care plan regarding the non-compliant behaviors OS #1 stated, "We do not do a smoking care plan. We are smoke-free." On 6/15/11 at 10:15 a.m., LPN # 1 stated, "I was not aware until last night that she (Resident #15) was smoking. One day last week, though, a staff member came to me and said she was smoking outside. I went out and she was just sitting there reading. I did not see her smoking. She did not have any cigarettes and she told me she didn't smoke. It was in her record that she denied smoking when she was admitted ...I would have expected to see it on her care plan that she had been seen smoking. If it were there I would have known to be watching her closely for behaviors and non-compliance and the staff would have known what to do..." On 6/15/11 at 12:00 the DON stated, "We did identify the situation and met with her (Resident #15) and she promised she would not smoke again...it has come to light that she may have wanted to get caught...I agree we did not get it on the care plan and if we had the staff would have known...She refused a psychiatric evaluation ..." On 6/15/11 at approximately 4:00 p.m. the surveyor met with Resident #15 and the DON. Resident #15 stated, "I was not smoking. Now I have to have someone following me all the time...I have a guard. Well, this was an isolated incident..." When Resident #15 was interviewed further regarding being seen smoking, Resident #15 stated, "Well I guess I've done it a few times..." On 6/15/11 at 4:50 p.m., the facility administrator stated, "We certainly only want the best for our residents. We were not aware upon admission that she (Resident #15) was a smoker, however when it came to light we did meet with her about it...we should have taken it a step further..."