Every finding on record at Carriage Inn of Cadiz

Based on funds account review, record review, policy review, and interview, the facility failed to ensure accurate accounting of a resident account. This affected one (Resident #54) of three residents reviewed for Personal Fund Accounts. The facility held funds for 31 current and former residents. The facility census was 53.Findings include:Review of Personal Funds Accounts 05/28/26 with Business Office Manager #100 revealed Former Resident #54's account was closed 05/22/26. The facility was the payee for Resident #54's social security and pension. As of 01/01/26 his personal allowance increased from 50 to 75 dollars. The account had a balance of $100.01 on 01/01/26. Review of the Resident Funds Management Service (RFMS) revealed in January of 2026 the facility allotted a 50-dollar allowance, not the new 75-dollar amount. Resident #54 was hospitalized [DATE] till 02/03/26. In February of 2026 the facility allotted the 75-dollar allowance on 02/03/26 when a social security check for $2791.00 was deposited. The resident transferred to another facility 02/09/26. On 02/20/26 $75.03 (personal allowance plus interest) was withdrawn from the account. A check dated 03/18/26 for $150.06 was sent to the resident's new facility leaving a zero balance. The facility did not send the prorated amount of social security due to the new facility to the resident's power of attorney so she could pay his portion of the bill at the new facility. Interview 05/28/26 at 3:23 P.M. with Co-Owner #104 verified the facility's third-party biller failed to provide the resident with the correct amount of personal funds due. Further verified the facility used the entire February social security check to pay the resident liability instead of sending the prorated amount to the power of attorney for her to pay the resident's new facility his liability due there. The facility was issuing checks for the shorted personal allowance and the entire February check to the power of attorney that day. Review of the facility's Resident Personal Funds policy implemented 02/21/24 included if the resident chooses to deposit personal funds with the facility, upon written authorization of a resident witnessed by a third party individual, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage and account for the personal funds of the resident deposited with the facility. This deficiency represents non-compliance investigated under Complaint Number 2808403.

Based on observation, record review, and interview, the facility failed to provide safe and secure medication storage, including proper labeling and maintaining temperatures of medication storage refrigerators, of all medications. This had the potential to affect all residents of the facility. The facility census was 51.Findings include:On 12/09/2025 at 9:05 A.M., an observation of the treatment cart in the Kerrozin medication room was performed. The observation revealed Medihoney 1.5-ounce tube which was opened, unlabeled, and undated. The treatment cart observation further revealed a Dermasyn hydrogel wound dressing 3-ounce tube which was opened, unlabeled, and undated. This was confirmed by Registered Nurse (RN) #179 at the time of the observation.On 12/09/2025 at 9:20 A.M., an observation of the medication refrigerator in the medication room of [NAME] Hall revealed the refrigerator held medications and vaccinations for residents. The temperature of this refrigerator was noted to be 60 degrees Fahrenheit (F). This was confirmed at the time of observation by RN #174.On 12/09/2025 at 10:19 A.M., a second observation of the medication refrigerator in the medication room of [NAME] Hall held Aplisol, Humalog Kwik Pens and Lantus Solostars, among other medications. Further, this observation revealed the refrigerator temperature was noted to be 50 degrees F. This was confirmed at the time of observation by Licenses Practical Nurse (LPN) #152.A review of storage instructions revealed Aplisol (tuberculin testing agent) should be stored in the refrigerator between 36- and 46-degrees F. Lantus Solostar (long-acting insulin pen) should be stored in the refrigerator between 36 degrees and 46 degrees F until it was opened. Review of storage instructions for Humalog Kwik Pen (Insulin pen) revealed the pen should be stored in the refrigerator between 36- and 46-degrees F until opened. Review of a facility form titled,Temperature Log for Refrigerator located on the [NAME] Hall medication room refrigerator, revealed twice daily temperatures for the month of December 2025. On 12/07/25, there was a temperature marked above the 46 degrees at 6:00 A.M., however no actual temperature was noted. The log revealed a temperature of 45 degrees on 12/09/25 at 6:00 A.M. This form had a section for Danger! Temperatures above 46 degrees F or below 36 degrees F are out of range. If found, write these temperatures and room temperatures below. The contents of this form were confirmed by LPN #152 on 12/09/25 at 10:23 A.M.Review of a facility policy titled, Medication Storage, dated 04/06/24 and updated 12/09/25, revealed all medications housed at the facility would be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.The policy indicated temperatures for medications requiring refrigeration were stored in refrigerators located in the pharmacy and each medication room. Temperatures were to be maintained between 36-46 degrees F. This was to be documented daily on the log by the charge nurse. In the event the refrigerator malfunctioned, the Maintenance Department would be contacted immediately.

Based on review of the facility's infection control surveillance logs and interview, the facility failed to adequately monitor for patterns of infection and provide oversight to identify the cause of identified patterns of infection. This had the potential to affect all 51 residents.Findings include:Review of the July 2025 infection surveillance logs revealed six residents had urinary tract infections (UTI), with Resident #7 being treated twice for UTI. The surveillance logs did not contain information regarding what microorganisms were involved. Review of the August 2025 infection surveillance records revealed microorganisms were not monitored. During an interview with Registered Nurse (RN)/Infection Control Preventionist (ICP) #102 on 12/11/25 at 12:13 P.M., RN #102 verified when tracking for patterns of infection, she did not monitor the microorganisms involved. RN #102 stated there had been an increase in UTIs during the summer. There was no documented plan/course of action. RN #102 stated there had been an increase in fluids provided and staff had been educated regarding perineal care. However, upon review of education records, RN #102 verified the only records she had related to hydration was dated 02/28/25 and there was no education provided related to perineal care/incontinence care since the pattern was identified in July 2025. RN #102 stated the topics were addressed during an annual education day but no records were provided.In addition, during an interview of RN #102 on 12/11/25 at 1:04 P.M., RN #102 stated there had been no audits specific to infections. After the pattern for increased UTIs was identified in July 2025, no audits of perineal/incontinence care or handwashing were completed to determine if they contributed to the increase in UTIs. RN #102 stated she was part of the Quality Assurance (QA) team and she was responsible for reporting on antibiotic use to enable the QA team to determine if any action needed taken. As part of the report, she did not address how many of the infections actually met criteria for antibiotic use.

Based on review of infection surveillance records, policy review and interview, the facility failed to ensure antibiotic orders were thoroughly researched to determine if residents met the criteria for infections, failed to ensure when criteria was not met the prescriber was informed, and failed to provide education and reports regarding antibiotic use to prescribers in accordance with policies. This affected three (Residents #7, #21 and #61) of four residents reviewed for antibiotic use and had the potential to affect any other residents for whom antibiotics were ordered.During review of the August 2025 infection surveillance reports, the following were identified:1. Review of Resident #7's medical record revealed diagnoses including secondary Parkinsonism, irritable bowel syndrome, and dementia. A nursing note dated 07/21/25 at 11:00 P.M. indicated new orders were received for a Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP) to be obtained the morning of 07/22/25 and telehealth was requesting a urine sensitivity report. The hospital lab reported a culture and sensitivity was unable to be completed from the urine sample collected 07/18/25 as a culture and sensitivity was not ordered. A new urine sample would need obtained. On 07/22/25, an order was received for Bactrim DS (antibiotic) 800-160 milligrams: one tablet twice a day for Urinary Tract Infection (UTI) until 07/27/25. Review of an infection report form revealed the criteria for UTI was not met. A notation dated 07/24/25 revealed the urinalysis and culture results were sent to a covering physician. The antibiotic was to continue. The log revealed Resident #7's infection had carried over from the July infection surveillance.An infection report form indicated Resident #7 returned from the hospital on [DATE] with a diagnosis of Urinary Tract Infection (UTI). The evaluation for whether the antibiotic use met UTI criteria was blank. Notes indicated the physician reviewed medications and confirmed he wanted the antibiotic continued.During an interview with Registered Nurse (RN)/Infection Control Practitioner (ICP) #102 on 12/11/25 at 12:13 P.M., RN #102 stated when she contacted the physician regarding continuing the antibiotic on 07/24/25, she did not recall informing the physician that Resident #7 did not meet the criteria of UTI. RN #102 reported when Resident #7 returned from the hospital on [DATE] she was already diagnosed with a UTI. RN #102 verified she did not check to see if the criteria for infection was met. There was no evidence this was discussed with the attending physician who decided to continue the antibiotic. 2. Review of Resident #61's medical record revealed diagnoses including Congestive Heart Failure (CHF) and hypertension. Review of an infection report form revealed under the area to evaluate for UTI a notation to see report. The report indicated Resident #61 did not meet the criteria for UTI. A notation on 08/04/25 revealed the physician had reviewed medications ordered upon admission on [DATE] and decided to continue antibiotics as ordered by the hospital. On 12/11/25 at 1:04 P.M., RN #102 verified Resident #61 did not meet the criteria for UTI on 08/01/25. RN #102 did not contact the physician about the criteria for UTI not being met as he had already reviewed medication orders. 3. Review of Resident #21's medical record revealed diagnoses including chronic obstructive pulmonary disease and anxiety disorder. Review of an infection report form indicated Resident #21 met one of the two criteria for UTI (culture results). However, the evaluation indicated criteria was met.Cefuroxime Axetil (antibiotic) 500 mg was ordered twice a day by mouth for ten days on 08/17/25. On 08/25/25, an order was received to change the Cefuroxime Axetil to ceftriaxone sodium (antibiotic) one gram intramuscularly at bedtime for seven days.On 12/11/25 at 1:04 P.M., RN #102 verified based on the information she had available, criteria for UTI was not met. Because she had assessed that criteria was met she would not have communicated otherwise to the physician.4. Review of the facility's Antibiotic Stewardship Program policy, reviewed/revised 12/08/25, revealed at least annually or per facility policy, each attending physician should be provided feedback on his/her antibiotic use data in the form of a written report to improve prescribing practices and resident outcomes. Education regarding antibiotic stewardship should be provided at least annually to facility staff, prescribing practitioners, residents and families.On 12/11/25 at 12:55 P.M., RN #102 stated she did not do annual training of physicians on antibiotic stewardship and did not provide an annual report/feedback to physicians on antibiotic use. RN #102 stated during quarterly Quality Assurance (QA) meetings she provided reports regarding the frequency of antibiotic use. The medical director was present at those meetings. The reports did not include information regarding how often antibiotics were utilized when criteria for infection was not met.

Based on review of medical records, activity calendars, activity logs, facility policy, and interviews with staff and residents, the facility failed to maintain an activity program specific to meet the individualized needs of Resident #40. This affected one resident (Resident #40) of one resident reviewed for the activities program. The facility census was 51.Findings include: Record review of Resident #40 revealed admission to facility on 01/23/25 for diagnosis including encephalopathy (fluid on the brain) adult failure to thrive, depression, moderate protein- calorie malnutrition, surgical after care for large tumor removal to abdomen on 7/8/25, insomnia (inability to sleep), anemia (low blood counts), Alzheimer's disease, dementia (confusion and forgetfulness) with moderate mood disturbances.Review of Resident #40 Minimum Data Set (MDS) quarterly assessment completed on 10/04/25 revealed a Brief Interview for Mental Status score of 4/15 indicating severe cognitive deficit (impaired memory and confusion). Further review of the MDS revealed inattention and disorganized thinking that fluctuates. Resident #40 needed set up or supervision assistance with personal care and bathing. Review of the most recent annual comprehensive MDS assessment revealed the activities and individual preferences section was not answered.Review of the care plan, most recently revised on 10/07/25, revealed Resident #40 enjoys spending time in garden and listening to music. Review of care plan further revealed Resident #40 has little involvement in activities. Interventions included but not limited to encourage the resident to participate in activities that will stimulate mental functioning, invite/escort to activities of interest, provide 1:1 visits as needed, provide activity calendar, provide items needed for self-directed activities as indicated, individual activity of choice.Observation on 12/08/25 at 10:00 A.M. revealed Resident #40 was in room alone and unable to elaborate on activities that she participates in. There was no television or music on. Observation on 12/08/25 at 2:40 P.M. revealed Resident #40 up walking around independently in her room. No music or television was on. Observation on 12/09/25 at 8:57 A.M. revealed Resident #40 sleeping on ride side at bottom of bed, with no music or television on. Observation and interview on 12/09/25 at 2:44 P.M. revealed Resident #40 was sitting up in bed dressed and groomed and you could hear bingo being played down hall. Resident #40 denied interest in playing bingo and declined to go to the activity. Resident #40 further reported most of the activities do not interest her. There was no television or music on.Observation and interview on 12/10/25 at 2:46 P.M. revealed Resident #40 lying in her bed. Resident #40 revealed she did not want to participate in the Christmas ornament making activity. Further observation revealed a flowered blanket that Resident #40 stated her son had brought her and that it would look nicer with some flowers in her room. There was no television or music on.Observation and interview on 12/10/25 at 3:24 P.M. revealed Resident #40 was still not interested in activity. The daily chronicle paper, coloring page, and crossword puzzle were present on bedside table not completed. There was no television or music playing.Observation on 12/10/25 at 4:35 P.M. revealed Resident #40 sleeping in bed with lights out. Observation on 12/11/25 at 9:32 A.M. revealed Resident #40 lying in bed awake looking at wall. There was no music or television on. Review of monthly activity calendars for October, November, and December 2025 revealed a daily coffee cart at 10:00 A.M. and then a daily activity scheduled at 2:00 P.M. Bingo was noted to be the 2:00 P.M. activity twice a week and some Saturdays. There were 4-5 music related activities scheduled for each month. There were no gardening or flower type activities noted for October, November, or December.Review of the monthly activity participation logs for August, September, October, November, and December of 2025 revealed in August 2025 Resident #40 participated in 8 activities in which 4 were related to music, in September 2025 Resident #40 participated in 5 activities in which 3 were music related, in October 2025 Resident #40 participated in 7 activities which 4 were music related, November 2025 Resident #40 participated in 7 activities which 4 were music related, and Resident #40 had participated in 3 music related activities for December 2025. There were no activities logs for any 1:1 activities or independent activities.Interview on 12/09/25 at 3:24 P.M. with Activities Director (AD) #101 revealed Resident #40 was on a handwritten list for residents needing 1:1 interaction due to self-isolation. AD #101 confirmed Resident #40 declines most activities and it was hard to coax into leaving her room. AD #101 further revealed Resident #40 will sometimes come to her doorway or stand near nurses' station when facility has music events. AD #101 reported that Resident #40 does show interest in music activities. AD #101 further reported that a coffee cart is brought up from the kitchen every day at 10:00 A.M. and the activity aides pass out coffee to each resident in their rooms along with three handouts, The Daily Chronicle, a coloring page, and a daily word search. AD #101 reports Resident #40 always accepts coffee. Continued interview revealed AD #101 reported having a tablet to set up face time calls with Resident #40 daughter but they were having issues with the password and haven't called her daughter yet to get it working. AD #101 confirmed there were not documented notes in the medical record or in the activity logs of any 1:1 activities or independent activities being completed with Resident #40.Interview on 12/10/25 at 4:17 P.M. with Certified Nursing Assistant (CNA) #125 revealed Resident #40 has been more withdrawn since the passing of her room mate three weeks ago. CNA further reports that Resident #40 rarely participates in activities despite encouragement.Interview on 12/10/25 at 4:30 P.M. with Registered Nurse (RN) #138 revealed Resident #40 doesn't really participate in activities and rarely leaves her room. Interview on 12/11/25 at 9:35 A.M. with RN #167 revealed that Resident #40 can be difficult to engage and get out of her room. RN #167 denied knowledge of any special interests of Resident #40 but reported she does like the music entertainers when they come to the facility.Interview on 12/11/25 at 9:42 A.M. with CNA #183 revealed that Resident #40 rarely ever participates in activities.Interview on 12/11/25 at 1:20 P.M. with the Assistant Director of Nursing (ADON) #168 confirmed Resident #40's care plan dated 10/07/25 did not have specific interventions for her interest and that the annual/comprehensive MDS section for patient preferences and activities was not completed on 01/28/25.Review of the facility policy titled Activities, dated 10/2022 revealed each resident's interest and needs will be assessed on a routine basis, including residents' interest, preferences, and needed adaptations. The policy further indicated special considerations will be made for developing meaningful activities for residents with dementia and/or special needs, including but not limited too, Residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of day.This deficiency represents non-compliance investigated under Complaint Number 2669867.

Based on medical record, policy review, staff and resident interviews, the facility failed to provide routine dental services to one (Resident #53) of two residents reviewed for dental services. The facility census was 51.Findings Include:Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including kidney disease, enlarged prostate, lung disease, anemia, high blood pressure, reflux, Alzheimer's Disease, dementia, anxiety and depression.Record review of Resident #53 most recent Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15/15 meaning the resident was cognitively intact with no impairments. The MDS further noted Resident #53 use of wheelchair for mobility and supervision or minimal assistance with transfers and personal care. The MDS also noted no swallowing disorders and that Resident #53 was following a mechanical soft diet.Record review of dental progress notes dated 01/20/25 written by Dentist #310 revealed Resident #53 had a full mouth teeth extraction completed. Further review revealed a follow up dental evaluation completed on 08/01/25 with Dentist #310 noting that Resident #53 has no maxillary or mandibular bone to fabricate dentures on and would need to look into dental implants or implant support dentures. This information was relayed by the dentist to both the Social Worker Designee (SWD) #158 and Resident #53 at the time of the appointment. Interview on 12/08/25 at 10:12 A.M. with Resident #53 revealed he reported having trouble getting new false teeth. Resident #53 further reported that he had notified the Activities Director (AD) #101 several weeks ago and was told that his sister has to make his appointment and arrangements and check with his insurance and doesn't understand why the facility can't do it. Resident #53 further reported that he has been getting a mechanical soft diet and is tired of it and wants regular foods.Interview on 12/09/25 at 2:03 P.M with Resident #53 during resident council meeting revealed concerns with not getting his dentures. Resident #53 reported that he was last to the dentist about six months ago and was told he would have to live without them. Interview on 12/09/25 at 2:15 P.M. with AD#101 during resident council revealed she had talked to Resident #53's sister and told her she needed to make an appointment because she was the power of attorney and that the facility could not make the appointment. AD #101 further reported Resident #53 sister was working on getting him an appointment.Interview on 12/10/2025 at 10:19 A.M. with SWD #158 reveled she had not received any reports or concerns from Resident #53 or staff about him wanting new dentures. SWD #158 further confirmed that during the dental evaluation on 08/01/25 it was relayed to both her and Resident #53 that he would not be able to wear dentures and the Resident just said okay. SWD #158 reported that the Assistant Director of Nursing (ADON) #168 makes outside facility appointments for all residents and she coordinates with contracted ancillary service company 360 for dental, vision, hearing, and podiatry appointments. Interview on 12/10/2025 at 10:59 A.M. with the AD #101 revealed approximately six weeks ago Resident #53 reported he had seen some commercials that there was a place that could do dentures for anyone and he wanted to go there because the dentist from facility said he couldn't get them. AD #101 reported she told Resident #53 to call his sister who is the power of attorney and have her schedule an appointment. The AD #101 then reported that Resident #53 had his sister call the AD #101 and his sister said she would have to look into his Medicaid to see if he was allowed to have another dental visit or if Affordable Dentures was covered by Medicaid. AD #101 further reported she had not talked with Resident #53 sister since. AD #101 reported she had not notified nursing or social services about the Resident #53 concerns. AD #101 further reported she did tell the SWD #158 yesterday after Resident Council meeting about Resident #53 concerns about [NAME] wanting dentures. Review of facility policy titled Dental Services dated 10/22/24 revealed the facility is to assist residents in obtaining routine and emergency dental care including if requested making dental appointments and arranging transportation. Further review of the policy revealed routine dental services to include taking impressions for dentures and fitting dentures and limited prosthodontic procedures.

Based on observation, interview and record review, the facility failed to ensure Resident #26's medication orders and administration record were accurate. This affected one (Resident #26) of six residents reviewed for medication administration. The facility census was 51.Findings include:Review of medical record for resident #26 revealed an admission date of 06/25/21. The resident had diagnoses that included Parkinson's Disease; anxiety disorder, unspecified; unspecified dementia, severe, with agitation; unspecified protein-calorie malnutrition; benign prostatic hyperplasia without lower urinary tract symptoms; essential hypertension; Parkinsonism; schizophrenia; unspecified mood; tremor; other bipolar disorder; specified peripheral vascular diseases; abnormal involuntary movements; vitamin D deficiency; constipation; restlessness; cramp and spasm; encounter for palliative care; anemia; depression; pain in knee; edema; unspecified urinary incontinence; full incontinence of feces; and Alzheimer's disease with early onset.Review of the Minimum Data Set (MDS) version 3.0, dated 10/28/25, revealed a Brief Interview for Mental Status (BIMS) could not be completed due to the resident was rarely/never understood. Further review of the MDS, Section E, indicated Resident #26 had no hallucinations or delusions. Section GG, functional abilities, indicated the resident was wheelchair bound, dependent for all activities of daily living.Review of the orders for Resident #26 revealed a Xanax order dated 08/07/24. The order was for Xanax 0.5 milligrams (mg), give one tablet by mouth three times daily for anxiety and written by Nurse Practitioner (NP) #304. The order remained active on 12/09/25. This was confirmed by RN #174 on 12/09/25 at 1:58 P.M., at the time the order was reviewed.Review of a document titled controlled drug/receipt/record/disposition form for Resident #26, dated 11/17/25, revealed a prescription sticker for Alprazolam 0.5mg by mouth three times a day as needed for anxiety and agitation. This prescription was ordered 11/16/25 by Hospice Physician #301 with delivery to the facility on [DATE]. The medical record failed to reveal a prescription confirming this prescription. Review of a prescription obtained from Remedi pharmacy revealed a prescription for Xanax 0.5mg one tablet by mouth three times daily as needed for anxiety. Review of the medication administration record for Resident #26 revealed from 11/17/25 through 12/09/25, the resident was receiving Xanax 0.5mg three times daily, despite an medication orders from Remedi pharmacy which indicated Xanax 0.5mg by mouth three times daily as needed. Interview with Certified Pharmacy Technician (CPT) #200 on 12/09/25 at 4:23 P.M. confirmed the as needed Xanax prescription was ordered.An interview on 12/09/25 at 4:25 P.M. with Director of Nursing confirmed the facility nurses were giving Xanax 0.5mg three times daily (scheduled), not as needed per most recent order. On 12/10/25 at 3:03 P.M., an interview with Registered Nurse (RN) #306 revealed the Xanax order should never have changed from scheduled three times daily to three times daily as needed. She explained an on-call nurse for hospice took the call from the facility on 11/15/25, indicating Resident #26 required a refill for his Xanax. The on-call nurse erroneously entered the prescription as an As needed or PRN medication, rather than a scheduled three times daily medication, which was the existing order. This order was then sent to the hospice physician for approval and submission to the pharmacy. RN #306 revealed the orders in the hospice medical record still indicated Resident #26's order for Xanax was 0.5mg one tablet by mouth three times daily for anxiety, and was never intentionally changed to as needed. Review of a facility policy titled Medication Administration, dated 08/25/25, revealed medications were to be administered by licensed nurses, as ordered by the physician, and in accordance with professional standards. Nurses were to ensure the six rights of medication were followed, which included the right dosage. Nurses should compare the medication source (bubble pack, vial, etc.) with the medication administration record (MAR) to verify resident name, medication name, form, dose, route and time.

Based on observation, policy review and interview, the facility failed to prepare and serve food in a sanitary manner. This had the potential to affect 54 of 55 residents residing in the facility. The facility identified Resident #55 not receiving nutrition by mouth. The facility census was 55. Findings include: On 06/17/24 between 9:45 A.M. and 10:01 A.M. observations of the kitchen revealed Dietary Director #69 and Dietary [NAME] #73 were observed to have beards and a mustache. Upon entrance to the kitchen, Dietary [NAME] #73 had his beard net below his chin and when the surveyor approached the dishwashing station, Dietary [NAME] #73 raised the beard net to cover his beard; however, his mustache remained uncovered. Dietary [NAME] #73 was washing dishes and removing clean dishes from the low temperature dishwasher at the time of the observation. Dietary Director #69 and Dietary [NAME] #73 were both observed with facial hair approximately one inch in length, uncovered at the time of the observation. On 06/17/24 between 11:56 A.M. and 12:08 P.M., observation of the lunch meal tray line service revealed Dietary [NAME] #73 was positioned over the kitchen steam tables and serving individual resident meals and placed them on a cafeteria-style serving tray to be distributed to residents. Dietary [NAME] #73 was observed to have a beard net covering only a portion of his beard and his mustache was uncovered. Dietary Director #69 was standing next to the surveyor and did not have his beard net covering his mustache during the lunch meal observation. Dietary Director #69 verified Dietary [NAME] #73's beard was only partially covered and his mustache was uncovered during the meal service. On 06/17/24 between 12:01 P.M. and 12:07 P.M., observation revealed Dietary [NAME] #100 washed his hands and donned gloves. Dietary [NAME] #100 then grabbed a package of hamburger buns placed them on the prep table, was handed a cafeteria-style tray from Dietary [NAME] #73 and placed it on the prep area to put the buns on. Dietary [NAME] #100 used a utensil to open the top of the bun package and then reached into the bag of buns and opened the buns with his gloved hands and put them on the cafeteria-style tray. Dietary [NAME] #100 repeated the above with a second bag of hamburger buns and Dietary [NAME] #73 was observed using the buns to serve a BBQ rib sandwich for the lunch meal service. Dietary [NAME] #100 did not change his gloves during the above observation. On 06/17/24 at 12:08 P.M., the above observation was verified by Dietary Director #69. Review of the undated policy: What to Wear revealed a hair covering was to be worn in prep areas, while prepping food, working in areas used to clean utensils and equipment and food handlers with facial hair should also wear a beard restraint. This deficiency represents non-compliance investigated under Complaint Number OH00154268.

Based on observation, record review, incident log review, procedure review and interview, the facility failed to maintain hot water temperatures below 120 degrees Fahrenheit (F). This had the potential to affect 16 residents (#6, #8, #11, #13, #14, #15, #18, #19, #20, #21, #23, #24, #25, #26, #28 and #30) identified by the facility as cognitively impaired and independent with mobility of 34 residents who reside on the 200 and 300 halls. The census was 55. Findings include: Record review revealed Resident #6 and #8 were moderately impaired for daily decision-making and resided on the long-term unit (200 hall). Resident #11, #13, #14, #15, #18, #19, #20, #21, #23, #24, #25, #26, #28 and #30 were severely impaired for daily decision-making and resided on the locked Alzheimer's unit (300 hall). On 06/17/24 at 10:15 A.M., observation of the second floor mechanical room with Maintenance Director (MD) #89 revealed two hot water tanks. One hot water tank was set to 140 degrees Fahrenheit (F) and the second tank did not have a temperature display visible. MD #89 verified the first hot water tank was set to 140 degrees (F) to ensure hot water was delivered to the 200 and 300 units. Further interview revealed resident room hot water temperatures were not to exceed 120 degrees (F). On 06/17/24 between 10:18 A.M. and 10:59 A.M., MD #89 was observed testing the following resident room bathroom sink hot water temperatures. MD #89 verified the readings at the time of the observation which included the following: a. Resident #6's water temperature was 121.1 degrees (F). b. Resident #8, #11, #25, #26 and #28's water temperature was 121.2 degrees (F). c. Resident #13, #14 and #15's water temperature was 121.4 degrees (F). d. Resident #18 and #24's water temperature was 120.8 degrees (F). e. Resident #19's water temperature was 120.9 degrees (F). f. Resident #20, #21 and #23's water temperature was 121.7 degrees (F). g. Resident #30's water temperature was 120.6 degrees (F). Review of Ambulatory with Cognitive Impairment resident list provided by the facility revealed Resident #6, #8, #11, #13, #14, #15, #18, #19, #20, #21, #23, #24, #25, #26, #28 and #30 were independent with mobility and cognitively impaired. On 06/17/24 between 10:33 A.M. and 10:47 A.M., Resident #11, #13, #14, #15, #18, #19, #20, #21, #23, #24, #25, #26, #28 and #30 were observed on the locked Alzheimer's unit. Resident #14 and #18 were observed ambulating in and out of rooms including the bathrooms and Resident #28 was in an unoccupied room, laying on a bed. On 06/17/24 at 10:59 A.M., interview with MD #89 verified the long term unit (200 hall) and the Alzheimer's locked unit (300 hall) hot water temperatures were above 120 degrees (F) and the water for those units came from the hot water tank set to 140 degrees (F). MD #89 stated he tests two rooms per unit per week and normally tested the water temperatures in the afternoon without any concerns. MD #89 verified the water temperatures exceeded 120 degrees (F) and should not be above 115 degrees (F) according to the facility's guidelines. On 06/17/24 at 11:09 A.M., interview with Registered Nurse (RN) #143 verified the water temperatures exceeded 120 degrees (F) and posed a burn risk. RN #143 stated there had been no reports of residents receiving a burn from the elevated water temperatures. Review of the Incidents by Incident Type report dated 04/17/24 to 06/17/24 revealed no resident burns. Review of the procedure: Resident Hot Water Temperature Log revealed all hot water for resident rooms and areas were supplied through a single closed loop system. Choose one patient room on the 2nd and 3rd floors to measure the water temperature. Each week rotate between all three wings. Take a thermometer and test the hot water in each restroom. It must be between 105 degrees (F) and 115 degrees (F). Water temperatures out of range must be corrected immediately. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00154268.

Based on interview and record review the facility failed to ensure that witness authorizations were obtained to manage resident funds. This affected five residents (#1, #6, #24, #26, and #56) of five reviewed for personal funds. This had the potential to affect 33 residents whose funds were managed by the facility. The census was 58. Findings include: Review of financial records for Residents #1, #6, #24, #26, and #56 revealed no witness signatures on the Authorization and Agreement to Handle Resident Funds Forms. On 02/06/24 at 2:55 P.M., an interview with the Administrator verified there were no witness signatures on the Resident Fund Management Agreement Forms. On 02/06/24 at 9:40 A.M. an interview with Business Office Manager # 511 verified there were no witness signatures on the Resident Fund Management Agreement Form.

Based on observation and interview, the facility failed to ensure residents disposed of cigarettes in the designated containers and that facility staff supervising residents smoking knew where the fire safety devices were located. This affected four residents (#3, #14, #19, and #20) of four identified by the facility as smokers. The facility census was 58. Findings include: On 02/05/24 at 9:12 A.M., observation of the courtyard, which was the designated resident smoking area, revealed there were 23 cigarette butts scattered throughout the grass, 21 cigarette butts scattered throughout the mulch, and six cigarette butts on the sidewalk. There was no fire extinguisher or fire blanket in the designated smoking area. On 02/05/24 at 9:26 A.M., interview with Licensed Practical Nurse (LPN) #582 verified cigarette butts were in the grass, mulch, and on the sidewalk. LPN #582 confirmed there was no fire extinguisher or fire blanket in the exterior courtyard which was the designated smoking area for residents. On 02/05/24 at 9:37 A.M., interview with Housekeeper #568, who was supervising residents smoking, stated she did not know where the fire blanket was and she confirmed the nearest fire extinguisher was inside the building on the other side of the resident common area.

Based on observation and interview, the facility failed to ensure there was sufficient staff to monitor dining activities on the secure unit. This had the potential to affect all 19 residents who resided on the secure unit. The facility census was 58. Findings include: During observations of the lunch meal delivery and service on 02/05/24 of the secure unit the following was observed: The first meal cart arrived at 12:25 P.M. and staff immediately began serving residents. At 12:43 P.M. all other residents at the main/long table in the dining room were eating or had received their trays with the exception of Resident #12. No staff were present at the table or directly monitoring the residents when Resident #12 reached over and took a bowl of applesauce from Resident #53's tray and started drinking the applesauce from the bowl. When staff did observed Resident #53 with the applesauce they stated they did not know where Resident #53 got it from. At 12:45 P.M., State tested Nursing Assistant (STNA) #521 sat beside Resident #12 to assist with her meal. One bowl of food was provided with staff providing cues and physical assistance. The last two bowls were provided at the same time. At 1:02 P.M., Resident #53, who had orders for a pureed diet, was observed with two bowls of regular carrots, one of which he had taken from Resident #12. Staff intervened after Resident #53 already had a regular carrot in his mouth telling him he was on a pureed diet and could not eat regular carrots. At 1:05 P.M., staff noted Resident #32 had left the table without eating much and asked staff on the floor to redirect him back to the dining room. Resident #32 was overheard indicating he did not want to eat any more. Resident #303 was observed pushing a piece of pie across the table to Resident #28 who was also eating a pureed diet. STNA #546 was informed of this by the surveyor prior to intervening and verified Resident #28 was on a pureed diet and should not have regular pie. At 1:39 P.M., Resident #32 was observed sitting at a table at the end of the hall near the nursing station eating food from Resident #54's tray. After about 20 second staff walking down the hall observed this and intervened. On 02/05/24 at 1:30 P.M., STNA #521 stated there was not enough staff to monitor resident behaviors and feed residents at meal time on the secure unit. STNA #543 agreed. Both STNA #521 and #542 acknowledged residents were taking food from one another and the food was not always appropriate for residents' diets. On 02/06/24 at 4:22 P.M., STNA #508 stated there was not sufficient staff on the secure unit because residents liked to wander and behaviors could be better monitored with a third aide. STNA #508 stated staffing was not sufficient enough during meals to prevent residents from taking one another's food or sharing food which was inappropriate for diets. On 02/06/24 at 4:55 P.M., Registered Nurse (RN) #571 stated there were some residents on the secured unit who fixated on food and who were sometimes able to get food which was inconsistent with their diets. It would be beneficial to have more staff to monitor behaviors. On 02/07/24 at 4:07 P.M., STNA #543 stated the secured unit had multiple residents with behaviors. Some of the residents required two assists to provide personal care which tied up both aides on the unit. The STNAs tried to reserve those residents' care to be provided when the nurse was available to monitor behavior of other residents. However, it was difficult to monitor residents with behaviors at times as they were mobile and behaviors could escalate quickly. On 02/08/24 at 1:55 P.M., STNA #546 verified after Resident #STNA #521 left the dining room on 02/05/24 during lunch and she was the only staff member monitoring the other residents she was unable to monitor the residents closely enough to prevent them from sharing and taking food. STNA #546 indicated she was asked to assist in the secure dining room on 02/05/24 but she did not normally do so. The facility identified Residents #7, #9, #12, #16, #24, #28, #30, #32, #35, #36, #39, #40, #43, #53, #54, #55, #56, #57, and #113 as residing on the secure unit. Review of the facility's policy, Nursing Services and Sufficient Staff, implemented October 2022 and reviewed/revised 02/06/24, indicated the facility's census, acuity and diagnoses of the resident population would be considered based on the facility assessment. The facility was to supply sufficient direct care services on a 24-hour basis to meet the needs of residents in an appropriate and timely manner. The facility would determine the number and type of additional staff required based on the services needing to be performed as identified in the care plan.

Based on observation, record review, policy review, and interview, the facility failed to complete a comprehensive assessment to determine if side rails were used as a restraint or an enabler. This affected one (Resident #56) of 24 residents observed for possible restraints. Te census was 58. Findings include: Review of Resident #56's medical record revealed diagnoses including severe dementia with agitation, abnormal posture, mood disorder, generalized muscle weakness and Parkinson's disease. An admission assessment dated [DATE] indicated Resident #56 had a siderail screening tool which indicated Resident #56 was non-ambulatory, had alterations in safety awareness due to cognitive decline, had a history of falls, demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed, had difficulty with balance or poor trunk control, was currently using side rails raised while in bed, and had not expressed a desire to have rails raised while in bed. The assessment indicated siderails were indicated and served as an enabler to promote independence. The functional status of the admission assessment indicated Resident #56 was totally dependent for bed mobility. Review of a baseline care plan dated 04/10/23 indicated Resident #56 had the potential for falls with interventions for 1/2 or 1/4 side rails up when in bed. Review of a care plan initiated 04/18/23 indicated Resident #56 was at risk for falls and fall related injury related to a history of falls with fracture prior to admission, muscle weakness, unsteadiness on her feet, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, disorientation, depression, age-related physical disability, atrial flutter, Alzheimer's disease, dementia, Parkinson's disease, and poor safety awareness. On 05/19/23 an order was written for bilateral enabler bars to assist with bed mobility, turning and repositioning, transfers and to promote independence. The care plan related to fall risk was updated to include an intervention dated 06/19/23 for the use of bilateral enabler bars to assist with bed mobility, positioning, and transfers. There was no evidence of assessments for side rail/enabler bar use after the admission assessment. On 02/05/24 at 10:18 A.M., Resident #56 was observed lying in bed with bilateral quarter side rails which were raised and located on the lower top half of the bed. On 02/05/24 at 11:26 A.M., Resident #56 remained in the bed with the side rails raised. A family member who was present stated the side rails were raised to prevent falls. Subsequent observations on 02/05/24 at 2:59 P.M., on 02/06/24 at 10:26 A.M., 11:15 A.M. and 4:32 P.M., and on 02/07/24 at 5:37 A.M. revealed Resident #56 was in bed with the side rails raised. Resident #56 was not observed using the rails for mobility or repositioning herself. On 02/06/24 at 4:44 P.M., Licensed Practical Nurse (LPN) #520 stated she was unaware of any side rails assessments being completed to determine if the side rail/mobility bars restrained movement. At 5:08 P.M., LPN #520 added Resident #56 would sometimes grab hold of the bar when being transferred with a gait belt and two assists. However, Resident #56 did not have enough strength to hold herself up. LPN #520 also stated Resident #56 would squirm in bed but did not make an effort to reposition herself or turn in bed with use of the rail/enabler bars. On 02/07/24 at 9:30 A.M., LPN #520 verified she could find no siderail assessment since Resident #56's admission. LPN #520 stated the use of siderails should be assessed quarterly. During an interview on 02/07/24 at 4:07 P.M., State tested Nursing Assistant (STNA) #543 stated Resident #56 squirmed in bed and sometimes got her legs over the bed but believed the rail might prevent her upper body from leaving the bed. Resident #56 did not use the rail for bed mobility or transfers. The rail was lowered before transferring Resident #56 to prevent skin tears/injury. During an interview on 02/07/24 at 4:40 P.M., Registered Nurse (RN) #581 stated she had Resident #56's siderails/enabler bars reassessed. The assessment indicated Resident #56 no longer used the side rails/enablers for bed mobility but that she sometimes got her legs out of the bed and it aided in her not falling from the bed. RN #580, who was also present, stated Resident #56 used to use the siderails for mobility but it was unclear when she was no longer able to. Review of the facility's Mobility Bars policy, dated November 2016 and reviewed/revised 02/06/24 indicated the facility would only use mobility bars to assist in bed mobility and transfer when it was appropriate. The therapy department or designee should work with nursing to assess the suitability of mobility bars for residents. The assessment should be done on admission, quarterly and with any major changes in residents' function.

Based on medical record review and staff interview the facility failed to ensure comprehensive assessments were completed accurately related to hospice services and medication use. This affected two (Resident #18 and #35) of 19 residents reviewed for comprehensive assessments. The facility census was 58. Findings include: 1. Review of Resident #18's medical record revealed an admitted [DATE] with diagnoses that included congestive heart failure, dementia and chronic kidney disease. Further review of the medical record including physician's orders revealed on 02/26/23 Resident #18 was admitted to hospice services. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment with a reference date of 11/03/23 indicated Resident #18 was not currently receiving hospice services. A previous quarterly MDS 3.0 assessment with a reference date of 08/03/23 indicated the resident was receiving hospice services. On 02/07/23 at 9:53 A.M. interview with [NAME] President of Clinical Services #581 verified the MDS with a reference date of 11/03/23 did not indicate Resident #18 was currently receiving hospice services. 22653 2. Review of Resident #35's medical record revealed diagnoses including depression, anxiety disorder and Alzheimer's disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated contradictory information regarding medication use. One section of the MDS indicated Resident #35 did not receive antipsychotic medication while another section indicated Resident #35 received antipsychotic medication on a routine basis only with a gradual dose reduction attempted 10/06/23. Review of the November 2023 Medication Administration Record (MAR) revealed no antipsychotic medications were administered. On 02/07/24 at 9:53 A.M., Registered Nurse (RN) #581 verified the coding on the quarterly MDS dated [DATE] was inaccurate as Resident #35 was not receiving antipsychotics on a routine basis.

Based on medical record review, observations, policy review and staff interview the facility failed to ensure Resident #21 was turned and repositioned as per the care plan and ordered by the physician. The facility also failed to accurately stage pressure ulcer wounds for Resident #44. This affected two (Residents #21 and #44) of two resident reviewed for pressure ulcer wounds. The facility census was 58. Findings include: 1. Review of Resident #21's medical record revealed an admitted [DATE] with admission diagnoses that include a stage four pressure ulcer (full thickness skin loss with exposed bone, tendon or muscle) to the sacral region, Parkinson's disease with dementia and chronic kidney disease. Review of wound assessments revealed a chronic unhealed stage four pressure ulcer wound to the sacrum/coccyx area which was present upon admission. Review of Resident #21's Minimum Data Set (MDS) quarterly assessment with a reference date of 11/08/23 indicated the resident had a severely impaired cognition level and was dependent upon staff assistance for bed mobility. Further review of the medical record including physician's orders dated 07/05/22 staff were to encourage the resident to turn and reposition every two hours. Review of Resident #21's plan of care related to impaired skin integrity revealed an intervention to turn and reposition the resident every two hours. Observation of Resident #21 on 02/06/24 from 9:37 A.M. to 3:17 P.M. revealed the resident lying in bed on her back with no evidence of turning and repositioning. Interview with State tested Nurse Aide (STNA) #524 on 02/06/24 at 3:20 P.M. verified Resident #21 had not been turned and repositioned since early that morning. STNA #524 indicated the resident prefers to stay on her back and previous use of foam wedges for positioning failed due to comfort of the resident. Interview with the Director of Nursing on 02/06/24 at 3:40 P.M. verified Resident #21's care plan did not indicate a preference to remain on her back and non-compliance with turning and repositioning. Review of the facility policy titled Turning and Repositioning with an implemented date of 10/25/23 and reviewed/revised on 02/08/24 indicated; All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. The frequency of turning and repositioning will be documented in the resident's plan of care. 2. Review of Resident #44's medical record revealed an admitted [DATE] with diagnoses that included dementia, diabetes mellitus and congestive heart failure. Review of Resident #44's weekly skin assessments revealed on 12/27/23 a suspected deep tissue injury (SDTI (purple or maroon localized area of discolored skin, may include a thin blister over a dark wound bed)) to the right heel was found. Further review of the weekly wound assessments revealed the wound was described as dry with 100% eschar (leathery, scab like tissue) to the wound from onset to the last assessment completed on 02/05/24. Review of the weekly wound nurse practitioner consultant assessments revealed the wound was initially staged as a SDTI on 01/08/24 and then changed to an unstageable pressure ulcer wound on 01/15/24. Observation of wound care for Resident #44 on 02/07/24 at 8:45 A.M. with Licensed Practical Nurse (LPN) #582 revealed a wound to the right heel. The wound bed was covered with 100% black and dry eschar tissue. On 02/07/24 at 8:55 A.M. interview with LPN #582 revealed she described the wound as an unstageable pressure ulcer wound. Additional interview on 02/08/24 at 8:12 A.M. with LPN #582 verified inaccurate wound assessment which indicates wound is a suspected deep tissue injury and is currently an unstageable wound as indicated by wound nurse consultant. Review of the facility policy titled Documentation of Wound Treatments with a date implemented of 2016 and Review/Revised date of 02/08/24 indicated; the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment. The following elements are documented as part of a complete wound assessment: stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury).

Based on review of the medical record, review of the facility investigation, and interviews with staff, the facility failed to ensure Resident #41 was free from accident hazards. Actual harm occurred on 10/16/23 when Resident #41, who was cognitively impaired, at risk for falls, and dependent on two staff for bed mobility, fell out of bed while State tested Nursing Assistant (STNA) #112 was providing incontinence care by himself. Resident #41 sustained a fracture to the right hip and hematoma to the back of her head. Resident #41 was transferred to the hospital and received surgical intervention to her right hip. This affected one resident (Resident #41) of three residents reviewed for accident hazards. The facility census was 57. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Resident #41's list of diagnoses included diabetes, diabetic polyneuropathy, protein-calorie malnutrition, intertrochanteric fracture of the right femur, atrial fibrillation, dysphagia, contusion to the scalp, psychotic disorders, major depressive disorder, mood disorder, anxiety disorder, malignant neoplasm of the skin, osteoarthritis, hypothyroidism, kidney disease, and glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severely impaired cognition and had delusions. She had physical symptoms such as hitting or scratching herself and screaming daily. She required total assistance from two staff members for bed mobility and transfers. Review of the plan of care dated 03/17/23 revealed Resident #41 was at risk for falls and fall related injuries related to dementia with behaviors, visual impairment, psychosis, osteoarthritis, anxiety, mood disorders, depression, abnormalities of gait and mobility, lack of coordination, muscle weakness, decreased sensation, physical debility, impaired cognition, incontinence, medication use, and poor safety awareness. Interventions included assist resident with wheelchair or walker for mobility as needed, assist with wearing proper footwear, assist with toileting needs and incontinence care, keep call light within reach, and non-skid gripper socks when not wearing shoes. On 10/07/23 the plan of care was revised to include mat to the floor and revised again on 10/16/23 to include two persons to assist for bed mobility and transfers. Review of the physician orders revealed Resident #41 had an order for bilateral grab bars dated 10/24/22, padding added to the bilateral grab bars for altered skin integrity dated 07/28/23, and her bed to be in the lowest position when not providing direct care dated 10/07/23. Further review of Resident #41's medical record revealed the State tested Nursing Assistant (STNA) task documentation for October 2023 indicated the staff were using total or extensive assistance of two staff members for all bed mobility for Resident #41. Review of an incident note dated 10/16/23 at 1:00 A.M. revealed the nursing assistant (STNA #112) was assisting Resident #41 during care when the resident became combative and rolled out of bed. Resident #41 was assessed and noted to have a golf ball size fluid filled hematoma to back of her head. Resident #41 was complaining of right hip pain, her pupils were equal and reactive to light. Two-person assistance with bed mobility and transfer was listed as a potential new intervention. Resident #41 was sent to the emergency room for evaluation. Review of the hospital emergency room radiology report dated 10/16/23 at 3:33 A.M. revealed Resident #41 had an acute, displaced intertrochanteric right femur fracture and a right scalp hematoma with no fracture. Review of health status reports dated 10/16/23 at 8:10 A.M. and 10/16/23 at 11:11 A.M. revealed Resident #41 returned to the facility with no surgical intervention. Resident #41's physician was on the unit, the son was at the bedside and the son wanted Resident #41 to be sent to another hospital for another evaluation of the fracture and the physician agreed. Review of the second hospital emergency room report dated 10/16/23 revealed Resident #41 had been seen at another hospital the same day, diagnosed with right hip fracture, was sent back to the facility then the family requested she be sent back to another hospital. Resident #41 was in no distress, appeared comfortable, was alert to person and had an internally rotated right hip with mild angulation but not displaced and no skull fractures or brain bleed. Resident #41 would be cleared for surgery for the hip fracture. Review of a psychosocial note dated 10/17/23 at 11:00 A.M. revealed Resident #41 was still at the hospital and would be having surgery for her fractured hip. Review of the progress note dated 10/22/23 revealed Resident #41 returned to the facility with post-surgical aftercare orders following hip repair surgery. Review of the facility's fall investigation dated 10/16/23 revealed Resident #41 fell out of bed during care being provided by STNA #112. Review of the signed witness statement from STNA #112 dated 10/16/23 at 1:00 AM revealed he was assisting the resident with her disposable brief change and the resident reached out, scratched him, he lost his grip and she fell out of bed. Review of a second signed witness statement from STNA #112 dated 10/27/23 revealed he noticed Resident #41 had a bowel movement, so he gathered all the stuff he needed, raised the bed, lowered her head and feet in bed and removed the wedge and pillow from under her legs. STNA #112 then tucked the adult brief the resident was wearing to one side so he could pull the brief when he turned Resident #41. After telling the resident what he was about to do and turning her, he was getting ready to pull the old brief out when Resident #41 pinched and scratched the hand and arm he was using to steady her. STNA #112 reacted by letting go of her and that was when she fell out of the bed. Review of the signed witness statement from LPN #114 dated 10/16/23 revealed the nursing assistant came running down the hall stating the resident fell on the floor. LPN #114 followed him back to the room and a head-to-toe assessment was completed. Vital signs were normal, and the resident was found to have an area to the back of her head and a red area to the right hip. LPN #114 initiated neurological checks while another nurse arranged transportation to the emergency room at the hospital. Review of the signed witness statement from Licensed Practical Nurse (LPN) #113 dated 10/16/23 revealed LPN #113 assessed the resident with the other nurse, the resident was having pain with palpation to the right hip, and she had redness noted to the area. She had a hematoma to the back of her head. Her range of motion (ROM) to the right hip was abnormal and she complained of pain with ROM. On 11/21/23 at 2:24 P.M. an interview with the Director of Nursing (DON) verified STNA #112 was the aide working when Resident #41 had fallen out of bed. The DON stated STNA #112 was providing care to Resident #41, and she fell out of bed. The DON verified Resident #41 was a two person assist with turning and repositioning. On 11/21/23 at 2:40 P.M. an interview with STNA #109 revealed he had provided care to Resident #41 prior to her fall on 10/16/23 and Resident #41 required two staff members to provide care. On 11/21/23 at 2:45 P.M. an interview with STNA #110 revealed she provided care to Resident #41 prior to her fall on 10/16/23 and Resident #41 required two staff members to provide care. On 11/21/23 at 2:47 P.M. an interview with STNA #111 revealed Resident #41 required two staff members to provide incontinence care prior to her fall because she usually became combative and resisted care. STNA #111 stated she was very hard to roll with only one staff person so two staff were required, and the resident was a two person assist for transfers. On 11/21/23 at 2:53 P.M. an interview with LPN #103 revealed the nursing assistants usually used two STNAs when providing care to Resident #41 because she was difficult to turn and could become combative. On 11/21/23 at 4:00 P.M. an interview with STNA #112 verified on 10/16/23 he provided incontinence care to Resident #41 by himself, and Resident #41 rolled out of bed onto the floor. STNA #112 stated he did have another aide working with him, but she was in the other room. STNA #112 stated he was rolling Resident #41 to change her brief and she did not like to be rolled in the bed so would become combative and grab at staff. STNA #112 stated when he rolled her towards the window to pull the brief out from under her, she reached around, grabbed at his arm and hand, and scratched him. STNA #112 stated he let go of her as a reaction to being scratched and she fell out of the bed onto the floor between the bed and the wall and from a waist high position of the bed. He stated this was the first time he had ever had anyone fall out of bed and he ran out to get the nurse. On 11/22/23 at 10:15 A.M. an interview with STNA #106 revealed the STNAs have always used two staff to turn and position, provide incontinence care, and transfer Resident #41 because she was a heavy woman and had very limited mobility. STNA #106 added Resident #41 could become combative very easily with care. Review of the facility policy titled, Falls and Fall Risk Managing, date revised 05/06/2020, indicated staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Number OH00147981.

Based on observations, interview with staff and review of the facility policy, the facility failed to implement the smoking policy to maintain a safe and clean environment free from discarded cigarette butts at the facility main entrance door. This had the potential to affect all the residents in the facility. The facility census was 57. Findings included: Observation upon entrance to the facility on [DATE] at 8:00 A.M. revealed there were numerous (20 plus) cigarette butts on the left side of the entrance door laying in the mulch beds. On 11/21/23 at 8:30 A.M. an interview with Receptionist #102 verified the cigarette butts in the mulch by the front door, and verified there was no smoking receptacle at the main entrance to extinguish cigarettes properly. On 11/21/23 at 1:20 P.M. an interview with Maintenance Director (MD) #100 revealed there was not supposed to be anyone smoking at the entrance because it was not the designated smoking area. MD #100 explained the housekeepers were supposed to be checking outside for cigarette butts but evidently had not been checking for the cigarette butts. Review of the facility policy titled, Resident Smoking, dated 04/05/22 with a revision date of 11/20/23, revealed the facility would provide a safe and healthy environment for residents, visitors and employees including safety as related to smoking. Smoking was prohibited in all areas except the designated smoking areas. This deficiency represents non-compliance investigated under Complaint Number OH00147981.

Based on observation, record review and interview, the facility failed to ensure therapy recommendations were implemented upon discontinuation of therapy services. Actual harm occurred when Resident #1 had worsening contractures and decline in range of motion when restorative/maintenance programs for application of hand splints, passive range of motion (PROM) exercises and a timed out of bed schedule was not provided as recommended impacting the resident's mobility and skin integrity. This affected two residents (Resident #1 and #40) of three residents reviewed for range of motion. The census was 59. Findings include: 1. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses including anoxic brain damage, nontraumatic intracerebral hemorrhage, neuromuscular dysfunction of bladder, presence of cerebrospinal fluid drainage device, need for assistance with personal care, contracture left elbow, right hand, left hand, muscle wasting and atrophy. Review of the Admission five-day Minimum Data Set Assessment (MDS) dated [DATE] included the resident was never understood, required extensive two-person physical assist with bed mobility, and dressing; total dependence and two-person physical assist with transfer, eating, and toileting. Review of an impaired range of motion as evidenced by contractures of bilateral hands, left elbow and paraplegia plan of care dated 06/11/22 revealed interventions including to apply any assistive devices needed for contracture management. Review of Resident #1's therapy evaluations revealed she was initially admitted [DATE] and evaluated by occupational therapy on 06/06/22. The resident was totally dependent (on staff) for all activities of daily living. She was unable to follow commands, or track with visual movements. She did open her eyes and fixate (her) gaze on the therapist. She was admitted with resting hand splints (a splint used to maintain hand(s) in functional positioning by supporting the hand and wrist joint during periods of inactivity). The resident was evaluated by physical therapy on 06/07/22. Initial evaluation included the resident was totally dependent for sitting, with no right or left upper or lower extremity strength. The resident was readmitted to the hospital and returned to the facility 06/18/22. The Occupational therapy evaluation (upon re-admission) was unchanged and included she was admitted with two resting hand splints however they would need to be trialed and slightly modified due to bilateral upper extremity contractures and wear tolerance of two hours. The resident had a left elbow contraction with 55-140 degrees of motion on the left and 40-150 degrees on the right elbow (normal ROM of the elbow is 180 degrees). The resident was approved for a specified number of therapy visits, three of which were used for Occupational Therapy, and discharged from therapy on 06/24/22 until she could be re-evaluated under Medicaid part B. She was discharged with hand splints up to two hours a day and weighted stuffed animals to her arms since the left arm brace did not arrive. The resident resumed services on 07/20/22 under Medicaid part B and provided services until 10/10/22. She was thin and the elbow brace was too large for her. The therapists were looking for a pediatric elbow brace and utilized weighted stuffed animals in her arms to extend her elbows. Upon discharge from therapy, restorative/maintenance programs included out of bed up to four hours a day, passive range of motion (PROM) bilateral upper extremities two sets of 10 and bilateral resting hand splints four hours on and four hours off after PROM with skin checks. The resident was also to hold a large stuffed animal to left elbow to prevent contracture. Education was provided to the Director of Nursing, Assistant Director of Nursing and restorative/ MDS nurse on donning resting hand splints every four hours and not using washcloths because they do not prevent worsening of contractures. PROM education prior to donning splints was provided. Review of the medical record revealed no evidence a restorative or maintenance program was written for the nursing staff to provide. There were no instructions for the STNAs to follow, there was no physician order or treatment orders written and there was no restorative plan of care. On 03/06/23 a therapy screening was completed for Resident #1 and therapy services for contractures, positioning for promotion of skin integrity, as well as increased out of bed participation was planned. The resident was re-evaluated on 03/08/23 by occupational therapy secondary to having an increase of contractures and poor out of bed tolerance. The resident presented with decreased joint mobility in bilateral upper extremities impacting her positioning and skin integrity. The resident was re-evaluated 03/15/23 by physical therapy due to decreased range of motion in her lower extremities and had a decrease in her prior level of function with PROM of left hip abductor declining from 30 degrees of motion to 15 degrees, left hip flexion declining from 100 degrees of motion to 70 degrees, and PROM to knee extension declining from zero extension to minus 15 degrees. The goal was to improve trunk and lower extremity range of motion to improve positioning in bed and up in chair. The resident had no existing lower extremity contracture. The left lower extremity was tight in all muscle groups. The resident presented with decreasing range of motion in bilateral lower extremities and trunk due to neurological insult of traumatic brain injury and being bedfast. The Quarterly MDS dated [DATE] revealed the resident required total dependence, two-person assist for bed mobility, transfer, and personal hygiene. The resident was total dependence, one-person assist for dressing and eating. The resident had functional range of motion (ROM) impairment on both sides of upper and lower extremities. Review of the 06/01/23 occupational therapy discharge note included a referral for a restorative nursing program and functional maintenance program to be completed to maintain progess. Review of the STNA TASK section and care plans dated 06/02/23 included a Restorative Range of Motion Program: Needs Passive Range of Motion: Gentle stretching to bilateral upper and lower extremities, three sets of five, two times a day for at least 15 minutes. Ensure completing upper extremity stretching before and after palm guard application. A 06/02/23 Restorative: splint application and removal program-complete passive range motion gentle stretching prior to applying and after removing palm guards. Guards to be encouraged to be in place six to eight hours daily, six to seven days a week, at least 15 minutes of staff restorative direct care per day. Observation on 06/12/23 at 9:28 A.M. revealed Resident #1 sitting in tilt-in-space wheelchair, in the common area beside the nursing station. There were no splints, braces, or rolled washcloths applied to either hand. An observation was completed at 11:18 A.M. and remained unchanged. Observation on 06/12/23 at 11:26 A.M. revealed Resident #1 was removed from the common area to receive care. No washcloths, splints, palm guards, or braces were in her hands. Observation on 06/12/23 at 11:52 A.M. revealed Resident #1 was she was in the hall with a stuffed animal in each arm. No washcloths, splints, palm guards or braces were observed to the resident's hands. Interview 06/12/23 at 2:58 P.M. with Certified Occupational Therapy Assistant (COTA) #140 revealed when Resident #1 was screened on 03/08/23 therapy became aware staff were not utilizing the resting hand splints and were not getting Resident #1 up in the custom chair. Some staff said they were providing restorative recommendations from the 10/10/22 discharge from therapy and other staff stated they were not providing the recommendations. Therapy stated facility staff had been educated on out of bed transfers and splint placement in October when therapy was discontinued. The restorative program would have been given to the MDS nurse when the resident was discharged from therapy for follow-up and/or implementation. When the resident was discharged from therapy, she was wearing the resting hand splints. The resident's hands were now rigid. Therapy located her resting hand splints and she was not able to wear them at that time, due to the worsening of her hand contractures. The resting hand splints did not move enough and she could not use them. The COTA stated panacea palm guards were trialed and they were misplaced. She had skin sloughing with them and could not tolerate them (palm guards) and therapy noted the panacea palm guards were heavy. On 05/23/23 COTA #140 emailed supply to order sheep skin palm guards and they have not yet arrived. She included they are currently using washcloth roll ups on Resident #1's hands until the ordered palm guards arrive. The therapy department was never able to restore motion back to her hands to resume use of the resting hand splints. Observation on 06/12/23 at 3:09 P.M. revealed Resident #1 lying in bed on her back. There were no splints, braces, palm guard or rolled washcloths applied to either hand. Interview 06/12/23 at 5:24 P.M. with State tested Nurse Aide (STNA) #122 revealed she had never been trained on splints. She had never been trained to put washcloths in Resident #1's hands. She had never been told to do it. She has rarely seen washcloths in Resident #1's hands. She verified she did not see washcloths in the resident hands today. She is usually only able to put one finger in her fist to make room to clean her hands. She cannot manually straighten her fingers or elbows. Interview 06/12/23 at 5:31 P.M. with STNA #152 revealed she had not been trained in putting on splints on Resident #1's hands. She has never put them on. She said therapy would put them on. She is not able to straighten the residents fingers out all the way. We put a washcloth in her hand when we shower her and check her nails. The nurse cuts them every other weekend at least; to keep her fingernails from cutting into her palm. She has not been told to put washcloths rolls in her hands during the day but has seen them in there before. She assumed therapy was putting them in. She is not able to straighten the resident's elbows. She always has the weighted stuffed animals in her arms. She is not able to straighten the resident's knees. Observation on 06/12/23 at 6:04 P.M. revealed Resident #1 was in bed with stuff animals in her arms. Her fingers/hands were clenched into fists. There were no splints, braces, or rolled washcloths applied to either hand. Interview and observation 06/12/23 at 6:04 P.M. with STNA #117 revealed she attempted to provide range of motion to Resident #1's fingers and was unable to move them on either hand. STNA #117 was able to get the resident's right wrist to straighten but not the left. Both knees were contracted with the left knee worse than the right knee. The STNA was unable to straighten either knee fully. STNA #117 verified the resident did not have a washcloth, splints or palm guards on her hands. Interview 06/12/23 at 7:28 P.M. with the Administrator and the Director of Nursing revealed the Director of Nursing just started the end of March so she would not of been the one taught about the restorative program for Resident #1 in October. The Administrator verified they did not have a restorative program in October of 2022. They had a maintenance program the aides were to do. The Administrator and Director of Nursing verified they could not find where the October programs were written for Resident #1. A paper referral would have been written for nursing. They verified the staff would not know to do it when the programs were not written in the TASK or treatments. They included a nurse was trained for restorative 03/16/23 and they started a restorative program 03/29/23. A new unit manager had been hired with restorative experience, but he had not started yet. 2. Review of Resident #40's medical record revealed a 04/23/21 admission with diagnosis including wedge compression fracture of first lumbar vertebra, Vitamin D deficiency, dementia with behavioral disturbance and mood disturbance, spinal stenosis, and Alzheimer. Review of the 03/02/23 Quarterly MDS revealed the resident was severely impaired for daily decision making with delusions, but no rejection of care or other behaviors. The resident was extensive, two-person assistance for bed mobility, transfer, and toileting. Extensive, one-person assistance for dressing, and walking in room. The resident was supervision, one-person assistance for eating. She had no impairment of the upper or lower extremities. Mobility devices included a walker and wheelchair. She was always incontinent of urine and frequently incontinent of bowel with no venous or pressure ulcers. Review of therapy records revealed the resident was in occupational therapy from 01/02/23 to 03/02/23 working on sitting with functional endurance, bilateral upper extremity strength, good positioning in bed for feeding, improving wheelchair posture and the ability to complete toileting with contact guard assist. Review of the Occupational therapy discharge revealed a 03/02/23 discharge date . The discharge read a referral was completed to the restorative nursing/functional mobility program. There was no evidence of what the program was related to and no evidence the program was written by the nursing department. There were no instructions in Task for the State tested Nurse Aides to follow, there was no physician order or treatment orders written. There was no restorative plan of care for March of 2023. Interview 06/12/23 at 7:21 P.M. with COTA #140 revealed the resident was picked up for therapy based on a screening. A handwritten referral sheet would have been given to nursing outlining what the restorative program was to include/address. COTA #140 included the resident was picked up by physical therapy on 03/17/23. Interview on 06/12/23 at 7:28 P.M. with the Administrator and the Director of Nursing revealed they did not have any evidence of the resident receiving a restorative/maintenance program after her 03/02/23 discharge from occupational therapy. The facility did not provide a restorative program policy. This deficiency represents noncompliance investigated under Master Complaint Number OH00143484 and Complaint Number OH00138029.

Based on record review, email review, policy review and interview, the facility failed to provide requested copies of resident medical records timely. This affected one resident (Resident #1) of three residents reviewed for medical records. The census was 59. Findings include: Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses including anoxic brain damage, nontraumatic intracerebral hemorrhage, presence of cerebrospinal fluid drainage device, need for assistance with personal care, contracture left elbow, right hand, left hand, muscle wasting and atrophy. Review of the Admission five day Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident was never understood, extensive two-person physical assist with bed mobility, and dressing, total dependence, and two-person physical assist with transfer, eating, and toileting. The Quarterly MDS assessment dated [DATE] revealed the resident was never understood, had no psychosis, no behaviors or rejection of care. Total dependence, two-person assist for bed mobility, transfer, and personal hygiene. The resident was total dependence, one-person assist for dressing and eating. The resident had functional range of motion (ROM) impairment on both sides of upper and lower extremities. The resident had an indwelling catheter, and was always incontinent of bowel. Interview on 06/12/23 at 12:13 P.M. with Medical Records #86 revealed the guardian had requested medical records three times. Review of emails revealed on 09/03/22 a request from the residents brother, who was filing for guardianship, was emailed to the Admission Director #83 for care plans. The email was forwarded to medical records on 09/06/22. Also on 09/06/22 Admissions sent the guardian an email that requests for medical records would need to go through Medical Records #86. Medical Records #86 was copied on the email. There was no evidence of Medical Records #86 forwarding a release of medical record form to the guardian. On 09/13/22 the guardian emailed Medical records #86 as well as the Administrator informing them he had not heard back on the care plan documents and he also requested the emergency evacuation plan for his sister who was totally dependent on staff. He said he filed for guardianship and was waiting on the background check. He emailed again on 09/14/22 and asked if he could get the medical records on his sister by 09/15/22. On 09/15/22 Admissions #83 emailed the guardian medical records was off. On 09/16/22 Medical Records #86 emailed the brother 29 pages of care plans without proof of guardianship or a signed medical release. On 09/21/22 Medical Record's #86 sent an email to the company's lawyer. She wrote the brother was going for guardianship and she doesn't feel comfortable with this (providing medical information). He (the company lawyer) emailed her back the same day and told her to give the resident's brother a release form as the first step and explain the facility can only give the information based on the criteria on the form. Medical Records sent the brother an Authorization for Release of Health information on 09/21/22. After being informed Resident #1 reached her maximum potential in therapy on 11/18/22 the guardian emailed a request to Director of Therapy #90 as well as the Administrator, Social Services #90, for Resident #1's start to finish dates for therapy and day to day exercises that were performed. On 11/23/22 the guardian sent a follow up email to the same staff expressing he did not receive a response related to his request. The Administrator emailed the guardian and stated she did not realize medical records was not copied on the email and advised him to go through medical records, who she copied on the email. The guardian sent an email to medical records on 11/23/22 requesting physical and speech therapy records, time and date of attempts on the following: concussion specialist, cardiology referral, and date change of the cat scan of the brain in 03/2022 to evaluate for reoccurrence of aneurysm. Medical Records #86 sent him an authorization for release on 11/25/22. The guardian returned the request the same day requesting physical and speech therapy records. He noted the office had a copy of the guardianship from probate court. Medical Records #86 sent him a copy of the cost to obtain the medical records 09/28/22 and he paid the fee the same day electronically. The records were available for pick up on 11/29/22. On 05/31/23 the guardian sent an email to Activities #138, Social Services #82, Medical Records #86, Registered Nurse #139, Director of Rehabilitation #90, the Director of Nursing and Registered Nurse #121 with a release form for what exercises or program was provided and completed during physical and occupational therapy, the baseline data and progress reports, information on how often the restorative information would be reviewed and what exercises, therapies would it entail and if activities had worked with the resident prior to now. The Director of Rehabilitation emailed him back on 06/01/23 and informed him he could request therapy documentation from medical records that would show the baseline and progress made. The Director of Rehabilitation Informed him therapy screened every three months to check for a decline and nursing would also notify therapy if there were concerns. The restorative program would consist of passive range of motion to the upper and lower extremities up to five days a week. Palm guards/hand rolls up to six hours daily. The guardian replied the same day he attached the release in the first email and included Medical Records #86. He also asked to please confirm he did the correct process so he could get the records in a timely manner. The Administrator replied the same day that Medical Records works part time. Medical Records was added to the email on 05/31/23 and would reach out to him directly with any concerns. Each new request needed a new signed request. If Medical Records is out of the building another staff would fill the request. She informed him Medical Records could email the information or fax if he preferred. The guardian responded the same day, on 06/01/23 asking medical records to let him know as soon as possible if medical records needed anything else signed. He asked that the records be left at the front desk for his mother to pick up. If this is an issue or will hold up getting the information to him he will provide a secure email/fax. Last time he was told she did not do that. Also asked that the cost be sent to him so he could log in to pay the fee. The resident's brother was not provided the therapy records until 06/08/23. The activity records were not provided at that time. Interview on 06/12/23 at 1:47 P.M. with Medical Records #86 revealed she did not respond to the 09/03/22 request for medical records timely. She did not reach out to the resident's brother and inform him of the need for a signed release and the fee schedule to obtain the medical records. The resident's brother had requested medical records 09/03/22 and they were not provided until 09/16/23. Further, she provided the records without a signed release or proof of guardianship. For the 11/18/22 request no one sent her the email to inform her of the request until 11/23/22. She was off and no one else provided the release of information authorization to the guardian which delayed them being ready until 11/29/22. On 05/31/23 the guardian requested information and copied her on the email. The guardian was not provided the requested records until 06/08/23. With that the activity records were not provided because there were none available. Review of the facility release of medical records policy revised 06/2023 revealed request for records to be referred to the Director of Nursing or Administration or another staff member previously designated by the facility. Upon request to assess or obtain copies of medical records the facility should review the authorization to ascertain access rights of that person. Authority to assess or release records is only granted by the resident or the resident's legal representative. The facility should request copies of any legal papers necessary to authenticate authority. The legal papers should be attached to the request for records. A valid request for medical information concerning a resident, by a party other than the resident includes: name of resident, name and address of facility and name and address of individual or organization requesting information, specific information reports requested, period of stayed for which information is to be released, date of request, signature of the resident or legally appointed representative authorizing release of information. Upon receipt of a request for medical record copies the facility should notify the requesting party in writing of the cost for obtaining records, and that records are available two days after receipt of payment for the copies. Copy should not be released prior to receipt of payment for copying charges. The resident and or his legal representative may receive a copy of his or her record within two working days after the request has been made. Family has no right to assess the resident's medical record without a valid authorization by the resident or his her legal representative. This deficiency represents noncompliance investigated under Master Complaint Number OH00143484 and Complaint Number OH00138029.

Based on medical record review and interview, the facility failed to ensure assessments accurately reflected activities of daily living (ADL) assistance level. This affected one resident (Resident #1) of three residents reviewed for ADLs. The census was 59. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included non-traumatic intracerebral hemorrhage, anoxic brain damage, poisoning by unspecified drugs, presence of cerebrospinal fluid drainage device, paraplegia, muscle wasting, and neuromuscular dysfunction of bladder. Review of a hospital history and physical report, dated 05/04/22, revealed Resident #1 responded to noxious stimuli, opened eyes, was unable to follow commands, and unable to voice needs. Review of the Physical Therapy Evaluation and Plan of Treatment, dated 06/07/22, revealed the functional assessment for bed mobility indicated Resident #1 was totally dependent without attempts to initiate and had flaccid muscle tone. Review of the Minimum Data Set (MDS) 3.0 Five-Day assessment, dated 06/10/22, inaccurately revealed that Resident #1 required extensive, two-person physical assistance for bed mobility and dressing. During interview on 06/12/23 at 11:29 A.M., Licensed Practical Nurse (LPN) #120 confirmed Resident #1 is totally dependent on two-staff for bed mobility and dressing. During interview on 06/12/23 at 5:45 P.M., MDS/LPN #80 stated the MDS 3.0 5-Day assessment, dated 06/10/22, was incorrect and should have indicated the resident required total dependence with bed mobility and dressing. This deficiency represents non-compliance investigated under Master Complaint Number OH00143484.

Based on observation, review of the medical record, facility soft file, the facility policy titled At Risk for Wandering Resident, the facility policy titled Missing Resident and/or Elopement, the facility policy titled Accidents and Incidents- Investigating and Reporting, the accuweather.com weather website, staff interview, interview with Physician #50 and Medical Director (Physician) #60 the facility failed to provide adequate supervision to prevent the elopement of two residents (Residents #17 and #27) who were identified to be at risk for elopement and had physician orders for wander guard (a patient tracking bracelet device that alerts staff of unaccompanied exit) devices. This resulted in Immediate Jeopardy when Resident #27 eloped from the facility on 02/26/18 at 10:29 A.M. without staff knowledge. The potential for serious harm occurred when Resident #27 was found by an off duty employee on 02/26/18 at 10:52 A.M. 0.4 miles from the facility. The Immediate Jeopardy continued on 03/16/18 at 5:55 P.M. when Resident #17 eloped from the facility without staff knowledge. The potential for serious harm occurred when Resident #17 was observed outside the facility by Resident #2 who alerted staff. Staff located the resident off the facility premises on 03/16/18 at 6:07 P.M. 0.1 mile from the facility. This affected two of 11 residents identified to be at risk for elopement with wander guard bracelets in place (Resident #8, #17, #20, #27, #28, #31, #33, #45, #48, #50 and #51). On 05/21/18 at 2:45 P.M., the Administrator, Vice President of Clinical Services #27 and Corporate Director of Clinical Compliance #61 were notified the Immediate Jeopardy began on 02/26/18 at 10:29 A.M. when Resident #27 left the facility without staff knowledge. Staff were unaware the resident was missing until off duty employee, State tested Nursing Assistant (STNA) #45 found the resident 0.4 miles from the facility. The resident reported she was going home and provided the name of a town 28 miles away from the facility. The Immediate Jeopardy continued on 03/16/18 at 5:55 P.M. when Resident #17 left the facility without staff knowledge. Staff were unaware the resident was missing until Resident #2 reported to staff that Resident #17 was outside and was not supposed to be. Resident #17 was located 0.1 miles from the facility. Both residents had active care plans in place reflecting they were at risk for elopement and both residents had physician orders and a care planned intervention to wear a wander guard bracelet. Neither resident was wearing the wander guard bracelet at the time they exited the facility unattended and unknown by staff. The Immediate Jeopardy was removed on 05/22/18 when the facility implemented the following corrective actions: · On 02/26/18 after returning to the facility, Resident #27 was placed on 15 minute checks. The resident was subsequently transferred to the hospital for a psychiatric evaluation on 02/27/18. On 05/14/18 the resident's wander guard was discontinued. On 05/22/18 Resident #27 was reassessed by the DON and determined to be at risk for elopement. A wander guard was applied at that time and orders were written to check the wander guard placement three times a day by the nurse. STNA staff were provided with a plan of care task to check and document the resident's wander guard placement every two hours. On 05/22/18 a new plan of care for elopement was implemented by Registered Nurse (RN) #8. · On 03/16/18 after returning to the facility Resident #17 was placed on 15 minute checks for 72 hours after the incident. The resident's wander guard was discontinued on 05/14/18. Resident #17 was reassessed by the DON on 05/22/18 and determined to be an elopement risk. The wander guard was reapplied at that time and orders were written to check the wander guard placement three times a day by the nurse. STNA staff were provided with a plan of care task to check and document wander guard placement every two hours. On 05/22/18 a new plan of care for elopement was implemented by RN #8. · On 05/11/18 and then again on 05/21/18 all department heads including the Administrator, the DON, Assistant Administrator #95, Therapy Director #500, STNA Supervisor #40, Activity Director #55, Dietary Manager #74, Housekeeping Supervisor #37 and Business Office #501 provided all staff in-service training related to At Risk for Wandering Resident and Missing Resident and Elopement of resident policies. This included 7 housekeeping and laundry staff, nine licensed nurses, nine dietary staff, three activity staff, 13 therapy staff, 15 department managers and 22 STNAs. A plan for educating the seven remaining facility staff members (RN #2, LPN #47, STNA #62, Nursing Assistant (NA) #12, Housekeeping Aide #70, NA #19 and STNA #49) prior to their next scheduled shift was implemented. · On 05/15/18 at 9:08 A.M. and 3:25 P.M. and on 05/21/18 at 1:12 P.M., 3:20 P.M. and 6:10 P.M. Maintenance Director #67 and the Administrator conducted elopement drills for staff on duty at the time of each drill. Sign in sheets were completed for record of the staff participating in each drill. · On 05/20/18 and 05/21/18 by 4:30 P.M. Maintenance Director #67 and Assistant Administrator #95 inspected all doors to ensure the door alarms were functioning properly for residents who utilize the wander guard system. · On 05/21/18 all residents were re-assessed by the DON and RN # 8 for risk for wandering. In addition, the DON and RN #8 verified wander guard orders were complete, wander guard placement was checked, care plans were in place for exit seeking risk and Kardex information was updated for residents with exit seeking risk. · On 05/21/18 at 7:00 P.M. the facility identified nine additional residents at risk for elopement/wandering (Resident #8, #20, #28, #31, #33, #45, #48, #50 and #51). All residents at risk for wandering were reviewed to ensure wandering interventions remained appropriate. · On 05/21/18 at 6:45 P.M. a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, DON and Medical Director #60 to discuss concerns identified by the State agency in regard to resident elopements. A plan was developed for the DON/designee to monitor weekly for four weeks and then monthly for two months on staff response to elopement risk residents with the results to be reported to the QAPI committee. · On 05/22/18 Assistant Administrator #95 and Receptionist #65 checked Resident #17 and #27's room for sharp objects that could be used to remove a wander guard band. A plan for the rooms to be checked every shift by nursing staff and provide plastic knives only with meals was implemented. · On 05/22/18 at 2:30 P.M. the DON updated the elopement books maintained by the facility. The books were kept at both nursing stations and the front desk/main reception area of the facility. · On 05/22/18 a plan to install a delayed egress mag lock on the solarium door, the door into the lobby/main entrance area was implemented. On 05/23/18 at 3:15 P.M. observation of the solarium door revealed the mag lock had been installed and the door had a 15 second delayed egress function with a key code pad required to enter to the main lobby installed by Interstate Fire Company. · On 05/22/18 between 1:30 P.M. and 1:45 P.M. interviews with LPN #23, Receptionist #65, Social Service Director #52, Laundry Aide #56 and Activity Director #55 revealed all staff were knowledgeable of the facility elopement policy and procedures, able to identify residents at risk for elopement and able to identify what to do if a resident voiced a desire to leave the facility. Although the Immediate Jeopardy was removed on 05/22/18, the deficiency remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that was not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan to ensure all residents at risk for elopement were monitored appropriately for on-going compliance. Findings include: 1. Review of Resident #27's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care, initiated 12/26/15 which identified Resident #27 was at risk for elopement related to impaired safety awareness as evidenced by a history of attempts to leave the facility unattended. Interventions included to distract resident from wandering by offering pleasant diversions, food, conversation, television and books, make sure all staff were aware of elopement risk, resident to reside on secured unit related to mild cognitive impairment, staff or family to accompany resident when the resident leaves the unit and/or facility and in 10/2017 the use of a wander guard device. Record review revealed a Statement of Expert Evaluation, dated 07/13/16 and completed by Physician #100 which indicated due to Resident #27 not being capable of caring for activities of daily living or making decisions concerning medical treatments, living arrangements or diet and the condition not being stabilized and not reversible, guardianship was recommended. As of 05/23/18, guardianship had not been established for the resident. Record review revealed a physician order dated 10/03/17 for a wander guard device to be worn at all times, check placement every shift. A second order, dated 10/08/17 indicated to check placement of wander guard every Sunday. Review of a Risk of Elopement/Wandering Evaluation, dated 12/06/17 revealed Resident #27 was at low to no risk for elopement risk due to no previous attempts to leave the facility. Further review revealed an evaluation, dated 03/02/18 that noted the resident was at low to no risk for elopement. However, there were no changes made to the resident's plan of care for elopement and no changes to the physician's order for the wander guard device following either of these evaluations. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #27 had moderate cognitive impairment and displayed inattention. The assessment revealed Resident #27 wandered one to three days during the assessment period. Further review revealed the resident required supervision with activities of daily living including locomotion on and off the unit and the resident wore a wander/elopement alarm daily to monitor the resident's movement and alert the staff when movement was detected. Review of the nursing progress note, dated 02/26/18 at 10:28 A.M. and authored by the DON revealed Resident #27 had been seen walking throughout the facility that morning as she often does daily. The note revealed the resident had capacity and stated she had a home in another town that she could go to live but this was not the case for the resident. The resident could give detailed directions to the home. The weather outside was sunny and 53 degrees when the resident decided she wanted to walk out of the facility. Resident #27 was dressed appropriately wearing a tee shirt, sweatshirt, sweat pants and tennis shoes. The note stated the resident returned to the facility on her own accord. The note indicated the Director of Nursing (DON) and Social Service Director #52 met with the resident about the proper way to discharge from the facility. The note indicated the resident did wish to discharge and social services was working on the discharge process with the resident. Although the note was dated 02/26/18 at 10:28 A.M. it was entered into the resident's electronic medical record until on 02/26/18 at 4:29 P.M. Review of the nursing progress note, dated 02/26/18 at 4:27 P.M. revealed Resident #27 was pacing the hallways, making comments You can't keep me locked up back here. I'll leave out that emergency exit. You better give me a sedative or I'm leaving out that back door. The resident was provided one to one and verbal counseling with little effect. Checking wander guard placement frequently and continuing with 15-minute checks. The resident was in her room watching television at the time. Review of the nursing progress note, dated 02/27/18 at 1:00 A.M. revealed Resident #27 was lying in bed with her eyes closed. The note indicated tolerating room and hall change (but provided no additional information related to when or why a room change was completed). On 02/27/18 at 7:07 P.M. the resident was transferred to the local hospital where she was treated for [REDACTED]. The hospital record reflected the resident had left the facility unsupervised with the intent of walking home. The resident was assessed by hospital staff to have poor insight and judgement with thought processes becoming extremely disorganized and tangential (sidetracked) with pressured speech. Review of a Hospital Report of Consultation Discharge Summary, dated 03/01/18 revealed Physician #200 assessed the resident not to be competent to make informed healthcare decisions. Review of the Hospital Discharge instructions, dated 03/02/18 revealed Resident #27 was to live with supervising staff. The instructions reflected she had been admitted for a brief [MEDICAL CONDITION] and was delusional at times. The resident was unable to sign her discharge instructions due to her cognitive function. Review of the nursing progress notes dated 03/02/18 at 4:30 P.M. revealed Resident #27 returned from a local hospital. A code alert (wander guard) bracelet was applied and 15-minute checks were implemented. Review of the (MONTH) (YEAR) Treatment Administration Record revealed daily documentation of the wander guard placement being checked every shift through the week of 02/26/18. During the onsite survey, from 05/19/18 through 05/21/18 at 8:38 A.M. the facility was unable to provide any documentation/investigation related to the incident of Resident #27 leaving the facility unsupervised. There was no evidence the incident had been identified as an elopement, investigated as an elopement or reported to the State Agency as a possible incident of neglect. The only documentation of the incident was the nursing progress note as documented above on 02/26/18 at 10:28 A.M. On 05/19/18 at 10:55 A.M. interview with State tested Nursing Assistant (STNA) #45 revealed she was not working on 02/26/18 but was sitting on her porch at home the morning of 02/26/18 when she saw Resident #27 walk past her house at a quick pace, headed toward the flower shop. The STNA revealed the weather was chilly that morning. STNA #45 stated she was unsure of the time but told her boyfriend to get her shoes and coat and she began to walk with the resident. STNA #45 stated she called the facility and informed Registered Nurse (RN) #1 that Resident #27 had left the building and did not have staff with her. STNA #45 shared the resident was about five to six blocks from the facility and was wearing a sweatshirt, sweat pants and shoes. STNA #45 stated the resident informed her she was walking to her hometown. An additional interview with STNA #45 on 05/20/18 at 9:41 A.M. revealed the area beyond the flower shop began to be less and less populated, less traveled and more of a wooded area. On 05/19/18 at 12:23 P.M. the suspected route the resident took after leaving the facility was observed. The distance from the facility to the floral shop was 0.4 miles. The first 0.2 miles of the walk was up a gradual incline hill, with uneven sidewalks. The resident had to cross a main street to proceed with the walk. On 05/19/18 at 2:02 P.M. interview with Resident #27 revealed she felt she was stuck at the facility and was able to recall that she tried to leave the facility during the end of February. The resident stated the facility made her empty promises to get her to return. When asked about the empty promises the resident indicated the social services director informed her they would work on a discharge plan but nothing had been done. Lastly, Resident #27 shared the DON had removed her wander guard bracelet a few days ago stating, I trust you. The resident was not observed to have a wander guard device in place at that time. On 05/19/18 at 3:29 P.M. interview with RN #1 revealed on 02/26/18 she received a phone call but was unsure who the caller was. The caller stated Resident #27 was missing but she wasn't sure if the caller was accurate. A head count was completed in the facility at that time RN #1 determined Resident #27 was missing. A code white (missing resident) was announced and a search began. RN #1 was unsure how long the resident had been gone without staff knowledge. The RN stated residents, (including Resident #27) with wander guard devices were not to be outside unsupervised due to their risk of elopement. Residents able to leave the facility without supervision were to sign themselves out, however Resident #27 had not signed out which was another indicator she could not be out of the building unsupervised. RN #1 stated the facility did not consider Resident #27 leaving the facility without staff knowledge an elopement because the resident's Brief Interview for Mental Status (BIMS) score was high (cognitive level). RN #1 did not recall assessing the resident upon her return to the facility despite the policy for missing residents that indicated an assessment should be completed upon the resident's return. RN #1 stated if she completed an assessment, it would have been documented in the medical record. Lastly, RN #1 stated after the resident returned to the facility, she was moved to the secure unit for her safety and then subsequently transferred to a local hospital for a psychiatric hospital stay due to behaviors she was exhibiting. On 05/20/18 at 9:45 A.M. interview with Housekeeper #33 revealed Resident #27 had told her on several occasions she wanted to leave the facility and would do so when someone wasn't at the front desk. Housekeeper #33 revealed the resident had told her the best time to leave would be during the morning meeting when no staff were monitoring the doors. Housekeeper #33 stated she had informed RN #1 of the resident's statement but could not recall when. On 05/20/18 at 11:25 A.M. interview with STNA #4 revealed she worked on the unit Resident #27 resided on at the time the resident left the building unsupervised. STNA #4 stated the last time she could recall seeing Resident #27 on the day of the incident was at approximately 9:00 A.M. She stated when the code white was announced, STNA #4 assisted with a full head count and then was directed to continue to provide care to the residents on the unit. On 05/20/18 at 11:59 A.M. interview with Physician #50 revealed Resident #27 required 24-hour care and was unable to make good decisions about her safety every day. Further interview revealed he did not have a psychiatric background but trusted the assessments from psychiatrists indicating the resident could benefit from a guardian. On 05/20/18 at 2:30 P.M. interview with Receptionist #65 revealed she was not working the morning Resident #27 left the building. The receptionist said when she was not scheduled to work, a receptionist was not at the front desk. Receptionist #65 stated the resident had expressed in the past she wanted to leave and could not be outside unsupervised due to the wander guard bracelet which indicated the resident was at risk for leaving the facility unsupervised or wandering. Receptionist #65 stated the resident left during a time no one was present at the front desk. Morning meeting began at 9:30 A.M. and non-medical staff were present for the first 20 to 30 minutes of the meeting. On 05/20/18 at 3:17 P.M. interview with Maintenance Director #67 revealed only the front door of the facility was equipped and alarmed with the wander guard system. All of the other doors to the exterior of the facility were delayed egress doors which alarmed when they were opened regardless of whether a resident was wearing a wander guard device. Maintenance Director #67 verified he was working on 02/26/18 and participated in the search for Resident #27. The resident was not located on the premises but other staff had left to search off facility property. Maintenance Director #67 revealed the wander guard system was checked weekly and to his knowledge Resident #27 had removed her wander guard before exiting the building. On 05/21/18 at 9:19 A.M. an additional interview with Maintenance Director #67 revealed he had reviewed the security camera footage on 02/26/18 and determined Resident #27 exited the building on 02/26/18 at 10:29 A.M. Maintenance Director #67 stated he received a text message from RN #1 at 10:52 A.M. stating the resident had been found. This camera footage was not available for the surveyor to review during the onsite investigation. On 05/20/18 at 5:30 P.M. interview with the Administrator, DON, Vice President of Clinical Services #27 and Administrator in Training #76 revealed on 02/26/18 between 9:30 to 10:30 in the morning, during the morning meeting, the DON was informed Resident #27 had cut off her wander guard bracelet and left the building unsupervised. The DON stated Activity Director #55, Central Supply #77 and Social Services Designee (SSD) #52 left the facility in vehicles to search for Resident #27. The DON verified facility staff reached the resident on 02/26/18 at 10:52 A.M. 0.4 miles from the facility at a local floral shop. The DON shared the facility did not determine the incident was an elopement because the resident had a BIMS score of 11, which reflected moderate cognitive impairment. The DON did however verify the resident had a current plan of care in place related to a risk for elopement with interventions and a physician order for [REDACTED]. Further interview with the DON revealed the facility did not investigate the incident and verified the only documentation available was the nursing progress note, written by the DON and the 15-minute checks completed by the staff following the incident (the 15 minute checks were completed from the time the resident returned to the facility until she was transferred to the hospital). The DON was unable to provide details related to the incident due to the lack of investigation. The DON shared the resident was taken to the facility secured unit after the incident to ensure the resident's safety and then she was sent for a psychiatric evaluation the following day. The Administrator then stated the only interventions implemented for the incident were 15 minute checks for Resident #27 until she transferred to a hospital. The Administrator then revealed a door chime was also placed on the front door to prevent residents from exiting the building unsupervised. On 05/21/18 at 8:55 A.M. interview with Housekeeping Director (HD) #35 revealed he was directed to look for Resident #27 in her room by RN #1 and he discovered Resident #27's wander guard bracelet in the top drawer of her night stand under some papers with a butter knife also in the drawer. He stated the band looked as if someone had sawed at the band to remove it. HD #35 stated he thought he had seen someone walk past the window from room [ROOM NUMBER] on(NAME)but was unable to determine if it was Resident #27 or a staff member searching the area. HD #35 stated he was not asked to give a statement related to the incident until 05/20/18. On 05/21/18 at 11:00 A.M. interview with Vice President of Clinical Operations #27 verified the incident involving Resident #27 met the definition of an elopement per the facility policy and she was unsure why the facility did not treat the incident as an elopement. On 05/22/18 at 8:34 A.M. interview with the Medical Director, Physician #60, revealed he was the medical director of the facility and had provided medical care to Resident #27 in the past. He shared the resident no longer wanted his services, viewed him as the facility warden and blamed him for her being at the facility. Resident #27 had previously requested another physician and fired Physician #60. The physician stated he had a psychiatry background and felt Resident #27 was unable to make safe decisions and would be unable to live alone. Physician #60 stated he was aware of the incident but was not asked to assist with implementing measures to prevent Resident #27 from eloping again. Physician #60 stated it may be beneficial to obtain a psychiatric evaluation to determine why the resident was cutting off her wander guard bracelet On 05/22/18 at 2:24 P.M. interview with RN #38 revealed Resident #27 would discuss leaving the facility and expressed she was not always happy with placement. RN #38 stated since the resident expressed leaving the facility, she would consider the resident at risk for elopement. RN #38 stated night shift staff were responsible to monitor all residents to ensure they don't elope from the facility. Review of the Accuweather.com weather website revealed the low temperature on 02/26/18 for Cadiz was 36 degrees Fahrenheit and the high was 52 degrees Fahrenheit. Review of the facility incident log for three months did not indicate elopements had occurred. 2. Review of Resident #17's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care, initiated on 09/11/17 indicating the resident was at risk for elopement related to [MEDICAL CONDITION]. Interventions included to observe for signs the resident may be planning on leaving such as statements that he is going to leave, intervene by asking him if he is going somewhere and offer an alternate activity. The care plan was updated on 09/11/17 to reflect a wander guard was to be worn at all times to alert staff of attempts to leave the facility without supervision. Record review revealed a physician order, dated 09/17/17 for a wander guard device and an order dated 10/03/17 to monitor for exit seeking behavior every shift. On 09/17/17 an order was obtained to check wander guard placement every shift. Review of the quarterly MDS 3.0 assessment, dated 03/31/18 revealed Resident #17 had moderate cognitive impairment and required supervision with activities of daily living including locomotion on and off the unit. The resident did not exhibit wandering behavior during the assessment period but wore a wander/elopement alarm daily. Review of the Risk for Elopement/Wandering Evaluation, dated 03/08/18 revealed Resident #17 was not identified as an elopement risk. However, no changes were made to the resident's plan of care or physician orders related to the use of the wander guard at that time. Review of the nursing progress notes, from 02/01/18 to 05/23/18 revealed no indication Resident #17 left the facility unsupervised. Interviews with three anonymous staff members on 05/19/19 and 05/20/18 revealed they were aware Resident #17 had eloped from the facility. Although none of the staff interviewed could provide an exact date. all of the staff indicated Resident #17 had eloped after Resident #27 had eloped from the facility. On 05/21/18 at 11:40 A.M. during an interview the DON verified Resident #17 had eloped from the facility on 03/16/18. Interview with the DON verified Resident #17's medical record did not contain any documentation of the incident. The DON stated this was because the facility did not consider it an elopement because of the resident's BIMS score even though the resident had a care plan in place indicating he was at risk for elopement and had a physician order for [REDACTED]. The DON shared she was informed of the incident on 03/16/18 and stated she thought the resident had left the facility and made it across the street and then was discovered by staff. Further interview revealed the resident was originally observed by Resident #2 walking out of the front door of the facility and it was Resident #2 who alerted the staff. Review of the typed note from the soft file, dated 03/16/18 revealed the DON was notified by the facility that Resident #17 was seen by another resident walking up the parking lot. Resident #17 was safely returned to the facility by staff. No injuries were reported. The resident verbalized he was going to see his niece that takes him out on leave periodically. The DON advised the staff to place the resident on 15-minute checks throughout the weekend. On 05/22/18 at 8:34 A.M. interview with the Medical Director, Physician #60, revealed he was the medical director of the facility and was the primary care physician for Resident #17. The physician stated he had a psychiatry background and felt Resident #17 was unable to make safe decisions for himself. Physician #60 stated he was aware of the incident but was not asked to assist with implementing measures to prevent Resident #17 from eloping again. Physician #60 stated he did not recall being informed the resident had actually made it out of the facility parking lot. On 05/22/18 at 12:17 P.M. interview with Dietary Manager #74 revealed he saw RN #38 on 03/16/18 waking on the street in front of the facility looking for Resident #17. The resident had stated he was going to his niece's. He stated staff were able to bring Resident #17 back to the facility. On 05/22/18 at 1:05 P.M. the route to the location the resident was located at was traveled. The car wash, which was noted to be 0.1 miles from the facility was not an operational car wash and had large work truck/equipment trucks on site. On 05/22/18 at 2:24 P.M. interview with RN #38 revealed Resident #17 would frequently discuss leaving the facility and going to his niece's house. Further interview revealed the resident had been seated in a chair by the Shay unit nurses' station on 03/16/18 during shift report/change of shift. RN #38 stated Resident #2 then informed LPN #20 and herself that Resident #17 was walking on the sidewalk at the front of the building. RN #38 immediately went out the front door to find the resident. She saw the resident headed towards the small car wash/truck area near the facility. Dietary Manager #74 approached RN #38 with his personal vehicle and asked RN #38 to ride with him to get the resident from the car wash. Both staff were able to get the resident to return to the facility in DM #74's personal vehicle. RN #38 stated Resident #17 was at risk for elopement and utilized a wander guard device prior to and at the time he eloped from the facility. Interview revealed RN #38 stated she kept an eye on Resident #17 because of his frequent expressions to leave the facility to see his niece and his successful elopement to the car wash. Review of the facility policy titled, Accidents and Incidents- Investigating and Reporting dated 2001 and revised 02/2014 revealed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the facility premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident Form: the date and time the accident or incident took place, the circumstances surrounding the accident or incident, where the accident or incident took place; the names of witnesses and the accounts of the accident or incident; any corrective action taken; follow up inf (TRUNCATED)

Based on observation, medical record review, policy review and interview the facility failed to ensure two residents at risk for pressure ulcers (Residents #9 and #67) were provided care and services including implementation of treatments and interventions to prevent the development or worsening of pressure ulcers. Actual Harm occurred when the facility failed to prevent the development of a deep tissue injury to Resident #9's right and left heel, failed to prevent the deterioration of the area to the right heel to an unstageable pressure ulcer, and failed to ensure adequate treatment and pressure relieving interventions were in place to promote healing. Actual Harm occurred when Resident #67's facility acquired Stage II coccyx pressure ulcer deteriorated to a Stage III pressure ulcer on [DATE] and the pressure ulcer continued to decline without a change in treatment for 27 days. This affected two (Resident #9 and #67) of three residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. Findings include: 1. Medical record review revealed Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan: Impaired Skin Integrity initiated on [DATE] revealed interventions including to update family with changes in condition or treatments. Review of the Braden Skin Risk assessment dated [DATE] revealed Resident #9 was at moderate risk for pressure ulcer development. Review of the progress note, dated [DATE] revealed Resident #9 had a deep tissue injury resulting from a facility acquired broken blister on the right heel. The resident's left heel was intact at the time of the assessment. Review of the Physician Orders, dated (MONTH) (YEAR) revealed to float heels in bed with bilateral pressure relief ankle foot orthosis (PRAFO) boots and a foot board in bed with a black cushion for heel protection. The order also indicated for the PRAFO boots to be worn when up in chair/wheelchair. On [DATE] at 10:40 A.M., observation revealed Resident #9 was lying in bed on his right side. The resident was not wearing any pressure relieving boots and feet were crossed without any pressure relief. On [DATE] at 3:06 P.M., observation of Resident #9's right heel dressing change revealed the entire heel was covered with adherent black/brown eschar with scant bloody drainage. The wound measured approximately 5.0 cm in (l) by 5.0 cm in (w). The outer left ankle was observed to have a circular black eschar area measuring approximately 1.0 cm in diameter. There was no dressing or treatment completed to the area. On [DATE] between 9:15 A.M. and 9:26 A.M., observation revealed Resident #9's feet were crossed without any pressure relief. The left foot was observed to be pressed against the medial and top portion of the right foot. The resident's specialty mattress was set to firm, normal pressure. At the time of the observation, Licensed Practical Nurse (LPN) # 20 verified the resident's pressure relieving interventions were not in place as ordered and a healed pressure area on the left ankle had reopened. On [DATE] between 11:58 A.M. and 12:06 P.M., observation and interview revealed Resident #9 was seated in the dining room in his wheelchair with bilateral feet pressed against the foot pedals. The resident was wearing a gripper sock on the left foot and had a Kerlix dressing to the right foot and heel. There were no pressure relief interventions including ordered specialty boots observed on the resident. Interview with Licensed Practical Nurse (LPN) #31 verified the resident did not have any pressure relief to either foot. LPN #31 stated when the resident first developed the area to the right heel staff had told her it was a blister but did not say if it was blood-filled or fluid filled. It was unknown how he developed the blister and by the time she arrived to assess the area, the blister had burst. LPN #31 stated it was classified as a deep tissue injury as the area was covered with eschar (dead tissue) and had some bleeding around the outer edge of the wound; however, the pressure ulcer was assessed to be an unstageable pressure ulcer this day. LPN #31 stated the pressure relieving boots were discontinued because the resident crosses his feet, with and without the boots, and that caused additional pressure leading to the decline in the wound. LPN #31 stated that was why the boots were not currently on the resident. LPN #31 stated wearing the pressure relief boots was more detrimental to the residents pressure ulcer than the heel pressed against the foot pedal with only a dressing or bone-to-bone contact. When asked what interventions were to be in place when in the wheelchair, the LPN stated the residents Kerlix dressing and foam dressing provided adequate pressure relief for his unstageable pressure ulcer. On [DATE] at 12:38 P.M., observation revealed Resident #9 sitting in his wheelchair in his room with a green pressure relieving boot to the right foot. At the time of the observation, interview with State tested Nursing Assistant (STNA) #21 verified the resident was to wear a pressure relief boot to his right foot. At 12:45 P.M., LPN #31 was observed walking pass the residents room, looked into the room with the resident still sitting in the wheelchair with pressure relief boots on and she did not respond to him wearing the boots. 2. Closed medical record review revealed Resident #67 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #67 expired at the facility on [DATE]. Review of the Braden Skin assessment dated [DATE] indicated the resident was at high risk for pressure ulcer development. Review of the Wound Observation Evaluation assessment dated [DATE] revealed Resident #67 developed a facility acquired Stage II (partial thickness dermis loss) coccyx pressure ulcer measuring 0.6 centimeters (cm) in length (l) by 0.3 cm in width (w) by 0.1 cm in depth (d). The pressure ulcer was documented as healed on [DATE]. Review of the care plan: Potential Impairment to Skin Integrity initiated on [DATE] and revised on [DATE] revealed interventions including to report abnormalities in wounds including failure to heal to the physician. Review of the care plan: Impaired Skin Integrity: Stage II area to coccyx initiated [DATE] revealed interventions including to observed for signs of decline in healing and consult with the physician as needed regarding decline in condition, effectiveness of treatment and/or need for treatment order change. Review of the Wound Observation Evaluation assessments revealed the following: On [DATE], the resident's healed Stage II coccyx pressure ulcer reopened. A treatment was ordered and the wound was being monitored weekly between [DATE] and [DATE]. On [DATE], the coccyx pressure ulcer declined to a Stage III (full thickness tissue loss) pressure ulcer measuring 0.8 cm in (l) by 0.6 cm in (w) by 0.4 cm in (d) with moderate serous drainage. A new treatment to apply zinc paste to the surrounding area, apply collagen and honey dressing to the wound bed, and cover it with AG (silver) foam dressing daily and as needed. There was no evidence the family was notified of the decline until [DATE]. On [DATE], the coccyx pressure ulcer further declined and measured 2.1 cm in (l) by 1.8 cm in (w) by 0.4 cm in (d). There was no change in the treatment of [REDACTED]. On [DATE], the wound continued to decline and measured 5.0 cm (l) by 4.8 cm in (w) by 2.0 cm in (d) with tan slough, a dark wound bed and serous sanguineous drainage. The assessment did not include the amount of slough in the wound, there was no change in treatment and no evidence the physician was notified. Review of the Treatment Administration Record (TAR) dated (MONTH) (YEAR) revealed Resident #67 was turned and repositioned every two hours side-to-side as tolerated and had an air mattress to his bed. The TAR also indicated the resident's coccyx was cleansed with wound cleanser and a treatment of [REDACTED]. Review of the TAR dated (MONTH) and (MONTH) (YEAR) revealed no change in Resident #67's coccyx pressure ulcer treatment between [DATE] and [DATE]. On [DATE] at 3:05 P.M., interview with the Director of Nursing (DON) verified Resident #67's pressure ulcer declined with no change in treatment and no evidence the physician was notified of the decline. On [DATE] at 4:06 P.M., interview with the DON verified the resident's coccyx pressure ulcer had healed on [DATE], the facility completed a treatment with collagen and a foam dressing to the coccyx between [DATE] and [DATE] for prevention and this was not an appropriate preventative treatment for [REDACTED]. At 4:26 P.M., the DON stated she had not seen Resident #67's pressure ulcer but the treatment nurse had informed her weekly of its status. On [DATE] at 8:34 A.M., interview with Physician #60 revealed he was typically notified on an ongoing basis of changes with pressure ulcers due to his frequent visits, as well as, through the facility documentation system. Further interview revealed he would expect an evaluation, at a minimum, to consider changing the resident's treatment if a pressure ulcer declined. The Physician stated declining wounds typically would see the visiting wound specialist at the facility. On [DATE] at 12:26 P.M. interview with LPN #31 revealed she was the treatment nurse, but not wound certified and her schedule was flexible to the needs of the residents. LPN #31 stated she kept the DON and Registered Nurse (RN) #8 informed weekly of the pressure ulcers in the building including measurements. She would either notify the nurse practitioner (NP) or the charge nurse of any changes in the pressure ulcers. LPN #31 verified there was no change in treatment of [REDACTED]. LPN #31 verified there was no documented evidence the NP had been notified and actually documented the area as a Stage II pressure ulcer after it had already declined to a Stage III. The facility had a wound consultant who comes once a month to offer suggestions and recommendations but they do not treat the wounds. Their recommendations were to be reviewed with the physician but the physician does not do anything with the wounds so she only tells the NP. LPN #31 verified this was not documented and the NP note did not correspond with her assessment. Review of the policy: Pressure Ulcer Treatment revised (MONTH) 2013 revealed the facility was to provide for the care of existing pressure ulcers and prevent the development of additional pressure ulcers. Pressure ulcer treatment required a comprehensive approach including debridement interventions and care strategies included to protect, fill dead space, manage drainage and promote a moist wound healing. This deficiency substantiates Complaint Number OH 898.

Based on review of medical records, Emergency Medical Services report, Emergency Department records, incident/accident log, observations, staff interviews, and review of the Missing Resident and/or Elopement of a Resident policy, the facility failed to provide adequate supervision to prevent the elopement of cognitively impaired Resident #55 who was a known elopement risk. This resulted in Immediate Jeopardy when Resident #55 successfully eloped from the secured dementia unit, (Victoria Way), through an alarming door. Licensed Practical Nurse (LPN) #48 did not know the alarm signaled an outside door was opened, was slow to respond to the alarming door and failed to look outside the door. Resident #55 was found alone approximately .25 miles from the facility by a concerned citizen, lying face down in the middle of the road beside a large amount of blood on the pavement from lacerations on his nose and left eyebrow. Resident #55 had suffered actual harm and was at risk for serious injury or death. This affected one of one resident reviewed for elopement (Resident #55). The facility identified 20 cognitively impaired residents who were independently mobile residing on the secured unit who had the potential to be at risk for elopement. The facility also failed to implement preventative measures to prevent bruising for one resident (Resident #16) with known unsafe behaviors and spastic movements that was not Immediate Jeopardy that is cited at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy). Resident #16 was one of five residents reviewed for accidents. On 05/11/17 at 3:30 P.M. the Administrator was notified that Immediate Jeopardy began on 11/05/16 at 6:45 P.M. when Resident #55, who had a history of [REDACTED]. The resident exited a door on the secured unit that was equipped with an alarm and 15 second delayed egress mechanism. Staff failed to timely respond to the alarming door resulting in the resident leaving the facility unattended. Resident #55 was found off facility property by a concerned citizen. Resident #55 was found approximately 0.25 miles from the facility lying in the road with facial lacerations. Local emergency medical services (EMS) were notified and the resident was transferred to the emergency room , treated for [REDACTED].M. The Immediate Jeopardy was removed on 11/07/16 when the facility implemented the following corrective actions: * On 11/05/16 all facility doors were inspected by maintenance staff to ensure the doors were functioning properly. * On 11/06/16 all residents identified as being at risk for elopement were reviewed by the Director of Nursing (DON) to ensure safety interventions were in place to prevent elopement. No new residents were identified as elopement risks. * On 11/06/16 the DON provided education to all 60 staff members, including 22 State tested nursing assistants (STNA), eight dietary staff, 13 licensed practical nurses (LPN), one social services designee, three registered nurses (RN), one assistant director of nursing (ADON), one administrator, two laundry staff, five housekeeping staff, two activity staff, one medical records staff and one receptionist on the facility Elopement Policy and responding to Door Alarms. * On 11/06/16, LPN #48, the LPN assigned to care for Resident #55 on 11/05/16, was provided coaching from the DON related to responding to any alarm. The coaching form indicated further issues would result in termination for the employee. * On 11/07/16 at 6:00 A.M. staff began documenting every 15 minute checks for Resident #55 to monitor his whereabouts. Although the resident returned from the hospital on [DATE] at 11:50 P.M, there was no evidence of monitoring being implemented until 11/07/16 at 6:00 A.M. * On 11/09/16 the DON added elopement triggers care plans and the Kardex for elopement risk residents to alert staff as to what might trigger an elopement for these residents. Twenty residents were identified to be at risk for elopement, Residents #55, #46, #51, #62, #11, #76, #48, #47, #17, #78, #30, #52, #61, #34, #57, #36, #72, #2, #65 and #59. * On 11/14/16 the Missing Resident and/or Elopement of a Resident was revised to reflect an initiated simultaneous search of the building and the premises if a resident was missing. * On 05/11/17 between 2:00 P.M. and 2:10 P.M. interviews with Activities #50, STNAs #67, #24, #23 and RN #11 revealed they were knowledgeable and aware of the elopement drill procedure and had been in-serviced on elopement. * On 05/11/17, review of the facility incident/accident log revealed no additional residents had successfully eloped since the incident involving Resident #55 on 11/05/16. The noncompliance continued at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) on 11/07/16. Findings include: 1. Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Record review revealed on 09/06/16 a plan of care was initiated related to risk for elopement/wandering. The plan reflected Resident #55 was disoriented to place, had impaired safety awareness, wandered aimlessly, had a history of [REDACTED]. The care plan revealed shift change was a trigger for the resident because staff from the previous shift were saying goodbye and leaving. Review of the facility shift times revealed staff worked 6:00 A.M. to 6:00 P.M. and vice versa. The resident's plan of care was revised on 11/08/16 to include interventions for staff to provide distraction from wandering and keep resident in visual field when wandering behaviors occurred. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/12/16 revealed Resident #55 had moderate cognitive impairment and required extensive assistance of two staff with bed mobility, supervision with dressing, toilet use, personal hygiene, walking in room and corridor and was independent with transfers. The assessment revealed the resident did not exhibit wandering behaviors. Review of Resident #55's nursing progress notes, dated 10/01/16 at 12:08 A.M. revealed earlier in the shift Resident #55 left the facility through the fire exit door on Victoria Way. Staff immediately responded to the exit alarms. The resident was found right outside the facility door and was brought back into the facility with staff assistance. The resident was evaluated by the nursing staff and the DON was notified. The family and physician were also notified. The note indicated Resident #55 was kept within visual field of a staff member until the behavior resolved. Further review of the nursing progress notes revealed on 10/01/16 at 11:42 P.M. the resident pushed the door handle at the end of the behavior unit setting off the alarm. The resident was easily redirected and the alarm was reset and fifteen minute checks continued. Additionally, the progress notes revealed on 10/07/16 at 12:10 A.M. the 15 minute checks were discontinued as no attempts to leave the building had been made. Record review revealed a risk of elopement/wandering evaluation dated 10/01/16 identified Resident #55 was at risk for elopement. The evaluation revealed the resident made numerous attempts to leave and had been allowed to exit the rear door with staff attending him and walking around outside. Review of a nursing progress note dated 11/05/16 at 6:45 P.M. revealed the alarm sounded on the emergency exit door on the Victoria Way unit. The note indicated LPN #48 investigated the door and a bed count was initiated. The facility and grounds were searched. The DON, police and family were notified. The nurse's note indicated on 11/05/16 at 7:05 P.M. LPN #48 was notified by an unidentified staff member the resident was found approximately 0.25 miles from the facility with injuries from a suspected fall. The note indicated the resident was transported to the emergency room (ER) for an evaluation of his injuries. On 11/05/16 at 11:36 P.M. the ER notified the facility of the resident's discharge from the hospital with [DIAGNOSES REDACTED]. On 11/05/16 at 11:50 P.M. Resident #55 returned from the ER with abrasions to the nose and above the left eye. Review of the facility Elopement Investigative Report, dated 11/06/16 revealed Resident #55 was unaccounted for on 11/05/16 from 6:45 P.M. to 7:02 P.M. when the resident was found 0.25 miles from the facility and said he was looking for his car. The report revealed the resident eloped through the emergency exit door on Victoria Way. Although the resident had a wanderguard bracelet in place at the time he left, the door the resident left through was not equipped with a wanderguard system. The investigation did not indicate who last saw the resident in the facility, the last time the resident was seen and/or what the resident was doing at that time. Review of an undated and untitled facility document provided in conjunction with the investigative report revealed on 11/05/16 at approximately 6:45 P.M. the door alarm on the Victoria Way unit sounded. Staff (not identified by name) investigated and a head count was performed. It was determined Resident #55 was missing and the facility elopement protocol was implemented. Unidentified staff members started an outside search with no findings of the resident in the immediate area. An unidentified staff member got into her vehicle and drove down the streets near the facility to look for the resident. The resident was located 0.25 miles from the facility and had an abrasion to the face from an apparent fall. Further review revealed the facility documented that staff had responded appropriately to the situation. However, following the incident all staff were re-educated by the DON on elopement, behaviors and responding to door alarms. Record review revealed the facility obtained a statement from LPN #48. The statement, dated 11/05/16 revealed at 6:45 P.M. the emergency door sounded. An unidentified STNA informed the LPN that the alarm could be a possible elopement. Per the LPN's statement, upon investigating outside, no resident was found. LPN #48 proceeded in the direction of the main entrance area of the facility and investigated but saw no one and re-entered the facility. An unidentified STNA on the hall had done a head count and suspected Resident #55 was missing. The facility had been searched and other staff were continuing the search. The police, DON and Resident #55's sister were notified. Around 7:02 P.M. LPN #48 was informed Resident #55 had been located with injury and was going to be taken to the ER for evaluation. The DON and family were notified and paperwork was completed for the emergency medical service responders. Record review revealed the facility obtained a statement from STNA #49, one of the two STNAs working on the Victoria Way unit at the time of the incident. The statement from STNA #49, dated 11/15/16 revealed STNA #49 was in the shower room with a resident and upon her exit the door alarm sounded. The statement indicated the STNA did a room sweep and kept in constant communication with the nurse at all times. Review of the EMS report, dated 11/05/16 revealed a call was received by EMS at 7:12 P.M. and they were enroute at 7:14 P.M. Upon EMS arrival, Resident #55 was observed surrounded by people in the middle of the road. The resident was lying face down on the pavement with a large amount of blood on the pavement and lacerations to the nose and above the left eyebrow. The resident had dementia and did not speak. The resident was placed on a backboard with a cervical collar and was transported to the hospital. Review of the emergency room report, dated 11/05/16 revealed Resident #55 was brought to the hospital via EMS on a backboard with a cervical collar. A one centimeter laceration was noted at the left eye brow, a half centimeter laceration to the mid-forehead and abrasions over the nose and right cheek. The resident had a normal CT scan of the facial bones and was discharged back to the facility. On 05/11/17 at 12:57 P.M. Resident #55 was observed in his room, seated in his recliner chair, eating lunch. A wanderguard bracelet was observed on his right ankle and was verified with STNA #67. Doors to the enclosed courtyard were also noted on the unit and required the use of a code with a key punch pad to exit. On 05/11/17 at 1:02 P.M. observation of the emergency exit door Resident #55 eloped through on 11/05/16 revealed the door was equipped with a 15 second delay before the door would release. The door also had an alarming mechanism in place. After applying 15 seconds of pressure, the door was designed to open and alarm. A wanderguard bracelet had no impact on the ability to open the door. The door also had a key punch pad for exit and a key box at the top of the door to manually reset the alarm. The alarm would sound until manually reset. On 05/11/17 at 1:13 P.M. interview with LPN #48 revealed he was the nurse working Victoria Way the night Resident #55 eloped from the facility. LPN #48 shared he was a newer employee and was briefly trained on the facility elopement policy upon hire. LPN #48 also shared he was administering medications near the dining area and two STNAs (STNA #13 and STNA #49) were providing resident care to other residents when the door alarm sounded. LPN #48 was unsure what the alarm sound represented at that time until STNA #13 stepped into the hallway and informed him he needed to investigate the alarm as a possible resident elopement. LPN #48 stated he did not open the door to the outside to observe the surroundings outside but instead, searched for the key to reset (turn off) the alarm. Other staff members who were working began to search inside the facility and initiated a head count. Staff determined Resident #55 was missing and began to search the grounds. STNA #19 (who was working on another unit) began a search on nearby streets via her car. LPN #48 shared he was unsure who actually discovered the resident but thought it was someone from the public and also thought the resident had hit his head when he fell . An additional interview on 05/11/17 at 2:25 P.M. revealed the last time LPN #48 could recall observing Resident #55 on 11/05/16 was during report at approximately 6:00 P.M. and he was observed at the nurse's station. Once medication administration began LPN #48 was in the Victoria Way dining area and unable to visualize the emergency exit on the unit. He verified Resident #55 would not have been in sight of staff while performing their job duties. LPN #48 shared Resident #55 would pace a lot and sometimes wear his coat and go out to the courtyard near the dining room but had not been displaying the behavior when he made his observation. LPN #48 shared other staff were more familiar with the elopement protocol and he did not believe a facility nurse had assessed the resident while waiting the arrival of EMS. On 05/11/17 at 2:39 P.M. interview with STNA #19 revealed she was working on another unit the night Resident #55 eloped. STNA #19 indicated she was the first facility employee who observed the resident after the elopement and he was two alleyways away from the facility (off facility property) with an approximate distance of 0.25 miles. STNA #19 shared she notified the facility the resident had been found. The resident was wearing his coat and was appropriately dressed for the chilly weather. STNA #19 stated there were passersby with the resident at the time she arrived and it was one of those people (a concerned citizen) who had called 911/EMS services. STNA #19 stated at the time she arrived to the scene, EMS had already been called and was enroute. The resident told her he was going home. STNA #19 shared it had been awhile since she worked on the secured unit but remembered the resident would wander while wearing his coat. He would enter the courtyard and say he wanted to go home. On 05/11/17 at 3:00 P.M. interview with the DON revealed it was common for Resident #55 to wear his coat and pace the unit. The DON also shared the resident was an elopement risk with an unsuccessful attempt to elope on 10/01/16. Following the incident on 10/01/16, the resident was placed on 15 minute checks for a few days and then the checks were discontinued because he made no further attempts to elope. The DON verified the resident had a plan of care in place that reflected he was at risk for elopement. As a result of the incident, the DON felt LPN #48 had not been thoroughly trained upon hire resulting in his failure to timely respond to the emergency exit alarm, allowing Resident #55 to exit the building unsupervised, cross the street and experience a possible fall resulting in abrasions and lacerations to his face. The DON verified a facility nurse did not go to the scene to evaluate the resident and the resident required transport to the ER to assess his injuries. During the interview the DON also verified the facility investigation did not include statements from all staff who had knowledge or involvement with the incident, including the second STNA on the unit or the STNA who was the first and only employee to physically see Resident #55 after he eloped. The investigation failed to indicate the resident's status, whereabouts or elopement risk prior to exiting the facility and failed to identify causative factors related to the elopement. The DON stated no elopements had occurred since 11/05/16 and all staff were educated regarding the importance of responding to all alarms following the incident. Review of the Missing Resident and/or Elopement of a Resident Policy and Procedure initiated 02/2016 and revised 11/14/16 revealed staff shall investigate and report all cases of missing residents and or residents who are suspected to have eloped. A resident is considered to be missing when he/she are unable to be located in the facility's interior grounds. The resident is considered to have eloped if he/she has left the grounds unwitnessed. The policy further indicated staff to promptly report a resident who tries to leave the premises or is suspected of being missing to the charge nurse or DON. If an employee discovers that a resident is missing from the facility he/she shall: determine if the resident is out on authorized leave or pass; if the resident was not authorized to leave, initiate a search of the building and premises simultaneously; if the resident is not located notify the Administrator and the DON, the resident's legal representative, the attending physician and (as necessary) volunteer agencies; provide search teams with resident identification information including picture identification that will be updated annually; initiate an extensive search of the surrounding area utilizing the elopement kit; the administrator and DON will notify law enforcement agencies or designee. The change to the policy and procedure, noted on the revision dated 11/14/16 directed staff to initiate a search of the building and premises simultaneously. 2. Review of Resident #16's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care initiated 11/18/16 for potential for bruises of the upper and lower extremities (including the hands and feet) due to spastic movement, Huntington's disease, restlessness and agitation. Interventions included to attempt to alleviate cause of bruises when possible and padding to grab bars and head board (initiated 02/02/17). Review of the current physician's orders [REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/02/17 revealed the resident had modified independence for daily decision making. The resident required extensive assistance of one staff member with bed mobility, walking in her room, locomotion on the unit, dressing and personal hygiene. The resident required extensive assistance of two staff members with transfers and toilet use and was always continent of bowel and bladder. Review of the nursing progress note, dated 02/01/17 at 4:23 A.M. revealed during the midnight check a 10 centimeter (cm) by seven centimeter bruise was noted to the left inner, upper thigh. Earlier in the shift the resident was climbing out of bed by herself and putting herself on the bedside commode a few times. On 02/01/17 at 7:45 P.M. LPN #48 documented it was suspected the resident injured herself on the bed rail when attempting to stand without assistance. Further review of the progress notes dated 02/02/17 at 12:17 A.M. revealed the bruising was congruent with the resident climbing out of the top of her bed and hitting the side rail. The bruising to the forearm was due to [DIAGNOSES REDACTED] and hitting the forearm off the side rail. The side rails and head board were to be padded. Review of a facility self-reported incident (SRI) tracking number 9 dated 02/02/17 revealed an injury of unknown origin (IUO) had been discovered to Resident #16's left inner, upper thigh and the resident's right posterior forearm. The incident was investigated and determined to be caused by the resident's side rail of the bed. The resident was assessed to have spastic motions and lacked safety awareness. Per the investigation, multiple staff had observed the resident bumping the indicated area of her leg and arm on the side rail and the headboard previously. Interventions were implemented to include padded side rails and headboard. Review of LPN #48's documented interview, dated 02/02/17 at 1:35 A.M. revealed the resident got out of bed every night without staff assistance and staff regularly provided re-education related to the use of her call light. LPN #48 shared he had seen the resident's legs hit/bump the side rail. The resident would also get out of bed above the side rail between the head board and side rail. Review of LPN #10's documented interview dated 02/02/17 at 6:07 A.M. revealed the resident was constantly climbing out of bed and would hit her leg on the side rails. Review of the STNA electronic Kardex (computer system care directives) documentation system revealed padding to grab bars and head board (no date initiated) On 05/09/17 at 5:15 P.M. Resident #16 was observed lying in bed with the padded side rails in place. The resident's head board was not observed padded. Interview with STNA #24, at the time of the observation, verified the resident's head board was not padded. Further interview revealed STNA #24 had provided care to the resident for a few months and was unaware the head board was to be padded. On 05/10/17 at 9:57 A.M. interview with the DON revealed the resident was to have a blanket taped to her head board since she had been observed throwing herself back into her bed and could strike her head on the head board. Further interview revealed the staff was aware the resident had been bumping her legs on the side rails during self-transfers. The DON shared the staff should have implemented interventions to protect the Resident due to her history of spastic movements related to Huntington's Disease and bumping her extremities.

Based on closed medical record review, policy review, and staff interview, the facility failed to re-assess Resident #75, who was noted to have increased urinary incontinence and failed to implement comprehensive and individualized interventions in attempts to restore continence. This affected one resident (Resident #75) of one resident identified from Minimum Data Set (MDS) assessments for decline in urinary continence. The facility identified 33 residents as occasionally or frequently incontinent of bladder. Harm occurred to Resident #75 on 03/20/17 when the resident was assessed with [REDACTED]. Resident #75 was continent of bladder on admission and became frequently incontinent without evidence of interventions being in place to prevent the decline. Findings include: Review of Resident #75's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A pre-admission screen dated 12/14/16 indicated Resident #75 was continent of bowel and bladder. A hospital transfer form dated 12/14/16 did not reveal any incontinence but indicated Resident #75 required assistance with toilet use. A Bowel and Bladder Evaluation dated 12/15/16 indicated Resident #75 was moderately cognitively impaired, made poor decisions, and required cues and supervision. The evaluation indicated Resident #75 was always continent of bowel and bladder. The evaluation indicated Resident #75 was a good candidate for a restorative program for bowel and bladder. The nurse documented Resident #75 was willing to participate in a restorative program and one would be initiated. There was no indication a restorative program was initiated at that time. Review of the Admission Nursing Evaluation dated 12/15/17 revealed Resident #75 was alert and confused with short and long term memory problems and impaired decision making skills. Resident #75 was assessed as always continent of bowel and bladder with no restorative toileting referral due to continence. A Medicare five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #75 was able to make herself understood, did not reject care, required limited assistance for toilet use, and was always continent of urine with no toileting program. An Occupational Therapy discharge summary dated 12/23/16 indicated Resident #75 required minimal assistance with toileting. Bladder elimination records revealed between 12/14/16 and 01/26/17, Resident #75 was mostly continent of bladder with incontinence recorded on night shift on 01/03/17 and 01/21/17. Incontinence of bladder was recorded on day shift on 01/27/17, 01/28/17, 01/31/17, 02/02/17, 02/04/17, 02/06/17, 02/12/17, 02/13/17, 02/15/17, and 02/17/17. Urinary incontinence was recorded on night shift on 02/03/17, 02/04/17, 02/11/17, 02/12/17, 02/13/17, 02/14/17, 02/17/17, and 02/18/17. There was no indication staff re-assessed Resident #75 or made any attempts to initiate a toileting program with the identified increased incontinence. On 02/19/17 at 4:13 P.M., a nursing note indicated Resident #75 complained of painful urination earlier in the shift. An order was obtained for tests (urinalysis and culture and sensitivity) to determine if Resident #75 had a urinary tract infection. On 02/21/17, an order was obtained for an antibiotic, Bactrim DS 800-160 milligrams (mg) twice a day for ten days. A repeat urinalysis completed 03/06/17 revealed no bacterial growth. Resident #75 continued to exhibit urinary incontinence a minimum of daily from 02/22/17 through 03/31/17 except on 03/09/17, 03/13/17, and 03/24/17. Review of a quarterly Bowel/Bladder Evaluation dated 03/13/17 indicated Resident #75 was moderately cognitively impaired, independent with mobility, occasionally incontinent of bladder, and always continent of bowel. Resident #75 was assessed as a good candidate for a restorative program for bowel and bladder. Staff documented Resident #75 was willing to participate and a restorative program would be initiated. There was no indication of a restorative program being initiated at that time. A quarterly MDS 3.0 assessment, dated 03/20/17 indicated Resident #75 was usually able to make herself understood, required limited assistance for transfers, did not reject care, and exhibited frequent incontinence of bladder with no toileting program. A Bowel/Bladder Evaluation dated 03/31/17 indicated Resident #75 exhibited moderately impaired cognitive status, was frequently incontinent of bladder, and was at risk for skin-related complications due to incontinence and moisture. Resident #75's urinary incontinence was assessed as functional. The evaluation indicated Resident #75 was a good candidate for a restorative program for bowel and bladder but was unwilling to participate. No program would be initiated. Resident #75 was discharged to another nursing facility 04/07/17. During an interview on 05/10/17 at 3:24 P.M., State tested Nursing Assistant (STNA) #67 stated Resident #75 was both continent and incontinent. Resident #75 never refused care. Resident #75 was not on a toileting program but staff checked her for incontinence and changed her every two hours. During an interview on 05/10/17 at 4:49 P.M., the Director of Nursing (DON) stated Resident #75 was not appropriate for a toileting program because there were times she could not recall her own name. During an interview on 05/10/2017 at 5:53 P.M., STNA #78 stated Resident #75 was continent when she was first admitted . STNA #78 stated she believed Resident #75's incontinence started when she had a urinary tract infection. Resident #75 would walk to the bathroom with staff and had some control as she was never totally incontinent. Resident #75 did not refuse care. On 05/10/2017 at 6:42 P.M., the DON verified Resident #75 was continent when admitted . The DON verified Resident #75 had increased urinary incontinence with lack of intervention and became frequently incontinent. On 05/11/17 at 7:31 A.M., the DON stated he wished to clarify. The DON verified Resident #75 had increased incontinence during her stay. After being treated for [REDACTED].#75 remained incontinent. The DON verified there had not been a comprehensive evaluation of Resident #75's incontinence or attempts to establish a pattern of incontinence. The DON verified there had been no changes made in the delivery of care related to the increased urinary incontinence. Review of the facility's Bowel and Bladder Continence Care Management policy, dated March 2017, indicated the individualized care plan based on a resident's evaluated needs was to be reviewed quarterly, as necessary or after any change in condition which affected the resident's bowel/bladder continence status. A bowel and bladder continence evaluation was to be performed on admission, quarterly, as necessary or after any change in condition that could affect bladder or bowel continence. An interim care plan was to be initiated within 24 hours of admission based on the resident's evaluated elimination patterns. Staff were instructed to monitor and evaluate the care plan at least quarterly and more frequently as required based on the resident's condition. If the interventions had not been effective, staff were instructed to initiate alternative approaches and update the care plan as necessary. Licensed nurses, restorative aids, and state tested nursing assistants were to report any changes in the resident's bowel or bladder routines to the licensed staff. Licensed nurse staff were to observe residents' intake and bowel and bladder functioning status on an ongoing basis and evaluate to determine if continence care strategies were effective and consider whether changes to the care plan were required.

Based on observation, medical record review, interview, and policy review, the facility failed to conduct comprehensive pain assessments, provide non-pharmacological interventions prior to the administration of pain medication ordered on an as needed basis, document effectiveness of pain medication, and report ongoing complaints of pain to the physician. This affected two residents (Residents #39 and #73) of three residents reviewed for pain. The facility identified 23 residents on pain management programs. Harm occurred to Resident #39 when the facility failed to implement an effective and individualized pain management program to identify and adequately treat pain resulting in the resident experiencing constant back pain with little to no relief which interfered with daily activities. In addition, on 05/04/17 after occupational therapy was discontinued staff failed to report ineffectiveness of pain medications to the physician resulting in constant back pain for the resident. Findings include: 1. Review of Resident #39's medical record revealed [DIAGNOSES REDACTED]. A pain interview assessment dated [DATE] indicated Resident #39 reported frequent pain over the previous five days which had interfered with sleep at night and limited day to day activities. Pain intensity was rated a six on a scale of zero to 10. Staff documented non-verbal sounds, vocal complaints of pain, and facial expression as indicators of pain. The frequency with which the resident showed evidence of pain was daily. Review of the February, 2017 Medication Administration Records (MARs) revealed documentation of pain severity with the administration of routinely scheduled [MEDICATION NAME]-[MEDICATION NAME] 5/325 milligrams (mg) twice a day. On one occasion (midnight dose on 02/21/17), Resident #39 denied pain. On one occasion (02/25/17 at 12:00 P.M.), Resident #39 rated her pain a severity level four on a scale of zero to 10. The other 54 doses the resident received revealed pain was rated between a five and 10 on a scale of 0-10. There was no documentation of the pain severity after the administration of the [MEDICATION NAME]-[MEDICATION NAME] to evaluate the effectiveness of the medication. Resident #39 received two doses of [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg (02/16/17 at 3:29 A.M. and 02/17/17 at 5:38 A.M.) ordered on an as needed basis with a pain severity of six recorded at the time of administration. There was no assessment of the pain severity after the administration of the medication, just a note indicating effective. Additionally, 12 doses of the pain medication, [MEDICATION NAME] one mg were administered with pain rated between six and nine at the time of administration with no documented assessment of pain severity after the administration of the [MEDICATION NAME]. Review of March, 2017 MARs revealed recorded pain levels between five and 10 with administration of [MEDICATION NAME]-[MEDICATION NAME] except one time (12:00 A.M. on 03/28/17) in which it was rated a four. Resident #39 received three doses of [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg three times. Pain was rated at eight, nine and 10 at the time of administration with no severity of pain recorded afterward. Resident #39 received three doses of Tylenol 650 mg which was ordered for mild pain. At the time the Tylenol was administered, Resident #39 rated her pain as a six on 03/01/17 at 10:27 P.M. and 03/02/17 at 10:17 P.M., and rated the pain a 10 on 03/18/17 at 3:07 A.M. The nurse documented the Tylenol administered on 03/18/17 for a pain severity of 10 was ineffective. Nineteen doses of [MEDICATION NAME] one mg were administered with pain rated between six and 10 at the time of administration. Nurse's did not document the pain severity after the administration of the [MEDICATION NAME]. A physical therapy (PT) discharge summary dated 03/09/17 indicated Resident #39's pain at rest was rated a five on a scale of zero to 10. (at baseline on 02/8/17 was 7/10). The summary revealed Resident #39 was being discharged from PT due to having reached her maximum potential with skilled services. On 03/29/17, an order was written for warm compresses and heating pad to Resident #39's back with instructions: 15 minutes on, 15 minutes off for two hours every Monday, Wednesday, and Friday of each week and not to be left on longer than 20 minutes at a time. A therapy screen was completed 03/31/17 at the Director of Nursing's (DON) request to address the heat treatments for pain relief. On 04/04/17, an order was written for Occupational Therapy (OT) to evaluate and treat Resident #39 with treatments including moist heat. The evaluation indicated Resident #39 reported pain intensity of seven on a scale of zero to 10 on a daily basis in the lower back and the pain was described as an ache. The evaluation indicated pain limited Resident #39's functional activities. Short-term goals were for Resident #39 to demonstrate good tolerance for pain management strategies to reduce pain to a severity of four. A pain interview conducted by staff on 04/08/17 revealed Resident #39 reported almost constant pain over the previous five days which interfered with sleep and limited day to day activities. Pain was rated six on a scale of zero to ten and described as moderate. The assessment/interview indicated Resident #39 received both scheduled pain medication and pain medication ordered on an as needed basis but did not reflect Resident #39 received non-pharmacological intervention for pain. Review of April, 2017 MARs revealed when [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg was administered on 04/07/17 at 12:00 A.M. and 04/14/17 at 12:00 P.M., Resident #39 reported no pain. All other assessments/rating revealed a severity of five to 10. On 12 occasions, nurses documented the [MEDICATION NAME]-[MEDICATION NAME] was not administered because delivery was pending from pharmacy. Eighteen doses of [MEDICATION NAME] 1 mg were administered with severity rated between six and 10. Four doses of Tylenol were administered with severity rated between four and seven. The severity of Resident #39's pain was not recorded after the administration of the medications. Review of May, 2017 MARs revealed severity of pain documented during the administration of routinely scheduled [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg ranged between five and 10 except 05/08/17 at 12:00 P.M. when pain was rated at two. [MEDICATION NAME] was administered four times with pain severity rated from six to nine. Two doses of Tylenol were administered with pain rating of four and 10. There was no documentation regarding severity of pain after the pain medications were administered. During an interview on 05/07/17 at 12:50 P.M., Resident #39 stated she had constant back pain. Resident #39 stated she received pain medication but got no relief from the medication she was receiving. During an interview on 05/08/17 at 5:50 A.M., State tested Nursing Assistant (STNA) #19 stated Resident #39 always complained of pain in her back. During observation of medication administration to Resident #39 on 05/08/17 at 9:40 A.M., Licensed Practical Nurse (LPN) #56 was observed asking Resident #39 if the pain medication administered earlier ([MEDICATION NAME] 1.0 mg at 6:52 A.M.) had helped relieve her pain. Resident #39 stated it helped little. LPN #56 did not inquire regarding what Resident #39's pain severity was at that time. Review of the May, 2017 MAR indicated [REDACTED].M. and documented by nursing staff to be effective. During an interview on 05/09/17 at 4:35 P.M., the DON verified the MAR indicated [REDACTED]. The lack of assessed pain severity after the administration of pain medication administered on an as needed basis, along with the observations and documentation regarding the administration and effectiveness of the [MEDICATION NAME] recorded on 05/08/17 were also discussed as noted above with no additional information provided. During an interview on 05/10/17 at 1:15 P.M., Certified Occupational Therapy Assistant (COTA) #4 verified during therapy, Resident #39's short term goal for pain relief was to achieve a severity of four on a scale of 0-10. COTA #4 stated Resident #39's reported pain during therapy fluctuated, with Resident #39 sometimes not reporting any pain. The time of therapy varied and was not related to administration of pain medication. COTA #4 stated nurses were unable to administer heat packs and application of heat would not be used outside of therapy which had been discontinued on 05/04/17. The COTA indicated the application of heat would not be appropriate as a long term intervention in pain relief. During a telephone interview on 05/10/17 at 9:34 A.M., Physician #5 stated he was not aware of Resident #39's complaints of pain or ineffectiveness of her pain management program. Physician #5 stated staff had not reported to him that Resident #39 complained of constant pain. Physician #5 stated Resident #39's condition was not expected to improve and after being made aware of Resident #39's complaints of pain from this surveyor, his goal was to determine possible causes of the pain and to determine what treatments and/or medications would best be suited in providing pain relief. Review of the facility's Pain Assessment and Management policy (revised March 2015) revealed recognizing pain included review of the Medication Administration Record [REDACTED]. The policy indicated staff should carefully document the results of the interventions. The policy instructed to monitor a resident's response to interventions and level of comfort over time, status of the underlying causes of pain, and the presence of adverse consequences of treatment to determine if the resident's pain was being adequately controlled. If pain was not adequately controlled, the multidisciplinary team, including the physician, should reconsider the approaches and make adjustments as indicated. Complaints of prolonged, unrelieved pain despite care plan interventions was to be reported to the physician. 2. Review of Resident #73's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #73's pain assessment, dated 11/23/16 revealed the resident complained or showed evidence of pain or possible pain daily. The section under pain management including scheduled pain medication regimen, as needed pain medication, and non-medication interventions was not completed. Review of Resident #73's pain care plan revealed the resident had pain related to impaired mobility, rhabdomyolysis, restless leg, chronic back pain, scoliosis, history of lumbar fracture, history of third metacarpal fracture, knee and right ankle pain. The goal included the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. There was no evidence of non-pharmacological interventions. Review of the quarterly Minimum Date Set (MDS) 3.0 assessment, dated 04/12/17 revealed the resident was receiving scheduled and as needed pain medication. The MDS 3.0 assessment indicated the pain assessment interview should be conducted however because the resident reported he did not have pain in the last five days the section was not completed. Review of the physician's orders [REDACTED]. Document Y if the resident has displayed s/s of pain this shift. Document N if the resident has not displayed s/s of pain this shift. If response was Y please see pain grid for details. Medication orders included: [MEDICATION NAME] (muscle relaxer) 10 milligrams (mg) by mouth once a day related to wedge compression [MEDICAL CONDITION] lumbar vertebra, [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 400 mg every six hours as needed for mild pain related to rhabdomyolysis, and [MEDICATION NAME] 400 mg twice daily related to rhabdomyolysis. Review of the MAR indicated [REDACTED]. There was evidence the resident had received as needed pain medication during this time period, however staff only documented E (effective)for the result and did not indicate what the resident's verbal pain rating was after receiving the medication. On 05/07/17 at 2:26 P.M., interview with Resident #73 revealed he had occasional pain in his back that was not always relieved. On 05/08/17 at 2:07 P.M., interview with RN #20 confirmed the orders to monitor pain every shift did not transfer over to the MAR, the care plan was not individualized to the resident and did not include non-pharmacological interventions. RN #20 indicated the pain evaluation completed on admission should have been re-evaluated at least every quarter and was not, and staff were not documenting what the resident's pain rating was after receiving pain medication. On 05/09/17 at 10:12 A.M., interview with Resident #73 with LPN #22 present revealed the resident reported the pain in his back was related to a fracture and not his rhabdomyolysis. The resident verbalized the as needed [MEDICATION NAME] he received didn't always relieve his back pain. LPN #22 reported the staff thought the unrelieved pain was related to his rhabdomyolysis and that was what they reported to the physician yesterday. LPN #22 indicated she would call the physician to clarify the location and cause of the the resident's pain (in his back). Review of Resident #73 nurse's notes dated 05/09/17 revealed staff contacted the resident's physician regarding a pain medication increase related to a [DIAGNOSES REDACTED]. Review of a nurse's note dated 05/09/17 revealed the nurse explained the pain was a fractured lumbar and not the rhabdomyolysis and the resident had stated I don't have pain right now but sometimes my back hurts and the pill doesn't always help. The nurse received new orders for [MEDICATION NAME] four times daily (routine) until his pain feels better with a note indicating it would then be re-evaluated to possibly change from routine to as needed. Review of the pain assessment and management policy and procedure, dated 03/2015 revealed the purpose of the procedure was to help staff identify pain in the resident, and to develop interventions that were consistent with the resident's goals and needs and that addressed the underlying causes of pain. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Discuss with the resident his or her goals for pain management and satisfaction with the current level of pain control. The pain management interventions shall be consistent with the resident's goals for treatment. Such goals will be specifically defined and documented. Non-pharmacological interventions may be appropriate alone or in conjunctions. If pain has not been adequately controlled the multidisciplinary team, including the physician, shall reconsider approaches and make adjustment as indicated.

Based on observation, record review, interview and policy review, the facility failed to implement interventions to prevent the development of pressure ulcers and/or failed to implement interventions to treat and prevent further skin breakdown for Resident #78 and Resident #81. In addition the facility failed to provide treatments and conduct accurate assessments for Resident #14's pressure ulcers. This affected three residents (Resident #78, #81 and #14) of three residents reviewed for pressure ulcers Harm occurred to Resident #78 when the resident developed an avoidable suspected deep tissue injury pressure ulcer to her left heel. The resident had sustained a fractured pelvis following a fall that impaired her mobility and made her bedfast. The facility did not implement appropriate interventions to prevent the development of an avoidable suspected deep tissue injury of the left heel despite the resident being identified as being a high risk for the development of pressure ulcers and bedfast. Findings include: 1. Review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A nursing evaluation completed on 03/18/17 revealed Resident #78 was alert and oriented to person only. She had confusion and memory impairment. She refused a body check at the time of her nursing evaluation. A review of a weekly skin round report dated 03/19/17 revealed Resident #78 did not have any areas of skin impairment over bony prominences or the heels. The skin of both of her heels was intact. An admission Minimum Data Set (MDS) 3.0 assessment, dated 03/25/17 revealed Resident #78 had clear speech and was usually able to make herself understood. She had both short and long term memory impairment and her cognitive skills for daily decision making was severely impaired and required supervision with the assist of one for bed mobility and toilet use. The resident required supervision with set up help for transfers and ambulation and was identified as being at risk for the development of pressure ulcers. Resident #78 did not have any unhealed pressure ulcers at the time of the assessment. Skin and ulcer interventions included a pressure reduction device for the bed. No other interventions were indicated as used. A review of Resident #78's nursing progress notes revealed a note dated 03/30/17 at 11:44 A.M. indicating the resident was found sitting on the floor behind the door to her room by staff . Subsequently Resident #78 was found to have a pelvic fracture on 04/03/17 as a result of the fall. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The resident refused a body check upon return to the facility. A review of a skin risk assessment (Braden scale) for predicting pressure ulcer risk dated 04/05/17 revealed Resident #78 was assessed to be at high risk for the development of pressure ulcers. Risk factors included skin being exposed to moisture on occasion, being bedfast, being completely immobile, probable inadequate nutrition and a problem with friction and shearing. A review of Resident #78's admission orders [REDACTED]. A nursing evaluation dated 04/06/17 at 1:33 A.M. revealed Resident #78's skin condition was assessed and did not show any areas of skin impairment. A significant change MDS 3.0 assessment dated [DATE] revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of three which indicated her cognition was severely impaired. The resident required extensive assistance of two staff for bed mobility, transfers, and toilet use and ambulation did not occur. The resident was marked as being at risk for pressure ulcers but not identified as having an unhealed pressure ulcer at the time of the assessment. A physician order, dated 04/17/17 revealed an order for [REDACTED]. A wound observation evaluation dated 04/24/17 revealed Resident #78 developed a deep tissue injury to the left heel on that date that was facility acquired. The area measured 2.5 centimeters (cm) in length by 0.6 cm width with no depth noted. Treatments included heel lift boots and an air mattress. A review of Resident #78's care plans revealed she had a care plan in place for having a deep tissue injury to the left heel. The interventions included those added on 04/24/17 for the use of an air mattress and to encourage the use of heel lift boots while in bed each shift as tolerated. There was no evidence any interventions were in place prior to the development of the deep tissue injury. A review of Resident #78's treatment administration record for April, 2017 revealed no evidence of any skin prevention interventions being implemented prior to the development of the pressure ulcers on 04/24/17. There was no evidence the resident was being turned and repositioned or of heels being elevated despite an increased dependence on staff for bed mobility and being bedfast. On 05/09/17 at 4:00 P.M., an interview with Licensed Practical Nurse (LPN) #54 confirmed Resident #78 developed an in house deep tissue injury to the left heel. LPN #54 confirmed when the resident was readmitted to the facility on [DATE] she was more dependent on care. LPN #54 described the resident as being a maximum assist with bed mobility and transfers and was non-ambulatory. LPN #54 stated they tried to turn and reposition the resident but she was not always compliant with her care. The LPN denied they had attempted to elevate the resident's heels up on pillows when in bed. LPN #54 was not sure if the resident would have refused that intervention since it was not attempted. On 05/10/17 at 9:10 A.M., an interview with the Director of Nursing (DON) revealed there was no evidence the facility had implemented any skin prevention interventions for Resident #78 after readmission on 04/05/17 following a pelvic fracture and being more dependent for care. The DON confirmed Resident #78 was assessed as being a high risk for pressure ulcers on readmission, but no preventative measures were implemented. The DON acknowledged there was no evidence of any skin prevention and treatment interventions being added to prevent skin breakdown until after 04/24/17 when a pressure area was discovered to the left heel. A review of the facility's prevention of pressure ulcers policy revised September 2013 revealed interventions and preventative measures for residents with risk factors that included immobility was to float heels ( keep heels off bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. 2. Review of Resident #81's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital transfer form dated 04/21/17 indicated Resident #81's skin was red and her buttocks intact. An admission nursing evaluation dated 04/21/17 indicated Resident #81 was able to make herself understood and she usually understood others. Resident #81 was assessed as alert and confused with short term memory problems. Resident #81's admission nursing evaluation indicated she required extensive assistance with bed mobility and personal hygiene. Resident #81 had an indwelling catheter. No positioning devices were used. Resident #81 was assessed with [REDACTED].#81 had documentation of a blister (Stage II pressure ulcer) on the coccyx. Her left and right buttocks were assessed as red and excoriated and her groin was red. Resident #81 denied pain during the admission evaluation. admission orders [REDACTED]. An admission/interim care plan dated 04/21/17 indicated Resident #81 was not at risk for impaired skin integrity and no interventions were implemented. On 04/23/17, Resident #81 was sent to the hospital for complaints of chest pain. Hospital reports indicated Resident #81 arrived in the emergency room at 4:47 P.M. and left at 2:00 A.M. on 04/24/17. A wound observation evaluation dated 04/24/17 indicated Resident #81's coccyx was assessed with [REDACTED]. The wound observation evaluation indicated it was the first observation of the wound. The area was assessed with [REDACTED]. The tissue around the wound was assessed as deep tissue injury. A treatment was initiated for hydrogel and foam twice a week and as necessary and to encourage Resident #81 to turn and reposition at least every two hours when up in the chair/wheelchair, and encourage to turn and reposition every two hours when in the bed. On 04/24/17, orders were written indicating Resident #81 could be up in the chair as tolerated and a pressure reduction mattress was applied to the bed to prevent skin breakdown. A wound consultant order was written 04/24/17. A second wound observation evaluation dated 04/24/17 indicated Resident #81 had a deep tissue injury to the right medial buttock with 100% [MEDICATION NAME] tissue measuring 4.6 cm by 0.6 cm with no depth that was open to air. The wound evaluations on 04/24/17 did not reflect pressure as the cause of the skin breakdown. Review of a Medicare five day MDS 3.0 assessment, dated 04/24/17 indicated Resident #81 was able to make herself understood and she understood others. Resident #81's BIMS score was 3, indicating severe cognitive impairment. Resident #81 was assessed with [REDACTED]. Resident #81 required the extensive assistance of two or more people for bed mobility and transfers. Resident #81 required extensive assist by one person for toilet use. Resident #81 did not walk. Resident #81 had an indwelling urinary catheter and bowel continence was not assessed. Resident #81 had received no pain medication and denied pain over the previous five days. Resident #81 had no swallowing disorder and had a significant weight gain, although she was not on a physician-prescribed weight gain regimen. The assessment indicated Resident #81 was at risk of developing pressure ulcers and was assessed with [REDACTED]. The assessment indicated Resident #81 had a pressure reducing device for the bed but no pressure reducing device for the chair, no turning/repositioning program, and no nutrition interventions to manage skin problems. The assessment indicated Resident #81 was receiving pressure ulcer care and application of ointments/medications other than to feet. Resident #81 was hospitalized [DATE]-04/25/17 for complaints of chest pain. A physical therapy (PT) evaluation dated 04/27/17 indicated Resident #81 required maximum assistance for transfers. Resident #81 was unable to ambulate during the evaluation. A dietary note dated 04/27/17 indicated Resident #81 was eating 51-100% of her diet but due to skin impairment a recommendation was made for house supplements. On 04/27/17 an order was received for 90 milliliters (cc) of house supplement to be provided three times a day. A wound observation evaluation dated 05/01/17 indicated Resident #81 had a Stage II pressure ulcer on the coccyx with surrounding deep tissue injury. The wound was improving with 50% granulation and 50% [MEDICATION NAME] tissue measuring 2.5 cm x 2 cm x 0.1 cm. The area of deep tissue injury was not measured. The treatment remained the same. A second wound observation evaluation dated 05/01/17 indicated the area on the right medial buttock was healed. A dietary note dated 05/01/17 indicated Resident #81 had experienced gradual weight loss since her original admission. Intakes were poor averaging 15%. The nutritional assessment indicated Resident #81 was accepting 45% of her house supplements. The dietitian documented she had recommended an appetite stimulant and the physician ordered [MEDICATION NAME]. On 05/02/17, the urinary catheter was discontinued. A care plan initiated 05/03/17 indicated Resident #81 had the potential for impairment to skin integrity related to episodes of bladder and bowel incontinence, decreased mobility, weakness, and [MEDICAL CONDITION]. Interventions included identifying and documenting potential causative factors and eliminating/resolving them when possible and use of a pressure relieving/reducing mattress to protect the skin while in bed. A dietary note dated 05/08/17 indicated Resident #81 had a 3.8% weight gain in the prior week and intakes were averaging 58% of her meals. Resident #81 was observed sitting in the wheelchair in her room on 05/07/17 at 10:51 A.M. and 12:35 P.M. with no pressure relief cushions. During an interview on 05/08/17 at 5:50 A.M., State tested Nursing Assistant (STNA) #19 stated Resident #81 was able to pivot for transfers but did not walk much distance. STNA #19 stated Resident #81 had a pressure reduction mattress to the bed but no pressure relief devices to the wheelchair and verified this with observation. During an interview on 05/08/17 at 8:47 A.M., Resident #81 stated she had not used any pressure relief cushions in the wheelchair. On 05/08/17 at 12:26 P.M., Registered Nurse (RN) #74 and Wound Nurse Consultant #88 were observed providing wound care to Resident #81. Resident #81 had a shallow open area on the coccyx which Wound Nurse Consultant #88 measured 0.6 cm in length by 0.4 cm width with 0.1 cm depth. The wound was 75% [MEDICATION NAME] tissue and 25% granulation tissue. There was a ruddy/maroon discoloration of the buttocks surrounding the wound. Wound nurse consultant #88 indicated she still suspected the discoloration was a result of deep tissue injury but stated the area was fading. Wound nurse consultant #88 indicated the same treatment would be continued. On 05/08/17 at 12:42 P.M., Wound Nurse Consultant #88 was interviewed regarding the lack of pressure relief interventions when Resident #81 sat in the wheelchair. Wound Nurse Consultant #88 indicated Resident #81 should have a cushion in the wheelchair when she was up. RN #74, who was present, stated there was no order for a pressure relief or reduction cushion but she could order one. On 05/08/17 at 3:25 P.M. and 5:00 P.M., Resident #81 was observed sitting in the wheelchair in the common area. There was no pressure relief cushion in the chair. On 05/08/17 at 5:10 P.M., STNA #26 verified Resident #81 was sitting up in her wheelchair without any pressure reducing/relief devices. On 05/08/2017 at 5:45 P.M., observations with STNA #67 revealed a minimum of three pressure relief cushions in central supply. STNA #67 stated he could order equipment like cushions from suppliers and they delivered quickly. Nobody had asked him if he had any cushions available. During an interview on 05/09/17 at 12:38 P.M., Certified Occupational Therapy Assistant (COTA) #4 stated Resident #81 had recently began taking a few steps with therapy but the majority of her time was spent lying in the bed or sitting in a chair. Review of the facility's Pressure Ulcer Treatment policy, revised September 2013 indicated pressure ulcer treatment programs should focus on assessing the resident and status of the pressure ulcer, use of support surfaces, pressure ulcer care, managing bacterial colonization and infection, and education and quality improvement. Review of the facility's policy, Prevention of Pressure Ulcers, revised September 2013, indicated if pressure ulcers were not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. Interventions and preventive measures listed for a person in a chair included use of a foam, gel, or air cushion to relieve pressure. For a person in bed, changing position at least every two hours or more frequently if needed, use of a special mattress in accordance with bed selection algorithm, and changing position at least every two hours or more frequently if needed. The policy indicated the care process should include efforts to stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and to modify the interventions as appropriate. For residents with risk factors of friction and shear, interventions included providing a sitting support surface that did not cause the resident to slide. For residents with a risk factor of bed fast, change position at least every two hours and more frequently as needed, determine if the resident needed a special mattress. If a resident was chair fast, interventions included encouraging changes in position at least every two hours, consider the need for pressure relief/reducing devices, change position at least every hour and use foam, gel or air cushion as indicated to relieve pressure. 3. Review of Resident #14's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's admission progress note dated 03/17/17 revealed Resident #14 had an abrasion to the left buttocks measuring 2.7 cm in length by 2.3 cm width with 0.1 cm depth. The area was pink in color with the top layer of skin being removed. The resident's groin area was red. The heels were mushy. There was no evidence of any area on the right buttocks. The resident was admitted with a urinary catheter and [MEDICAL CONDITION]. Review of the facilities wound observation evaluation, the visiting wound care nurse practitioner notes, and treatment administration records (TAR) and orders dated 03/17/17 to 04/09/17 revealed: On 03/17/17: -Wound observation evaluation -Resident was admitted with an abrasion on the left buttocks measuring 2.7 cm by 2.3 cm by 0.1 cm, scant amount of serous drainage. Apply [MEDICATION NAME] (barrier cream) to buttocks three times daily and as needed. -There was no evidence of an area on the right buttocks Review of TAR revealed no evidence the recommendation for [MEDICATION NAME] was applied three times daily or as needed. On 03/20/17: -Wound observation evaluation-no evidence of area on left buttocks -Wound observation evaluation-Right buttocks acquired on 03/17/17 (admission) area improving measuring 2.7 cm by 2.3 cm by 0.1 cm, no drainage noted. Cleanse wound with soap and water, pat dry, and apply moisture barrier daily and as needed. Wound care nurse practitioner (NP) to see resident. Review of admission notes revealed no evidence of an area on the right buttocks. On 03/24/17: -Wound observation Evaluation-Left buttocks Stage II (partial thickness loss of the dermis) pressure measured 3.0 cm by 3.0 cm by 0.1 cm. Duoderm (foam dressing) dressing applied. The area was originally Stage I (intact skin) pressure. -Wound observation evaluation-no evidence of area on right buttocks. Review of TAR and orders revealed no evidence an order for [REDACTED]. On 03/27/17: -Wound observation evaluation- Left buttocks originally a Stage 1 pressure ulcer measuring 2.0 cm by 1.5 cm by 0.1 cm with scant amount to serous drainage. Treatment included moisture barrier every shift and as needed and [MEDICATION NAME] powder added twice daily for rash. -Wound observation evaluation -Right buttocks. New area acquired 03/27/17 Stage II pressure, measured 0.5 cm by 0.4 cm by 0.1 with scant amount of serous drainage. Moisture barrier every shift and as needed. -Wound NP notes- Left buttocks 2.0 cm by 1.5 cm by 0.0 cm, small serous drainage, granulation greater than 75% and [MEDICATION NAME] less than 50%. Wound etiology moisture-associated skin damage (MASD) with partial thickness. The right buttocks were MASD partial thickness measuring 0.5 cm by 0.4 cm small amount of serous drainage, 75% to 100% granulation, and less than 25% epithelization. Interventions included redistribution cushion and house barrier cream to buttocks and peri area every eight hours and as needed. Treatment orders for left and right buttocks to apply honey impregnated paste with foam twice a week and as needed and [MEDICATION NAME] 2% powder twice daily for candidiasis until clear. Discussed treatment with nurse, resident and resident's daughter. Review of the TAR and orders revealed no evidence the wound NP recommendations were followed to apply barrier every eight hours or the honey impregnated paste twice a week and as needed to the left and right buttocks. On 04/03/17: -Wound observation evaluation- Left buttocks are originally Stage I measuring 1.8 cm by 0.3 cm by 0.1 cm current plan for medi-honey and foam dressing three times a week and as needed. -Wound observation evaluation- Right buttocks acquired on 03/27/17 current pressure Stage II, area worsening measuring 0.5 cm by 0.7 cm by 0.1 cm. Medi-honey and foam dressing three times a week and as needed. -Wound NP notes dated 04/03/17- left buttocks measured 1.8 cm by 0.3 cm by 0.05 cm small serous drainage. Right buttocks 0.5 cm by 0.10 cm by 0.03 cm small serous drainage. No change with interventions or treatments. Review of Resident #14's skin care plan revealed the resident had an open are on right and left buttocks related to moisture. Interventions included to administer treatments as ordered and monitor for effectiveness. On 05/11/17 at 11:20 A.M., interview with the DON confirmed in February, 2017 the wound NP notes were available by a website to print off however the DON had never set up his password to be able to print the notes. The DON confirmed he had to call the wound NP's office to have the notes faxed over as they were not a part of the resident's current medical records. On 05/11/17 at 12:25 P.M., interview with with RN #8 confirmed the [MEDICATION NAME] was not applied per recommendations on 03/17/17, the area on the right buttocks that was charted on 03/20/17 was not present on admission per documentation on wound observation evaluation, the facility wound care nurse charted the areas as pressure initially however the wound NP documented they were moisture associated skin [MEDICAL CONDITION] (MASD), there was no documented evidence the area on the right buttocks that was discovered on 03/20/17 had resolved, the wound NP new orders and intervention on 03/27/17 were not transcribed for the barrier cream every eight hours and the honey impregnated paste twice a week, and the recommendation for honey impregnated was changed to medi-honey and foam dressing three times a week on 04/03/17. RN #8 reported the facility might not have been able to get the impregnated paste in and the barrier cream might have been changed to twice daily since the facility staff worked 12 hours shifts. RN #8 confirmed she was not familiar with the resident or treatment orders and the wound nurse was not available to discuss the resident with the surveyor. RN #8 confirmed the facility did not have copies of the wound consultant notes to compare to the orders and the facility wound care nurse usually made rounds with the wound consultant and took notes.

Based on observation, record review, interview and manufacturer guideline review the facility failed to ensure fall interventions were implemented to prevent falls for Resident #24, #43, #76 and #78. The facility also failed to ensure a lap restraint was properly applied to Resident #78. Harm occurred when Resident #76, who was identified to be at risk for falls and had a history of [REDACTED]. This affected four residents (Resident #24, #42, #76 and #78) of six residents reviewed for accidents and/or restraints. The facility identified one resident with a restraint. Findings include: 1. Review of Resident #76's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to 02/26/16 due to vomiting and subsequently had a gastrostomy tube inserted during the hospitalization . Review of the Admission Interim Care Plan dated 02/26/16 revealed the resident was currently at risk for falls with interventions to include: non-skid slipper socks when not wearing shoes, encourage activities to prevent boredom and or/loneliness which can cause resident to get up unattended; If resident restless or fidgety, offer snack, assess for pain, see continence/alteration in elimination Plan of care; The resident needed activities that minimize the potential for falls while providing diversion and distraction. Review of current physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) 3.0 dated 12/04/15 revealed the resident had severe cognitive impairment and required limited assistance of one staff member with bed mobility, dressing and personal hygiene. Review of the fall assessment dated [DATE] and 02/27/16 identified the resident at risk for falls. Review of the fall investigation dated 02/27/16 revealed the resident had no previous falls and was a new admission on 02/26/16. Internal risk factors included dementia, depression, incontinence, instability caused by acute condition and the resident was restless at times. Further review revealed the resident had sustained a fall on 02/27/16 and was noted to not be wearing foot wear at the time of the fall which occurred at 6:35 P.M. The resident was walking and was incontinent of urine per the staff. Ten minutes prior to the fall, the resident was observed sitting on the bed, anxious. The resident went to the emergency room and was found to have a fractured right hip. The family declined treatment and the resident returned to the facility. Review of the incident report dated 02/27/16 revealed the resident's alarm was sounding, the state tested nursing assistant (STNA) entered the room and found the resident lying on the floor near the closet on her right side. A skin tear was noted on the right elbow. The resident could not describe the incident but stated she hit her head. The licensed practical nurse (LPN) stated the resident was incontinent and was in her bare feet when observed on the floor. The immediate intervention was to apply gripper socks when up and ensure wearing footwear with non-skid soles at all times. Rehab to screen and make recommendations. The physician ordered to send the resident to the emergency room due to the resident indicating she hit her head. On 03/03/16 at 12:40 P.M. interview with the Director of Nursing (DON) verified the resident did not have shoes or gripper socks on at the time of the above fall which resulted in a hip fracture. The DON verified the admission interim plan of care indicated the resident was to have gripper socks or non-skid footwear on at all times. Further interview verified the investigation indicated the resident was anxious prior to the fall but no care planned interventions such as offer snack, activities or assess for pain were attempted. On 03/02/16 at 1:21 P.M. Resident #76 was observed lying quietly in bed with a pull tab alarm/clip alarm lying on the mattress, clipped to the resident's gown but not secured to the bed. On 03/02/16 at 1:30 P.M. interview with Registered Nurse (RN) #11 verified the clip alarm was lying in the bed and not secured to the bed. Further interview revealed the clip alarm should be secured to the bed but since the resident had a fractured hip, she was unable to move and the staff just laid it in the bed. Review of the Safety Sentry Pull String Model data sheet dated 09/19/14 revealed the monitor attaches to bed or chair. the alarm sounds when magnetic connection is broken between magnet and monitor, indicating resident movement. The monitor is mounted to either a chair or bed using the clip on the back of the monitor or using the universal mounting clip or chair strap. On 03/03/16 at 11:10 A.M. observation of Resident #76 revealed the clip alarm was not attached or clipped to the bed. Interview with LPN #65 verified the alarm was not secured to the bed and would not work correctly if the resident attempted to get out of bed. 2. Review of Resident #78's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MDS 3.0 assessment, dated 02/06/16 revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility and transfers. The resident required extensive assistance of one staff member with eating, dressing and toilet use. Review of the fall risk assessment dated [DATE] revealed the resident was identified as a fall risk. Review of the actual fall, history of falls and potential for further falls related to conditions including cognitive deficits, impaired safety, weakness, use of psychotropic medications, impaired mobility, use of assisted devices plan of care dated 11/13/15 revealed interventions to include lap buddy when up in a wheel chair to promote and maintain upright posture, non-slip material to wheel chair seat, weight sensor alarm to bed and chair to alert staff in attempts of self transfer and ambulation. Review of the fall investigation dated 02/07/16 revealed the resident fell at 12:00 P.M. The resident had previously been sitting quietly in his wheel chair. The new interventions implemented was a lap buddy and non-skid material to the wheel chair seat. Review of the nurse's notes dated 02/09/16 revealed the resident was sitting in his wheel chair propelling self around the unit when another resident stated hey get him and when the nurse turned around the resident was laying on the floor on his left side. The resident who observed the resident fall stated he just fell out of his chair, leaning forward. The action implemented was to re-educate the staff on safety interventions. Review of the fall investigation dated 02/09/16 at 7:25 P.M. revealed the resident did not have the lap buddy in place or the non-skid material to his wheel chair seat. On 03/01/16 at 8:25 A.M. Resident #78 was observed seated in his wheel chair, in the Victoria Way dining room. The resident had a lap buddy (Posey Lap Hugger) in place. The lap buddy way bent up in the center and curved towards the resident's abdomen. Review of the Posey Lap Hugger application manufacturer's instructions revealed the hugger is to be placed so that it lays flat on the patient's lap On 03/02/16 at 8:29 A.M. interview with LPN #65 verified the lap buddy was not applied correctly. Further interview verified the lap buddy was applied upside down and backwards. On 03/03/16 at 9:30 A.M. Resident #78 was observed lying in bed. No bed alarm was observed on the resident's bed. The resident's wheel chair was also in the resident's room. A chair alarm was not observed on the wheel chair. On 03/03/16 at 3:00 P.M. interview with LPN #65 verified the resident did not have a bed or chair alarm in place. Further interview verified the resident was to have a bed and chair alarm due to a history of falls. On 03/03/16 at 3:30 P.M. interview with the DON verified the resident's lap buddy and non-skid material were not in place at the time of the fall on 02/09/16. 3. Review of Resident #43's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MDS 3.0 assessment, dated 02/20/16 revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with transfers and limited assistance of one staff member with ambulation in her room and corridor. Review of the actual falls and potential for further falls related to a [DIAGNOSES REDACTED]. On 03/03/16 at 9:02 A.M. Resident #43 was observed ambulating throughout the Victoria Unit dining room. Resident #43 was not observed to have her hip protectors in place. At the time of the observation, interview with LPN # 46 verified the resident did not have the physician's orders [REDACTED]. LPN #46 verified the hip protectors were to be in place at all times except for bathing. 4. Record review revealed Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment, dated 01/19/16 revealed the resident was cognitively intact and needed supervision with bed mobility, transfers, and locomotion. Resident #24's balance during transitions and walking was identified to not be steady but was able to stabilize without staff assistance. Resident #24 used a walker. Review of Resident #24's fall incident reports revealed Resident #24 fell on [DATE], 05/02/15, 09/19/15, 10/21/15, 12/17/15, and 01/22/15. The fall incident report, dated 09/19/15 revealed the resident fell ambulating down the hallway without his walker and was educated on using his walker. The fall incident report, dated 12/17/15 revealed the resident rolled out of bed, resulting in an abrasion to his arm, markings on his face, and was educated on keeping his body in the center of the bed. The fall incident report, dated 01/22/16 revealed the resident fell standing up from a chair without his walker present, resulting in the start of a restorative ambulation program. The fall incident report, dated 02/05/16 revealed the resident rolled out of bed, resulting in an abrasion to his right shoulder and adding grab bars to his bed. Review of Resident #24's current physician orders [REDACTED].#24 was ordered restorative ambulation program to ambulate with walker and stand by assistance from room to lounge and back to room two times each day for six to seven days per week for fifteen minutes. Resident #24 was to receive rest periods as needed during the ambulation program. Review of Resident #24's current care plan revealed a goal for the resident to remain free of fall related injuries. Interventions identified to remain free of falls were bilateral grab bars to the bed to promote mobility, and a scoop mattress to bed. Resident #24's current care plan included the restorative ambulation program order. Review of Resident #24's restorative ambulation program tracking log for February, 2016 revealed the resident only received his restorative ambulation program five days during the week of 02/07/16 through 02/13/16. Resident #24 received services that week on 02/07/16, 02/09/16, 02/10/16, 02/11/16, and 02/12/16. Observation of Resident #24's bed on 02/29/16 and 9:55 A.M. and subsequent observations during investigation on 03/01/16, 03/03/16, and 03/02/16 revealed Resident #24 did not have bilateral grab bars to the bed. Interview with LPN #59 on 02/29/16 at 10:10 A.M. revealed Resident #24 did not have bilateral grab bars to the bed. Observation of Resident #24's mattress on 03/03/16 at 12:58 P.M. revealed Resident #24 did not have a scoop mattress. LPN #59 was present during this observation and stated Resident #24 had a regular mattress. LPN #59 was unsure why Resident #24's care plan identified the need for a scoop mattress.

Based on observation, closed record review, staff interview, and policy review the facility failed to adequately assess and prevent the development of an unstageable pressure ulcer for Resident #70. The facility also failed to ensure pressure relieving devices were in place and treatments were provided as ordered for Resident #42. Harm occurred to Resident #70 when the facility failed to identify and provide interventions to prevent Resident #70 from developing an unstageable pressure ulcer to right elbow. Resident #70, who was admitted on [DATE] developed an unstageable pressure ulcer to right elbow on 11/03/15. This affected two residents (Resident #70 and #42) of three residents reviewed for pressure ulcers. Findings Include: 1. Review of Resident #70's closed medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #70 was discharged home from facility on 11/10/15. Review of the nursing evaluation dated 10/24/15 at 12:52 A.M. revealed Resident #70 required total assistance from staff for bed mobility, dressing, and hygiene. The nursing evaluation also revealed the resident had an unstageable pressure ulcer to coccyx and scattered bruising to bilateral arms, hands, and right shoulder. No areas of concern to the right elbow were identified on the nursing evaluation dated 10/24/15. Review of progress note dated 10/25/15 at 4:49 P.M. by Registered Nurse Supervisor #6 revealed a body check was completed and a small pressure area was noted to Resident #70's right elbow. Review of wound management service notes revealed the wound nurse visited on 10/28/15 at 9:53 A.M. The wound management note dated 10/28/15 revealed no mention of area to right elbow. On 11/03/15 at 7:44 A.M. a progress note revealed nursing staff reported to the Director of Nursing (DON), Resident #70 had an unstageable pressure ulcer to the right elbow. The area measured 0.3 centimeters (cm) long and 0.3 cm wide. The progress note further stated upon review of record, the area to right elbow was present on admission, however, not noted on the nursing evaluation. The wound nurse was notified on 11/03/15 and orders were obtained for treatment at that time. Orders dated 11/03/15 at 10:42 A.M. included to cleanse the wound to the right elbow with normal saline, apply Hydrogel Silver (Antimicrobial Wound Care Product) and foam dressing twice a week and as needed. An order on 11/03/15 at 10:45 A.M. was also received to keep right arm off of the bed with a pillow. On 11/03/15 a care plan was initiated to keep the right arm off the bed with pillows. On 11/04/15 at 8:07 A.M. a progress note revealed the wrong measurements for pressure ulcer were entered and the correct measurements were that the ulcer was two cm long by 2.5 cm wide. Review of Treatment Administration Record (TAR) for November 2015 revealed treatment to Resident #70's right elbow was performed on 11/05/15 and 11/09/15. Further review of TAR revealed right arm was kept off the bed with a pillow from 11/03/15 to 11/10/15. Review of wound assessment dated [DATE] at 3:48 P.M. revealed a facility acquired unstageable pressure ulceration to Resident #70's right elbow was identified on 11/03/15. The area debrided measured two cm long by one cm wide. The resident complained of pain the area, with a pain rating of 5 on a scale of 1-10. A wound management service note dated 11/14/15 at 10:20 A.M. revealed Resident #70 had a new wound to right elbow with an onset date of 11/03/15. The area, which measured one cm long by 0.5 cm wide with 0.2 cm depth was debrided at that time. On 03/03/16 at 2:08 P.M. an interview with the DON verified Resident #70 developed an unstageable pressure ulcer to right elbow on 11/03/15. The DON further stated the late entry note, dated 10/25/15 was entered after the pressure ulcer was identified on 11/03/15. The facility failed to implement interventions to prevent the development of a pressure ulcer, that was not identified until it was unstageable. Review of pressure ulcer treatment policy revised February 2014 revealed an unstageable pressure ulcer was full thickness loss in which the base of the ulcer was covered. The true depth cannot be determined until the base of the wound was exposed. 2. Record review revealed Resident #42 was admitted on [DATE] with [DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer of other site, Stage IV pressure ulcer of right heel, 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 blister) pressure ulcer of left buttock, chronic pain, a joint contracture, left nondominant side [MEDICAL CONDITION], and diabetes mellitus. Resident #42's admission nursing evaluation dated 10/06/16 revealed the resident had one Stage II pressure on the coccyx, one suspected deep tissue injury pressure ulcer on the coccyx, one Stage IV left lower front leg pressure ulcer, one Stage IV right heel pressure ulcer, one suspected deep tissue injury pressure ulcer on the left heel, one Stage IV side left lower leg pressure ulcer, and one Stage IV outer leg pressure ulcer, totaling seven pressure ulcers. Resident #42's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, totally dependent on staff for transfers and bathing requiring two person assistance and had impairment on one side of upper body and lower extremity. Resident #42's skin condition was noted to have one Stage IV pressure ulcer, and three unstageable pressure ulcers, totaling four pressure ulcers. Resident #42's wound management assessment dated [DATE] revealed the resident had one improving Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) coccyx pressure ulcer, one improving left heel unstageable pressure ulcer, one improving right heel Stage IV pressure ulcer, one improving left lower extremity lateral distal unstageable pressure ulcer, one improving left lower extremity lateral unstageable pressure ulcer, one left lower extremity lateral proximal unstageable pressure ulcer, one left heel deep tissue injury pressure ulcer, one left lower extremity lateral distal unstageable pressure ulcer, and once sacrum deep tissue injury pressure ulcer, totaling nine pressure ulcers. Review of Resident #42's wound round assessment on 02/29/16 and assessments since the resident's admission on 10/06/15 revealed Resident #42 at the time of investigation had a healing Stage IV pressure ulcer measuring 1.0 centimeter long by 2.0 centimeters wide by 0.0 centimeters deep on the right heel and an unstageable pressure ulcer measuring 0.6 centimeters long by 0.5 centimeters wide by 0.1 centimeters deep on the left lateral leg. Resident #42's current physician orders [REDACTED]. Resident #42's care plan included these orders. Observation on 03/03/16 at 7:59 A.M. of Resident #42 lying in bed revealed Resident #42's feet were not elevated. Interview with Resident #42 during this observation confirmed the resident's heels were resting directly on bed not floating. Resident #42 explained her heel lift boots were taken off on 03/02/16 by the nurse for her wound dressing change, and the facility never put them back on. One of the resident's heel lift boots was laying in the resident's geriatric chair near the bed. Resident #42's wound dressing was changed on 03/02/16 at 2:05 P.M. Observation on 03/03/16 revealed State tested Nursing Assistant (STNA) #38 walked in and out of Resident #42's room at 8:07 A.M. and 8:10 A.M. and did not put the resident's lift boots on or elevate the resident's feet. Observation on 03/03/16 revealed State tested Nursing Assistant (STNA) #45 walked in and out of Resident #42's room at 8:15 A.M., 8:45 A.M., and 8:47 A.M. and did not put the resident's heel lift boots on or elevate the resident's feet. Interview on 03/03/16 at 8:56 A.M. with LPN #59 revealed she did not put the resident's heel lift boots back on after the dressing change on 03/02/16 because the resident could not be transferred with them on, and the STNAs needed to transfer the resident to her bed from the geriatric chair. LPN #59 exposed Resident #42's feet under the blanket, and confirmed the resident's feet were not elevated and were directly resting on the bed. LPN #59 put the heel lift boot sitting in the resident's geriatric chair on the resident's left foot. Interview on 03/03/16 9:16 A.M. with STNA #45 revealed she repositioned Resident #42 at 6:30 A.M. and noticed the resident's feet were not elevated, and only one of her lift boots missing. STNA #45 entered Resident #42's room and revealed the resident then had a heel boot on the right foot. Resident #42 explained another STNA came in and found the boot on her table, so the STNA put it on. Interview on 03/03/16 9:27 A.M. with STNA #38 confirmed the STNA found Resident #42's heel boot in her drawer and put it on her right foot. Review of Resident #42's discontinued orders and treatment administration records (TAR) from October 2015 through January 2016, revealed the facility did not provide all pressure wound treatment as ordered. Resident #42 was ordered to cleanse left lateral lower leg wound with wound cleanser, apply calcium alginate and cover with a foam dressing three times a week and as needed every day shift on Monday and Wednesday from 10/12/15 though 10/26/15. Resident #42's TAR revealed the resident did not receive this treatment on 10/14/15, 10/16/15, 10/19/15, and 10/26/15. Resident #42 was ordered cleanse left lateral lower leg with wound cleanser, apply calcium alginate silver and foam dressing daily and as needed every day shift from 10/26/15 through 10/26/15. The TAR revealed the resident did not receive this treatment on 10/27/15. Resident #42 was ordered cleanse left lower leg with normal saline, apply [MEDICATION NAME] alginate foam every Monday during the day shift from 10/29/15 through 12/02/15. The TAR revealed the resident did not receive this treatment on 11/02/15 and 11/20/15. Resident #42 was ordered cleanse right heel with normal saline, apply [MEDICATION NAME] alginate foam every Monday during the day shift from 10/29/15 through 12/02/15. The TAR revealed the resident did not receive this treatment on 11/02/15 and 11/20/15. Resident #42 was ordered cleanse both areas on right leg with normal saline, apply two layers of [MEDICATION NAME] alginate foam every Monday during day shift through 12/02/15 through 12/18/15. The TAR revealed the resident did not receive this treatment on 12/17/15. Resident #42 was ordered cleanse left lower leg with normal saline, apply [MEDICATION NAME] every other day 12/03/15 through 12/18/15, and the TAR revealed the resident did not receive this treatment on 12/17/15. Resident #42 was ordered cleanse left lateral lower leg with wound cleanser, apply [MEDICATION NAME] alginate twice weekly and as needed from 12/22/15 through 01/19/16. The TAR revealed the resident did not receive this treatment on 12/28/15. Resident #42 was ordered cleanse right heel with wound cleanser, apply [MEDICATION NAME] alginate foam dressing twice weekly and as needed every Monday on day shift. The TAR revealed the resident did not receive this treatment on 12/28/16. Interview on 03/03/16 at 1:31 P.M. with Director of Nursing confirmed Resident #42's pressure wound treatments were not completed as ordered based on review of the above treatment administration records.