Every finding on record at Cedar Manor Nursing and Rehabilitation Center

Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents, staff and the public, as evidenced by; An industrial sized garbage can dumpster was seen outside the facility and not on a concrete slab. These failures could affect residents and could result in unsanitary conditions by creating a haven for pests could cause disease for the residents. Findings include: In an observation on 03/04/2026 at 11:02 AM, there was an industrial sized garbage can dumpster that was at the back of the facility. The dumpster was located on the dirt area and not on a concrete slab. Interview on 03/05/2026 at 4:45 PM the Administrator was made aware of the observation of the dumpster not located on top of a concrete slab. The Administrator said they would work on getting that resolved. The Administrator said they did not have a policy for the dumpsters.

Based on observation and interview, the facility failed to ensure each room was designed or equipped to assure full visual privacy for 6 of 6 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being. Findings included:Observation on 03/05/2026 at 2:35 PM of resident rooms 301, 303, 306, 307, 309 and 310 revealed that each room had dual occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the center of the room but stopped approximately 24 inches from the door. The curtains did not provide coverage and privacy around the entire beds. Interview on 3/5/2026 at 3:03PM the DON stated she was unaware the curtains failed to provide full visual privacy. The DON stated there was a possibility of residents being exposed during resident care if the door was not closed.Interview on 03/05/2026 at 4:02 PM the Administrator said if there was no full visual privacy in the resident rooms then there was a possibility of the residents being exposed during resident care. The Administrator said that they did not have a policy on full visual privacy curtains.

Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings included: Interview on 03/05/2026 at 11:05 AM the AD said she had been working at the facility as the AD since April 2025. The AD said she was currently not registered for an activities director course. The AD said there had been some changes in the administration and the previous administration had told her they would assist her with getting registered to take an AD course but since that administration had left she did not get registered. Interview on 03/05/2026 at 4:44 PM the Administrator said they were working on getting the AD enrolled in the AD course and would be working on that. Review of the current Activity Director personnel revealed she was not enrolled in an activity course nor was she a certified AD. Review of the facility's job description for the Activity Director dated 2014 revealed in part: The following is a non-exhaustive criteria that relates to the job of a Activity Director and it is consistent with the business needs if the facility. These are legitimate measures of the qualifications for a Activity Director and are related to the functions that are essential to the job of a Activity Director. Knowledge Base - High school graduate with certification where required by state regulations. Must be certified Activity Director.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:A. Dietary Manager and [NAME] D wore a hair restraint properly covering all of their hair. B. The bottom shelves throughout the kitchen were clean and not soiled.C. The stove and oven were clean and not soiled. D. The vent hood was clean and free of dust.E. The freezer in the pantry was clean and not soiled.F. The shelves in the pantry were clean and free of dust. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.The findings included: In an observation on 03/03/26 at 9:40 AM, during the initial tour of kitchen, the bottom shelves throughout the kitchen, including the shelves that held the dishes, pots and pans, were soiled with food crumbs and dust. The stove and oven were soiled with grease, food crumbs and dried food. The vent hood was covered with a layer of dust. In the pantry, the bottom shelf of the freezer was soiled and food crumbs and frozen foods. The shelf in the pantry that had the plastic covering over the shelves had a layer of dust and food crumbs on them. In a follow-up observation during food preparation on 03/04/26 at 11:15 am, the Dietary Manger's hair net only covered the bun or top part of her hair. [NAME] D had hair coming out of the back of her hairnet. In an interview and observation on 03/05/26 at 10:08 am, the Dietary Manager said that hair nets should be worn to cover all of the hair. She said that her hair net will roll up on top of her head, and she does not realize it. She did not notice that [NAME] D hair was hanging out of the back of her hair net. She said the failure to wear hair nets properly had the potential for residents to have hair in their food. The findings were observed and reviewed with the Dietary Manager, concerning the food crumbs and dirt on the bottom shelves; the stove and oven were soiled with grease, food crumbs and dried food; the vent hood was covered with a layer of dust; the freezer in the pantry bottom shelf was soiled and food crumbs and frozen foods; and the shelf in the pantry that had the plastic covering over the shelves had a layer of dust and food crumbs on them. The Dietary Manager said potential negative outcomes of not keeping the kitchen free of food crumbs, and dirt/dust could attract pests, produce bad smells, hair in the resident's food, and infection control issues. In an interview on 03/05/26 at 3:00 pm, the Administrator was made aware of findings in kitchen. He said it was his expectation for staff to wear hair nets correctly. The kitchen to be cleaned after each meal, including the stove and oven, and freezer/appliances. He said the vent hood is cleaned quarterly by a vendor but should be cleaned by staff in between vendor cleanings. He said the failure had the potential for infection control issues, pests, and hair in resident's food. Record review of the facility policy Infection Control, dated as revised 4.9.25, revealed the following [in part]:We will ensure that all employees practice infection control in the Food and Nutrition Services Department and maintain sanitary food preparation. Procedure: 1b: Clean hair is required. It is to be covered with an effective hair restraint. 5a: All kitchenware and food contact used in the preparation and/or serving of food are cleaned and sanitized before use and cleaned after each meal preparation.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #3 and #21) of 5 residents reviewed for infection control. LVN A failed to sanitize the glucometer after she performed a blood sugar test on Resident #21. CNAs B and C failed to use recommended PPE when they assisted Resident #3 with incontinent care and urinary catheter care as the resident was on EBP precautions. These failures could place residents at risk of cross contamination and the spread of infection.Findings include: Observation and an interview on 3/4/2026 at 11:40 AM revealed LVN A went in a Resident #21's room to obtain a fasting blood sugar. The LVN took a small blood sample from the resident's finger and applied it to the test strip that was in the glucometer. After the LVN checked the Resident #21's blood sugar, she exited the resident's room and set the glucometer on the cart without sanitizing it. LVN A stated she used a tissue and hand sanitizer to sanitize the glucometer. She said she was unaware of what she was supposed to use to sanitize the glucometer. Interview on 3/4/2026 at 11:46AM with the DON revealed the glucometers were supposed to be cleaned using bleach wipes. She stated the nurses were trained upon hire and annually on proper disinfection of the glucometers. The DON said the risk of not using the proper solution for sanitizing the glucometers was passing on infections. Record review of Resident #3's admission record dated 03/05/2026 revealed she was admitted to the facility on [DATE] with diagnoses of neuromuscular dysfunction of bladder (is a loss of bladder control caused by nerve damage, resulting in dysfunction of the muscles that store or empty urine) and muscle weakness. She was [AGE] years of age. Record review of Resident #3's care plan dated 12/20/2023 revealed in part: The resident has an Indwelling Catheter: Neurogenic bladder. The resident will show no signs and symptoms of Urinary infection throughreview date. Resident is on enhanced barrier precautions. There will not be any transmission of infection from or to the resident. Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Record review of Resident #3's MDS assessment dated [DATE] indicated in part: Section H - Bladder and Bowel. Check all that apply: Indwelling catheter. Observation and interview on 03/05/2026 at 09:54 AM CNA B and CNA C performed incontinent care for Resident #3. Both staff entered the resident's room, washed their hands and put on some gloves. They then proceeded to undo Resident #3's brief and it was noted that the resident had a urinary catheter. CNA C then took some wet wipes and wiped the resident's vaginal area and also cleansed the urinary catheter tubing. Both CNA's then turned Resident #3 on her right side and CNA C took some wet wipes and wiped the resident's rectal area and it was noted that the resident had a bowel movement. CNA B then repositioned the resident's urinary catheter on the bed and helped with turning the resident on her back. Both CNAs then fastened a new brief on the resident and they were done with the care. CNA B and CNA C were asked about the EBP posting posted outside of Resident #3's room. Both CNAs said that the posting was to indicate that they were supposed to use PPE such as gloves and a gown when providing personal care for a resident with a urinary catheter such as Resident #3. Both CNAs said they had forgotten to wear a gown while providing the care and they should have worn a gown along with the gloves. Both CNAs said if they did not wear the appropriate PPE then there was a possibility of spread of infections. Interview on 03/05/2026 with the DON and the ADON at 03:34 PM the ADON said staff were expected to wear EBP when providing care for residents that had a urinary catheter. The ADON said the staff had been trained on how and when to use PPE and that the CNAs that performed care for Resident #3's catheter were aware they had to wear PPE but had forgotten. The DON said that if the staff did not wear PPE as indicated it could possibly lead to infections although it had not been proven yet. Interview and record review on 03/05/2026 at 4:40 PM the Administrator said it was expected for nursing staff to use PPE when care was provided to a resident that was on EBP precautions. The Administrator said that if the correct PPE was not worn it could lead to cross contamination. Review of facility policy labeled glucometer on 3/4/2026 at 1:33PM revealed:4. Maintenance.1. Clean and inspect meter exterior with each use.2. Meter will be cleaned with a germicidal and allowed to air dry between patient testings. Record review of the facility document titled Infection control plan and dated 03/2024 revealed in part: The facility will establish and maintain an infection control program designed to provide a safe, sanitary comfortable environment and to help prevent the development and transmission of disease and infection. The facility will establish an infection control program under which it investigates, controls and prevents infections in the facility. Record review of the facility document titled Enhanced Barrier Precautions and dated 04/01/2024 revealed in part: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical device example include urinary catheters.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #1 and #2) of 5 residents reviewed for infection control.The facility failed to ensure RN A and MA B used personal protective equipment during a transfer when the residents were on enhanced barrier precautions. The facility failed to ensure RN A washed his hands correctly while completing wound care on Resident #1. These failures could place residents at risk for cross contamination and the spread of infection. Findings included:Resident #1Review of Resident #1's admission Record, dated 8/28/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a type of dementia) and chronic ulcer of the right foot with muscle involvement (Resident #4 had a sore that was deep enough to affect muscle tissue). Review of Resident #1's MDS Assessment, dated 6/16/25, revealed she had long and short-term memory impairment with severely impaired decision-making ability. She had one stage III pressure ulcer (the skin was completely gone which might expose fat, but bone or tendon were not exposed). Review of Resident #1's care plan, 4/9/24, revealed a goal of the resident had a potential for pressure ulcer development. The identified goal was the resident would have intact skin, free of redness, blisters or discoloration, by/through the review date. Identified interventions did not include anything related to wound care or enhanced barrier precautions. Review of the Order Summary, dated 8/28/25, revealed orders dated 8/26/25:Clean lateral right foot, apply skin prep (skin cleaner) around wound to prevent maceration (skin made soft by exposure to fluid(s)), apply collagen particles (a protein powder to assist in wound care), cover with bordered foam (type of bandage with foam in center and adhesive all the way around the bandage) every day shift related to other skin changes. Observation on 8/28/25 at 10:21 a.m. revealed there was no sign indicating Resident #1 was supposed to be on enhanced barrier protection and there was no personal protective equipment in the room. Continued observation showed RN A did not put on personal protective equipment prior to entering Resident #1's room. RN A washed his hands five times but did not use a paper towel to turn off the faucet when he washed his hands. Resident #1 was not interviewable. Interview on 8/28/25 at 1:05 p.m. RN A stated the proper way to hand wash was to rinse hands, get soap, lather, rinse hands, use paper towels to turn off the faucet, and then throw paper towels. RN A said to the best of his remembrance he washed his hands correctly. RN A said, I washed my hands multiple times, and can't say I washed them right every time. Interview on 8/28/25 at 1:55 p.m., the DON stated staff were expected to do hand hygiene after they touched bodily fluids or resident contact. The DON said she expected staff to wash their hands by turning on the water, put their hands in water, soap and lather for 20 seconds, rinse their hands, let hands drip-dry, grab a paper towel, pat hands dry, and turn off the water faucet with a paper towel and throw the towel away. The DON said there were annual checkoffs for hand washing procedures, but she did not do random checks. Interview on 8/28/25 at 2:36 p.m., RN A stated enhanced barrier precaution was used for residents with tubes and some kind of wound. RN A said he did not wear personal protective equipment when he did the wound care on Resident #1. RN A explained he did not see a sign when he went into the room and there was no tower (bin) of personal protective equipment to trigger him into thinking about it. Resident #2:Review of Resident #2's admission Record, dated 8/28/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra and lumbosacral region (infection in the bones of the lower back). Resident #2 was still in her MDS Assessment time frame. Record review of Resident #2's Care Plan, initiated 8/28/25, revealed the resident had intravenous (IV) access. The goal was the resident would not have any complication related to IV therapy through review date. Identified interventions included Administer IV medications as ordered. Review of Resident #2's Care Plan, initiated 8/28/25, revealed the resident was on enhanced barrier precautions. Identified interventions included gloves and gown should be donned (put on) if any of the following activities were to occur transfer or other high-contact activity. Posting at the resident's room entrance indicating the resident was on enhanced barrier precautions. Review of Resident #2's Care Plan, initiated 8/28/25, revealed Resident #2 was at risk for falls related to (blank). Identified goals included the resident would be free of falls through the review date. Identified interventions included staff x1 to assist with transfers. Observation on 8/28/25 at 4:32 p.m. revealed no Enhanced Barrier Sign posted outside of Resident #2's room or above the resident's bed. MA B did not put on gloves or personal protective equipment. There was a bin full of personal protective equipment inside Resident #2's room. MA B did not put on personal protective equipment prior to completing a one-person transfer with Resident #2. Interview on 8/28/25 at 1:55 p.m., the DON stated with residents on Enhanced Barrier Protections the rooms had bins had gloves, gown and gowns outside of their rooms if needed. The DON said the expectation was the staff were to put on the personal protective equipment prior to going into a resident room. The DON said the personal protective equipment was to be worn during wound care, so it did not infect the wound. Interview on 8/28/25 at 2:58 p.m., the Corporate RN stated Enhanced Barrier Protection was indicated when there was an Intravenous therapy or wounds. The Corporate RN said the staff were to wear personal protective equipment to avoid sharing organisms with the resident. Review of the facility's policy and procedure on Fundamentals of Infection Control Precautions, undated, version 03-8.0, revealed, in part: A variety of infection control measures are used for decreasing risk of transmission or microorganisms in the facility.Hand Hygiene: Hand Hygiene continues to be the primary means of prevention the transmission of infection. The following is a list of some situations that require hand hygiene: before and after isolation precaution settings; before and after changing a dressing; after handling used or soiled dressings.Consistent use by staff of proper hygiene practices and techniques is critical to preventing the spread of infections. Recommended techniques for washing hands with soap and water include: wetting hands first with clean, running warm water, applying the amount of product recommended by the manufacturer to hands, and rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers, then rinsing hands with water and drying thoroughly with a new disposable towel, and turning off the faucet on the hand sink with the disposable paper towel. Review of the facility's policy and procedure on Enhanced Barrier Precautions, effective 4/1/24, revealed: Multidrug-resistant organism transmission is common in long term care. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with [NAME]-drug resistant organisms. Enhanced Barrier precautions refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employ targeted gown and glove use during high contact resident care activities. Enhanced barrier precautions are used in conjunction with standard precautions and expand the use of personal protective equipment to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms to staff hands and clothing. Enhanced barrier precautions are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multi-drug resistant organisms. Wounds generally include chronic wounds, not shorter-lasting wounds, such as wound breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. The facility will ensure personal protective equipment and alcohol-based hand rub are readily accessible to staff. Discretion may be used in the placement of supplies which may include placement near or outside the resident's room. The facility will utilize postings outside the room and the electronic document program to communicate to staff if a resident requires enhanced barrier protections.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 6 resident halls (Hall 3) reviewed for environmental concerns. The facility failed to replace missing and damaged ceiling panels in Hall 3. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.Findings included: Observation conducted on 08/19/25 at 1:45 PM revealed the following: Hall 3 had numerous missing and damaged ceiling tiles. Electrical wires and air ducting in the ceiling were left uncovered. An interview on 08/19/25 at 2:20 PM Resident #6 stated that the tiles in Hall 3 had been torn up for a while now, and it looked like crap. He stated they paid good money to have a nice place, but that looked bad and cheap. Resident #6 stated he had asked staff why tiles were not repaired but they had no idea and stated that maintenance was working on it. In an interview on 08/19/25 at 3:00 PM the Maintenance Director stated that Hall 3 had some work done on it involving the air conditioning system and the tiles were removed. The Maintenance Director stated that the work was completed a few weeks ago and he had not had time to replace the ceiling tiles. The Maintenance Director stated that Hall 3's missing and damaged ceiling tiles needed to be replaced and looked bad. He said he would order tiles to make Hall 3 look better. In an interview on 08/20/25 at 3:30 PM the Administrator stated Hall 3 ceiling tiles needed to be replaced and she would order replacements and have them installed asap[KS1] . Missing and damaged tiles made the facility look junky and un-kept, and residents deserved to have a home that was well taken care of and looked nice. [KS1]Clarify who would order replacements, and have them installed asap

Based on observation, interviews and record reviews, the facility failed to ensure nurse staffing information was posted in a prominent place readily accessible to residents and visitors that included: The total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift for 12 of 12 days [KS1] (8/9/25, 8/10/25, 8/11/25, 8/12/25, 8/13/25, 8/14/25, 8/15/25, 8/16/25, 8/17/25, 8/18/25, 8/19/25, 8/20/25)reviewed for required postings. The facility failed to ensure the daily staffing information up to date and was posted in a prominent location on 08/20/25. This failure could place residents, their families, and visitors at risk of not knowing how many nursing staff are currently working to provide care on all shifts. [KS2] [KS1]List the dates of the 12 days in the based on statement [KS2]The failure statement should include the 12 datesFindings Included: During an observation on 08/20/25 at 9:40 AM, the daily staffing posted located outside the Administrator's door was dated 08/08/25. During[KS1] an interview on 08/20/25 at 10:00 AM, the Administrator stated her expectation was that the daily staffing be posted daily. The Administrator stated the ADON was responsible for posting the daily staffing. The Administrator stated she had not realized that it was not being kept current. During[KS2] an interview on 08/20/25 at 10:30 AM the ADON stated she was responsible for posting daily nurse staffing hours but had been busy with other job duties and just had forgotten to keep the posting current for the past 12 days. Review of policy titled Nurse Staffing Posting Information dated 01/01/2024 revealed: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time . The nurse staffing sheet will be posted on a daily basis. [KS1]Did we ask the Administrator why it was important the nurse staffing info be posted every day? It would be helpful to have her stating how residents were/could be affected if the information was not posted. [KS2]Did we ask the ADON about the 12 days referenced in the based on statement? It would be helpful to have the ADON saying she had not posted the info for 12 days, starting on 8/9/25.

Based on interview, and record review the facility failed to review and revise the Comprehensive Care Plan by the interdisciplinary team after each assessment for 1 (Resident #1) of 13 residents. The facility failed to update the care plan for fall interventions for Resident #1 after a fall assessment was completed on 04/13/2025. This failure could affect residents of the facility by placing them at risk for decreased quality of care. Findings included: Record review of Resident #1's electronic file revealed an [AGE] year-old female with an admitted [DATE] and diagnoses of muscle wasting and atrophy (loss of muscle mass and strength), Dementia with agitation (impairment of at least two brain functions like memory loss and judgement), anxiety disorder (persistent worry and fear), Abnormalities of gait (walks differently from normal), cachexia (ill health involving weight loss and muscle loss). Record review of Resident #1 Fall-Risk assessment dated [DATE] revealed a high-risk score of 10.0 with intermittent confusion, no falls in the past 3 months, and ambulatory. Record review of Resident #1's Care Plan on page 11 of 18 last updated on 11/27/24 revealed the resident was at risk for falls with interventions. No updated care plan interventions after 4/13/25 fall assessment. Record review of Nurse's note dated 4/13/25 for Resident #1 revealed an unwitnessed fall in the resident's room, attempted to toilet herself, and discovered on the floor with no noted interventions in place prior to fall on 04/13/2025 and increased monitoring initiated in response to fall. During an interview on 4/26/25 at 1:57 pm with RN A, who stated Resident #1 was a fall risk and staff did interval monitoring on her and reminded Resident #1 to use her call light. RN A stated staff use the 24-hour report and verbal report to receive updates on patients, not reviewing care plans. During an interview on 4/27/25 at 12:25pm with CNA B, who stated Resident #1 had a fall a couple of weeks ago and she heard the fall and went in to find the resident on the floor, and the nurse came and assessed the resident, and the nurse did neuro checks on her and staff increased monitoring on Resident #1. Resident #1 interventions placed were increased monitoring, and her bed in the lowest position too. CNA B stated staff communicate through verbal report on interventions. CNA B does not review care plans. Prior to this fall, her items were to be in reach. During an interview on 4/27/25 at 4:30pm, with the Regional Corporate Nurse, interim DON, who stated the DON would be responsible for updating clinical information in the care plans and he was not aware Resident #1's care plan had not been updated after her fall. He stated he will be auditing all care plans now. Record review of Fall Risk Assessment policy dated 2/01/2007 revealed Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family. A Fall Risk Assessment will be completed on admission and after each fall .7. After risk is assessed, individual plans of care will be implemented to prevent falls.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control. The DON and RN A failed to follow EBP procedures by not wearing a gown while providing Resident #1 wound care. This failure could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #1 's admission record revealed Resident #1 was an [AGE] year-old male with an admitted to the facility of 08/01/2015. Admission record revealed Resident #1 had diagnoses list that included acute osteomyelitis (Inflammatory condition of bone secondary to infection) left ankle and foot, type II diabetes, muscle weakness, mild protein calorie malnutrition, peripheral vascular disease (narrowing/blocking of the blood vessels), hypertension, and cerebral infarction (stroke). Record review of Resident #1 's quarterly MDS dated [DATE] revealed the resident had a BIMS of 15 indicating the resident was cognitively intact. Record review of Resident #1 's order summary revealed an order dated 02/03/2025 of Cleanse venous stasis ulcer to left distal great toe with wound cleanser. Pat dry, cover with therahoney, then cover dressing, every Monday, Wednesday Friday, util healed one time a day every Mon, Wed, Fri for wound care. Record review of Resident #1 's Care plan dated 12/30/2024 revealed a focus of Resident is on Enhanced Barrier Precautions. Observation on 02/26/2025 at 2:48 pm the DON nor RN A put on a gown prior to or during wound care for Resident #1. During an interview on 02/27/2025 at 4:30 pm with the DON, whom was also the infection preventionist, stated that Resident #1 is on EBP (Enhanced Barrier Precautions) and she and RN A should have been wearing a gown during wound care. The DON stated that she did not think about it and they had been so busy. The DON stated that this failure is a potential for cross contamination. During an interview on 02/27/2025 at 4:43 pm RN A stated that she didn't think about putting on a gown because she was nervous, and it had been busy. RN A stated the resident should be on EBP to prevent potential cross contamination. Record Review of the facility's policy titled Enhanced Barrier Precautions dated 4/012024 reads in part EBP are used in conjunction with standard precautions and expand the use of PPE (personal protective equipment) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistant organisms) to staff hands and clothing.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 2 meals reviewed for resident rights and for 10 of 10 residents in the confidential group interview. The facility failed to serve residents in the female secure unit in a manner that was not institutional-like and serve residents on trays. The facility failed to ensure staff provided care to residents while not on their cell phones causing residents to feel left out. This failure could place residents at risk for decreased meal satisfaction and could result in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation. The findings included: Observation on 12/10/24 at 12:17 p.m. of the female locked unit lunch meal revealed the lunch meal arrived on a lunch cart. There were six residents present in the dining room. The staff present took the meal off the cart, checked the card and brought the meal to the resident. The staff placed the meal on the tray in front of all six residents in the dining room. Comparison to the main dining room on 12/10/24 at 12:24 p.m. of the main dining room revealed all residents in the main dining room had their food placed on the table. Interview on 12/10/24 at 12:26 p.m. the DON observed the residents eating in the main dining room and then compared it to the female residents in the secured unit. She stated she could not identify a difference since the food was the same and the staff was sitting. The DON stated she did not eat off a tray at home then asked if it was a dignity issue. CNA A stated the last time she ate off a tray that was not fast-food was probably high school. Observation on 12/10/24 at 4:28 p.m. revealed staff setting up smoking materials while texting. Residents were present at the time of the texting. During the confidential resident council meeting on 12/11/24 10 alert residents stated staff were on the cell phones while providing care. The residents stated it did not matter what shift it was, and it did not make a difference what kind of care the staff was providing. One resident stated staff were on the phone while passing medications. Other residents stated staff were on the phone while in the dining room or doing transfers. The resident stated it made them feel left out and not there. Observation on 12/11/24 at 10:32 a.m. revealed the Activity Director cutting through the dining room on her phone with residents present. Review of the Resident Council Minutes, dated 10/16/24, revealed the residents' reported staff were on their cell phones. Review of the Resident Council Minutes, dated 11/20/24, revealed the residents' reported staff were on their cell phones. Review of the facility's Personnel Handbook dated 2015, on Personal Communication Devices, revealed: use of personal communication devices during scheduled work hours is not permitted at the facility. These devices include but are not limited to cell phones and laptop computers. You may only use your personal communication devices during scheduled lunch/ break times. Communication devices issued by the facility/company are permitted as they are tools of the job and are to be used accordingly. Employees may not bring any forms of audio entertainment devices into the facility. This provision does not apply to designated facility personnel who must use such devices in connection with their positions of employment. For the designated employees that are required to use such devices in connection with their position of employment. For the designated employees that required to use their cell phones in the course of business, the phone may NOT be used in the resident area or used in an unprofessional manner.

Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one (Resident #15) residents reviewed for wound care. The facility failed to ensure that RN B changed her gloves and performed hand hygiene while providing wound care to Resident #15. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #15's Admission Record, dated 12/12/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer or the left foot. Review of Resident #15's Quarterly MDS Assessment, dated 12/9/24, revealed: Resident # 2? had a mental status exam score of 3 of 15 (indicating severe cognitive impairment) He had 1 venous or arterial ulcer present. Review of Resident #15's Care Plan, initiated 10/18/24, revealed: Focus: The Resident has Venous/Stasis Ulcer related to decreased circulation - ulcer to left 2nd toe. Goal: the resident's ulcer will be healed by review date. Interventions: Document location of wound, amount of drainage, peri-wound (surrounding) area, pain, edema (swelling), and circumference measurements weekly. Evaluate wound for: size, depth, margins (edges). Document progress in wound healing on an ongoing basis, notify physician as indicated. Review of Resident #15's Order Summary, dated 12/12/24, revealed orders dated 11/16/24 Clean venous ulcer to top of 2nd toe of left (foot) with wound cleanser and apply a dry dressing daily and as needed until resolved every day shift. Observation and interview on 12/12/24 at 11:39 a.m. RN B stated Resident #15's orders were to clean, dry and cover with a dressing. RN B opened the cart, gelled her hands with ABHG, donned gloves (put on), and donned PPE. RN B closed the drawer to the cart. RN B pulled out the treatment supplies of wound cleanser spray, a bandage and gauze. RN B took off her gloves washed her hands and returned to the cart. RN B looked around realized she did not clean the bed side table or put a barrier down. RN B donned gloves, cleaned the bed side table and placed wax paper down. RN B brought her wound-care supplies in and placed it on the wax paper. RN B took off her gloves, used ABHG and donned new gloves prior to taking off Resident #15's bandage. Without using any type of hand hygiene. RN B donned new gloves, sprayed Resident #15's toe with wound cleanser and wiped the wound from top to bottom 21 times. RN B took off her gloves, did not use any kind of hand hygiene, and donned a new pair of gloves. RN B wiped the dry gauze across Resident #15's wound 10 times. RN B held the used (dirty) gauze in one hand, took off that glove with the gauze inside of it, and threw away the one glove. With no hand hygiene for the one hand RN B donned a new glove and placed the bandage on Resident #15's toe. RN B changed both gloves, with no hand hygiene and applied lotion to Resident #15's legs. RN B then put the wound cleanser back onto the cart without cleaning it while throwing all other equipment away in a bio-hazard bag. Interview on 12/12/24 at 11:58 a.m. RN B stated she told Resident #15 what she was going to do, gelled her hands, cleaned off the table, laid out her supplies, washed her hands, then reapplied gel. She stated she cleaned the wound well by spraying the wound with wound cleanser and covered it with the bandage, threw everything in a bag and washed her hands. RN B stated she changed her gloves and used alcohol between glove changes on each step. Follow up interview on 12/12/24 at 2:38 p.m. RN B stated when the wound care spray was brought into the room it was considered dirty and she probably did not remember to clean it. RN B stated Resident #15's wound was so small she did not think anything would be accomplished if she did or did not go over the wound repeatedly with the same gauze because there was not any infection to spread. Interview on 12/12/24 at 3:17 p.m. the DON stated her perfect wound care would be for staff to wash their hands, set up a barrier station, get a red bag for biohazard, wash their hands, don glove, remove the soiled dressing, doff gloves, use gel, don new gloves, clean the wound from cleanest to dirtiest, take off gloves, gel, don new gloves, apply the new dressing, take off the gloves and make sure everything went into the red bag. The DON stated by wiping the wound multiple times it re-contaminated the wound. The DON said everyone had wound-care check offs with their annual evaluations, including RN B but she could not remember exactly when RN B's evaluation was. The DON said she did in-services on all thing's infection control including wound care and hand hygiene in July 2024. The DON stated RN B did attend the in-services. Interview on 12/12/24 at 3:39 p.m. the Administrator stated her expectation for wound care was that the wound care be completed appropriately with proper hand hygiene and aseptic technique. The Administrator said wound care was a whole process and the expectation was it be done properly. Review of the facility's policy and procedure on Treatment Table, dated 2003, revealed: Wash hands, put on gloves, Place wax paper on wound care bedside table or small cart Gather treatment supplies (i.e. medicine, tape, extra gloves, etc.) Open up and place on top of wax paper. One end will be considered clean, and the other end of the table will be open for dirty (To replace scissors etc. to be cleaned) Place wax paper over top of supplies. On open end place linens, saline, red bag, scissors, pen camera, etc. on top of second cover of wax paper. After treatment place dirty linens, red bags, scissors, pen etc. to be cleaned on open end (considered dirty end of table). Wash hands, take bed side table/cart to treatment cart. Put on gloves. Discard linens, red bags etc. using universal precautions. Clean scissors, pen, etc. with alcohol prep. Clean top of treatment cart, bedside table/cart with disinfectant. Remove gloves. Wash hands.

Based on observation, interview, and record review, the facility failed to have certified resident rooms equipped for adequate nursing care, comfort, and privacy for 33 of 85 rooms (Rooms 701-710, 712-714, 717-722, 801-813, and 815). The facility failed to have 38 Title 18 beds in B Building resident ready. The facility failed to have 24 Dually Certified (Title 19/19) beds in B Building resident ready. This failure could affect residents by placing them at risk of residing in rooms without proper furnishings and privacy. The findings included: Review of the facility-completed Form 3740 Bed Classification, completed and signed by the Administrator on 12/10/24, documented the facility identified rooms 701-710, 712, 714, 717-719, and 801-805 as Title 18 Medicare-Only beds for both A and B beds in each room for a total of 38 beds. Form 3740 documented the facility identified rooms 709, 713-A, 720-722, 806, 807, 808-A, 810-A, 811, 812-A, 813, and 815 as dually certified (Title 18/19) for a total of 24 beds. Observation of B Building on 12/11/24 at 3:15 pm revealed 33 rooms that were not in use. All 33 rooms were not resident ready and could not be made resident ready within a reasonable timeframe due to B Building having not been in use for residents since 2020. In an interview on 12/11/24 at 3:35 pm with Corporate Compliance RN stated there was no possibility of getting all 33 rooms livable for residents in 24 hours. He stated it would take deep cleaning and removal of items being stored in the building to make the rooms adequate for housing residents. In an interview on 12/11/24 at 4:55 pm with the Administrator, she stated that the building had been used for storage since before she started working in the facility in 2023. She stated there had been no residents housed in the building in 4 years. The Administrator stated that the corporate plan was to remodel/update the building and use it for a rehabilitation unit, but due to low census, the remodel/renovation had not been priority. She stated that everything in the building was functional, but it needed to be thoroughly cleaned and have some cosmetic repairs done before it would be suitable for residents. She stated that the corporation did not want to lose the rooms and would not allow them to be declassified due to the cost recertifying the beds. In an interview on 12/12/24 at 5:11 pm, the Administrator stated that there was no facility or corporate policy regarding bed classification.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was developed and implemented describing services to be furnished to maintain the resident's highest practicable physical well-being, including services that are not provided due to the resident's exercise of the right to refuse care for 1 of 2 residents (Resident #1) reviewed for care plan revisions The facility failed to ensure Resident #1's care plan was revised to indicate the preference to keep socks on during skin assessment. These failures could place residents at risk of receiving inappropriate care. The findings include: Record review of Resident #1's face sheet dated 11/08/2023 revealed an admitted [DATE] with diagnoses which included: Type 2 diabetes mellitus, muscle weakness, and dementia. Record review of Resident #1's Care Plan, initiated on 8/29/23, had not been revised to include Resident #1's refusal to have shoes/socks taken off during skin assessments. During an interview on 11/7/23 at 2:45 PM RN A stated that to complete a full skin assessment, resident #1's socks would have to be removed, for the weekly skin assessment. He stated Resident #1 refused a lot, she never liked to have her socks taken off. During an interview on 11/7/23 at 3:30 PM CNA B stated that the resident really did not like to go without her socks or shoes. She stated in general she really did not like her socks removed. She stated that this happened often. During an interview on 11/7/23 at 3:50 PM CNA C stated that Resident #1 rarely had her socks off. She stated there were multiple times that she can remember that Resident #1 refused to take her socks off. During an interview on 11/07/2023 at 10:42 a.m. the MDS Coordinator stated that a change in condition is anything that has a pattern. She stated that if a resident or employee notices of a issue even it's a few times then it should be care planned. She stated it was not communicated to her that Resident #1 refused to take her socks off. She stated now that she knows this will be care planned. During an interview on 11/07/2023 at 12:41 p.m. the DON stated that she did go and talk with RN A, CNA B, and CNA C about Resident #1's refusal to take off her socks. She stated that all of them confirmed that Resident #1 did refuse to take socks off or shoes off. She stated now that she knows this information then it will be care planned, but it should have been care planned a few weeks ago. During an interview on 11/07/2023 at 12:41 p.m., Administrator stated that the care plan should have been done for refusal, but she and the DON did not know this was something stated by Resident #1 until 2 days ago. She stated it should have been care planned earlier, this puts the resident at risk for safety. Record review of a facility policy, titled Care Plan, Comprehensive Person-Centered change in condition should be care planned.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to accurately document Resident #1's ulcer assessment for new wounds to her left foot. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #1's face sheet, dated 11/08/2023, revealed an admitted [DATE] with diagnoses which included: Type 2 diabetes mellitus, muscle weakness, and dementia. Record review of weekly skin assessment, dated 10/10/23, indicated a skin tear posterior Left Upper extremity and question marked yes for does the resident have a pressure, venous arterial or diabetic ulcer? If yes complete the ulcer assessment. Signed by RN A Record review of weekly ulcer assessment, dated 10/10/23, indicated medial distal L foot Arterial L 2cm W 1.4cm, unable to measure depth, entire wound covered by necrotic tissue (slough and/or eschar) and unable to determine. Approximate necrotic tissue 76-100%. Currant wound treatment clean, hydro active dsg, q 3 days. Turning and repositioning q2h. PoA N/A wound is not a pressure injury. Signed by RN A Record review of weekly skin assessment, dated 10/17/23, indicated bruise LFA 12.6x15.2 and skin tear LFA 5.6, signed by RN D No documentation of weekly ulcer assessment provided for 10/17/23. Record review of weekly skin assessment, dated 10/24/23, indicated posterior L hand posterior to Ad R elbow hand distal lateral RLE. Signed by RN A Record review of weekly ulcer assessment, dated 10/24/23, indicated medial Left distal foot 2cm W1.4, 0 if unable to measure depth. Entire wound covered by necrotic tissue (slough and/or eschar) and unable to determine. Approximate necrotic tissue 76-100%. Currant wound treatment clean, hydro active dsg, q 3 days. PoA N/A wound is not a pressure injury. During a phone interview, on 11/10/23 at 12:45 p.m., RN D stated yes, it was absolutely her fault that there is no documentation of the Weekly ulcer assessment for 10/17/23. She stated she gets so busy sometimes she forgets to click things in the system. She stated that the ulcer assessment was physically done on 10/17/23 but the paperwork was not completed. She stated that the weekly ulcer assessment was necessary for the new wounds to track the improvement of healing. During an interview, on 11/10/23 at 1:05 p.m., CNA C stated she had her own written notes of each day she works and little things she observes while on shift. Her notes for the 17th of October stated that RN D did go and access the wound and clean the wound. She stated that she knows that RN D did come and accessed the wound. During an interview on 11/8/23 at 11:15 a.m., the DON stated that she did speak with RN D and confirmed that the assessment was done but no documentation was complete. She stated the assessment is key to the progress of the healing of the wounds for the resident. She stated that all wounds in the facility are to be monitored and accessed weekly by the charge nurse.

Based on interview and record review, the facility failed to ensure communication with hospice representatives in the provision of care for 1 (Resident #1) of 2 residents reviewed for hospice coordination of care,: The facility did not keep written documentation of communication between hospice and facility per hospice contract. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #1's face sheet, dated 11/08/2023, revealed an admitted [DATE], with diagnoses which included: Type 2 diabetes mellitus, muscle weakness, and dementia. Record review of Resident #1's care plan, initiated 8/29/23, revealed the resident had a terminal prognosis and/or was receiving hospice services, constipation, dehydration, skin integrity issues, decreased PO intake, weight loss, mental and physical decline in function may be unavoidable due to end-of-life issues from his terminal illness. Interventions to avoid these issues will be initiated but may be unavoidable r/t end stage disease processes. Interventions/tasks stated: If receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Record review of Progress Note dated 10/8/23, order details that were sent to physician state: Resident #1 exhibits arterial ulcers to posterior, superior, and distal medial Lfoot, physician notified, new orders received to clean apply hydro active 3 days. Entered by RN A. Record review of Order Details dated 10/8/23, by phone, ordered by physician, Description: clean arterial ulcers to posterior, superior, and distal medial L food, apply hypoactive, every-day shift, every 3 days, related to other specified peripheral vascular diseases. During an interview, on 11/7/23 at 11:15 am, RN A stated Resident #1 left the facility, with family, on October 7th and returned to the facility on [DATE]th. He stated new wounds were observed on top of the left foot and back of the heel. He stated all wounds were roughly the same, round little pieces of eschar (dead tissue that forms over healthy skin and then, over time, falls off (sheds). He stated that the heel wound was the worst. He stated he is not sure how the wound got this bad, his only guess is when they did the wound care on it, the eschar was removed, and the open wound was exposed. He stated he never noticed the wound or anything to the left foot until 10/8/23. He stated that he called the physician and put in an order for wound care due to the new wounds. He stated he did not call hospice because he figured he let the Hospice Nurse know next time she came to the facility which was twice a week. He stated he did not feel it was a big enough concern to contact Hospice immediately only to contact the physician immediately. He stated he verbally let hospice know about the new wounds on 10/10/23. He stated even though that was two days after the discovery of the new wounds and that this was a change in condition, it was not life threatening so he waited to communicate with the Hospice Nurse. He stated he had no idea he needed to keep written documentation of all communication with the hospice aids/nurses. He stated he communicated with them in person and never documented their conversation, he stated he did not know this documentation was required, per the facility contract. During an interview, on 11/10/23 at 11:15 am, DON- stated the newly identified wounds formed only after the resident went on a day pass, with her family, and she believed that the wound was formed because the resident was wearing a sock with shoes, that were too tight. She stated that she confirmed with the nurse and all 3 wounds were discovered on 10/8/23, after Resident #1 returned to the facility. She stated that communication with hospice was done in person. She stated that when she spoke with RN A, he stated that he just communicated in person with hospice and did not know it needed to be documented. She stated from this point on all communication will be either paper documented for the facility or in the progress notes of the resident. During an interview, on 11/10/23 at 11:15 am, Administrator stated that the lack of documented communications puts the resident at risk to know what is happening with the resident or what has been done. She stated informing the hospice company of a change in condition should have been done, immediately, on 10/8/23. Record review of Hospice-Nursing Facility Services Agreement revised 5/2020 stated: Hospice and facility shall communicate with one another regularly and as needed for each hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of hospice patients are met 24 hours per day. Record review of Hospice-Nursing Facility Services Agreement revised 5/2020 stated: Facility shall immediately inform hospice of any change in the condition of a hospice patient. This includes, without limitation, a significant change in a hospice patients physical, mental, social or emotional status, clinical complications that suggest a need to alter the hospice plan of care, a need to transfer a hospice patient to another facility, or the death of an hospice patient.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in 4 rooms (Rooms #103, #106, #203, #204) and one of 3 shower room for halls 100 and 200 reviewed for accident hazards, in that; The facility failed to ensure that the hot water temperatures in the restroom sinks for 4 resident rooms and the shower rooms did not exceed the maximum of 110 degrees Fahrenheit. This failure could place residents at risk for injuries related to hot water temperatures. The findings included: Record review of Resident #1's admission record dated 10/17/23 indicated she was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder and muscle weakness. She was [AGE] years of age. Record review of Resident #1's MDS dated [DATE] indicated in part: BIMS = 4. Severe impairment. During an observation and an interview on 10/17/23 at 11:18 AM revealed the hot water temperature in room [ROOM NUMBER] was 123 degrees Fahrenheit. The resident in the room said she had not noticed the water was too hot in the restroom whenever she washed her hands. During an observation and an interview on 10/17/23 at 11:20 AM revealed the hot water temperature in room [ROOM NUMBER] was 122.4 degrees Fahrenheit. The resident in the room said she had not notice the water was too hot in the restroom whenever she washed her hands. During an observation on 10/17/23 at 11:36 AM revealed the hot water temperature in halls 100 and 200 shower room was 120 degrees Fahrenheit. During an observation and an interview on 10/17/23 at 11:50 AM revealed the hot water temperature in room [ROOM NUMBER] was 122 degrees Fahrenheit. Resident #1 said the water in her rest room sink would get very hot at times when she washed her hands. The resident said she had not burned her hands. The resident said she had not told the facility staff the water felt too hot to her. During an observation and an interview on 10/17/23 at 11:55 AM revealed the hot water temperature in room [ROOM NUMBER] was 122.8 degrees Fahrenheit. The resident in the room said she had not noticed the water was too hot in the restroom whenever she washed her hands. During an observation and interview on 10/17/23 at 2:56 PM the Maintenance Director said the water temperature should be in the range of 103 to 108 degrees Fahrenheit. The Maintenance Director said if the water got too hot it could scald the residents. The Maintenance Director said he checked the water temperature once a week and had not noticed them being high, he checked them random rooms throughout the facility. The Maintenance Director was made aware of the temperature readings taken by the surveyor. The Maintenance Director checked the water temperatures in room [ROOM NUMBER] with the facility thermometer and it was 122 degrees Fahrenheit. The Maintenance Director said He would turn the temperature down as it was too high and that the same water heater controlled both halls 100, 200 and the main shower room. During an interview on 10/17/23 at 3:12 PM the Administrator said the water temperature should be around 110 degrees Fahrenheit. The Administrator said she was not sure what the temperature of the water was at the facility as she had just started working as the Administrator the day before today. The Administrator was made aware of the observations of the water temperatures being 122 degrees Fahrenheit on halls 100, 200 and the shower room in between the same two halls. The Administrator said they would get that corrected as the temperature was high and it could lead to the residents getting burned. Record review of the facility's titled Hot water systems dated 2003 indicated in part: Water temperatures should be maintained at 100 degrees Fahrenheit at a minimum and 110 degrees Fahrenheit at a maximum.

Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #55) of two residents reviewed for pain in that , 1. RN A failed to accurately assess and administer pain medication to Resident #55 when she complained of left arm pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. The findings included: Review of Resident #55's Admission Record dated 10/18/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, pain, major depressive disorder, and palliative care (specialized medical care that focuses on providing relief from pain). Review of Resident #55's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed: She scored an 8 on her mental status exam, indicating moderately impaired cognition. She had no signs or symptoms of delirium. She had no reported behaviors and no reported refection of care. She required only supervision or limited assistance for ADLs. She used a walker to ambulate. She did not report any pain at the time of the assessment. She received an antipsychotic medication, anxiety medication, diuretic, and opioid medication. She was on hospice services. Review of Resident #55's Care Plan last revised 10/17/23 revealed: Focus: I have the potential for pain related to end stage disease processes, arthritis, possible colon cancer. I am able to verbally report pain. I have Fentanyl PRN, Lidoderm patches PRN, acetaminophen PRN (date initiated: 8/29/23) Goal: I will not have an interruption in normal activities due to pain through the review date (Date initiated: 8/29/23) Interventions/Tasks: Administer analgesia as per orders. Give 1/2 hour before treatments or care. (Date initiated: 8/29/23). Anticipate my need for pain relief and respond immediately to any complaint of pain. (Date initiated: 8/29/23). Monitor/record/report to nurse any s/sx of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing). (Date initiated: 8/29/23) Focus: I have a terminal prognosis and/or am receiving hospice services for end stage senile degeneration of the brain. I have comfort medications ordered. Fentanyl PRN Pain, Acetaminophen PRN pain/temp (date initiated: 8/29/23) Goal: My comfort will be maintained through the review date. (Date initiated: 8/29/23) Interventions/Tasks: Observe me closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. (Date initiated: 8/29/23); Work with nursing staff to provide maximum comfort. (Date initiated: 8/29/23). Focus: I am resistive to care related to dementia. I will refuse assist from staff. I refuse medications frequently. I refuse to wear shoes. (Date initiated: 10/11/23, Revision date: 10/17/23) Goal: I have the right to refuse treatment through the review date. (Date initiated: 10/11/23) Interventions/Tasks: Allow me to make decisions about treatment regime to provide a sense of control. (Date initiated: 10/11/23). Instruct on potential side effects or possible adverse effects of not taking the medications or treatments. (Date initiated: 10/11/23) Review of Resident #55's Order Summary dated 10/18/23 revealed: Ativan/Benadryl/Haldol 1/25/1mg PLO 1ml/syringe every 6 hours as needed related to palliative care/dementia with agitation/anxiety (order date 9/8/23) Acetaminophen Oral Tablet 500mg give 1 tablet orally every 6 hours as needed for pain/temp (order date 6/6/23) Acetaminophen Rectal Suppository 650mg insert 1 suppository rectally every 6 hours as needed for pain/temp *not to exceed 3 grams in 24 hours (order date 6/13/23) Fentanyl citrate injection solution 250mcg/5ml give 0.2ml sublingually every 2 hours as needed for pain (order date 9/8/23) Fentanyl citrate injection solution 250mcg/5ml give 0.4ml sublingually every 2 hours as needed for pain (order date 9/8/23) Lidocaine external ointment 5% apply topically to bilateral lower extremities two times a day related to pain (order date 10/3/23) Lidocaine external patch 5% apply to proximal left upper extremity one time a day related to pain 12 hours on and 12 hours off (order date 10/18/23) Observation and interview on 10/17/23 at 2:54 PM revealed Resident #55 walking in the hallway in the women's secured unit asking CNA B if she could have a pain patch for her arm. CNA B explained to her that the patch had been discontinued by the doctor but told Resident #55 that she would go speak with the nurse to see if there was something different she could have for the pain. Resident #55 agreed, and CNA B assisted her to her room and into her recliner to wait. When Speaking with Resident #55 in her room, she complained of pain in her left upper arm. The Surveyor asked what happened to cause the pain to her left arm and Resident #55 explained that the footrest on her recliner had become difficult to put down with her legs due to her leg pain and she had been using her arms to push it down and her left arm had started aching in the last day or so. On inspection of the resident's left arm there did appear to be a small raised area protruding from the location she was rubbing and complaining about the pain. During the interview with Resident #55 in her room, RN A entered the room holding a plastic bag in each hand; one containing pre-filled syringes and one containing a prescription bottle, and offered Resident #55 two different pain creams for her arm, stating they were fentanyl and ABH (ativan-benadryl-haldol) cream. RN A began to tell Resident #55 that one of the creams was the same cream she used on her leg earlier and resident stated that she had a patch on her leg. RN A stated that no she had cream because she refused to wear the patches and so the patches had been discontinued. RN A asked Resident #55 if she wanted the cream or not and resident said yes. RN A asked Resident #55 to rate her pain on scale of 1 to 10 and Resident #55 stated oh honey it is a 20. RN A placed the two bags of medication on the resident's bed, donned gloves and applied the ABH cream to the resident's left upper arm. RN A did not assess Resident #55's left arm for injury or cause of the pain. Further inspection of the bags revealed that the bottle of fentanyl was not a cream rather it was oral liquid fentanyl. In an interview on 10/18/23 at 9:45 AM, the DON stated that she was not aware that Resident #55 had been experiencing arm pain. She stated that RN A had not reported the new complaint of pain to her on 10/17/23. She stated that Resident #55 had constant complaints of leg pain. The DON stated that she recently had her lidocaine patches discontinued because she would refuse to wear them. She stated that Resident #55 was a very difficult resident to give medication to because of her dementia. She stated that Resident #55 often refused to take oral medications because she believed the staff was trying to poison her and keep her drugged up. The DON stated that RN A should have assessed Resident #55's left arm for a source for the pain since she had never complained of pain in that location before. The DON acknowledged that ABH cream was not prescribed for pain but for anxiety and RN A should have attempted to give Resident #55 the fentanyl because it was a pain medication. She stated that Resident #55 did have anxiety and that anxiety could manifest as pain but without properly assessing the resident and administering or attempting to administer the appropriate medication it would be impossible to tell what the cause of the pain (DON used air quotes) was. During the interview, the DON opened Resident #55's EHR and found no documentation of the administration of the ABH cream in the nurse's notes regarding a pain assessment by RN A. The DON stated she would assess Resident #55 herself to follow up. In an interview on 10/18/23 at 5:45 PM, RN A stated that Resident #55 had delusions. She stated that Resident #55's family member put her in the facility due to her not taking her medications, not eating, not going to the bathroom, and generally just not being able to care for herself. RN A stated she believed Resident #55 came in on hospice and if not was admitted to hospice services right after her admission to the facility, five or six months ago. She stated that Resident #55 did not complain of pain when she first came to the facility. When Resident #55 first started complaining of pain, she complained of severe chest pain, which they acted on quickly because she did have a history of heart problems. RN A stated that the majority of pain Resident #55 complained of was in her legs, but she refused most of the meds they had for her and walked up and down the halls as though nothing was wrong. RN A stated 10/17/23 was the first time Resident #55 had ever complained about her arm hurting. RN A stated that she chose to give her the cream instead of the pain medication because historically Resident #55 would not take anything by mouth and she had been refusing the lidocaine patches that had recently been discontinued. She stated the cream was the only thing that she would allow the staff to give her even though it was not for pain. RN A stated she understood that the medication that she gave was not indicated for pain but that she knew her residents and what would work for them and sometimes that was more important than what the medication was prescribed for. RN A stated that Resident #55 was putting on a show because of the surveyor's presence in the room, that Resident #55 knew what the meds were and what they were for because she used to be a nurse. She stated that Resident #55 had dementia and she understood that caused residents to act out. She stated she did believe that Resident #55 was in some pain but not as much as she was claiming. RN A stated when she went back into Resident #55's room approximately 30 minutes after applying the cream on her left arm to ask how her pain was, Resident #55 told her she felt much better . When asked if she documented the initial complaint of arm pain, administration of the ABH cream, and the follow up with Resident #55 on 10/17/23, RN A stated she got busy and forgot but when she was called in to speak to the surveyor by the DON, she made a late entry progress note but she had to guess at the time because she was unable to remember the exact time she administered the medication to the resident. In an interview on 10/19/23 at 1:23 PM, CNA B stated that Resident #55 gave staff trouble taking medication every day regardless of which staff it was. CNA B stated Resident #55 had good days and bad days when it came to taking medication. She stated Resident #55 would refuse medication and then ask for it later. She stated that Resident #55 was paranoid that people were trying to keep her drugged up. CNA B stated it was not just oral medication, it was every kind of medication. CNA B stated she felt like it was partially attention seeking because of Resident #55's dementia and because her family did not get to visit her as much as she wanted them to. CNA B stated she believed Resident #55 did have pain at times in her legs and feet because she was constantly up and moving. She stated she had never heard Resident #55 complain of having arm pain before 10/17/23. She stated that Resident #55 was showered by hospice aides on Tuesday's and Thursday's. CNA B stated that the hospice aides did not leave notes but she asked about skin issues so she could document on the shower sheets, and no one reported anything unusual to her on Tuesday (10/17/23). CNA B stated that she had not noted any bruising or swelling to Resident #55's left arm but she had seen Resident #55 using a wheelchair to wheel herself around the secured unit on Monday and Tuesday (10/16/23 and 10/17/23), which she stated she did not require, and stated she believed that might be what caused the pain in her left arm since she was not used to propelling herself in the chair. She stated that Resident #55 told her she was using the wheelchair because her legs were hurting when she walked. In a follow up interview on 10/19/23 at 3:32 PM the DON stated she would expect a nurse to offer a pain medication to a resident when they asked for a pain medication, not an antianxiety medication. RN A should have told Resident #55 that the ABH cream was not for pain before she offered it to her and then asked if she still wanted it instead of just applying it. RN A should have assessed Resident #55 better before giving her anything. The DON stated that RN A told her (DON) and Regional Compliance RN that Resident #55 seemed more anxious than in pain and that when she went back to check on her 20-30 minutes later, she was fine and said her pain was gone. The DON stated she went to speak with Resident #55 the next day and assessed her with the Regional Compliance RN and did not find any abnormalities to her left arm. The DON stated they asked her how her arm was doing, and she told them it felt better, not as sore and that the cream worked well. The DON stated they advised Resident #55 that the cream was not prescribed for pain and that it was an anxiety medication and she (Resident #55) told them that was ok because it did help, and then asked if she could have the pain patch back. The DON stated an x-ray was obtained of Resident #55's left arm as ordered by her physician which showed no fracture or mass. The DON stated the Lidocaine patch was reordered as Resident #55 requested and they were waiting for an order to be approved for voltaren gel for pain since she did better with topical medication. The DON reiterated that Resident #55 was very difficult to give medication to due to her dementia and all staff had the same problem getting her to take medication. The DON stated that RN A had been written up for giving the ABH cream when she should have given pain meds and for not explaining to the resident the difference. The DON also stated that the Regional Compliance RN had started an in-service for all nurses regarding pain. Review of facility in-service Subject: Pain, dated 10/18/23, revealed: Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability need to be asked. If a resident is non-verbal, the questions will be a PAINAD assessment. When new acute pain is identified staff will complete a pain SBAR. Administer pain medication as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. Regardless of the resident cognition staff must address any c/o signs of pain and administer medication that is appropriate for the symptoms. Do not administer behavioral medication when it comes to addressing pain issues.

Based on observation, interview and record review, the facility failed to ensure, based on a comprehensive assessment, residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition for one (Resident #55) of two residents reviewed for pain. 1. RN A administered ABH cream which was prescribed for agitation or anxiety when Resident #55 complained of left arm pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. The findings included: Review of Resident #55's Admission Record dated 10/18/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, pain, major depressive disorder, and palliative care (specialized medical care that focuses on providing relief from pain). Review of Resident #55's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed: She scored an 8 on her mental status exam, indicating moderately impaired cognition. She had no signs or symptoms of delirium. She had no reported behaviors and no reported refection of care. She required only supervision or limited assistance for ADLs. She used a walker to ambulate. She did not report any pain at the time of the assessment. She received an antipsychotic medication, anxiety medication, diuretic, and opioid medication. She was on hospice services. Review of Resident #55's Care Plan last revised 10/17/23 revealed: Focus: I have the potential for pain related to end stage disease processes, arthritis, possible colon cancer. I am able to verbally report pain. I have Fentanyl PRN, Lidoderm patches PRN, acetaminophen PRN (date initiated: 8/29/23) Goal: I will not have an interruption in normal activities due to pain through the review date (Date initiated: 8/29/23) Interventions/Tasks: Administer analgesia as per orders. Give 1/2 hour before treatments or care. (Date initiated: 8/29/23). Anticipate my need for pain relief and respond immediately to any complaint of pain. (Date initiated: 8/29/23). Monitor/record/report to nurse any s/sx of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing); Body (tense, rigid, rocking, curled up, thrashing). (Date initiated: 8/29/23) Focus: I have a terminal prognosis and/or am receiving hospice services for end stage senile degeneration of the brain. I have comfort medications ordered. Fentanyl PRN Pain, Acetaminophen PRN pain/temp (date initiated: 8/29/23) Goal: My comfort will be maintained through the review date. (Date initiated: 8/29/23) Interventions/Tasks: Observe me closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. (Date initiated: 8/29/23); Work with nursing staff to provide maximum comfort. (Date initiated: 8/29/23). Focus: I am resistive to care related to dementia. I will refuse assist from staff. I refuse medications frequently. I refuse to wear shoes. (Date initiated: 10/11/23, Revision date: 10/17/23) Goal: I have the right to refuse treatment through the review date. (Date initiated: 10/11/23) Interventions/Tasks: Allow me to make decisions about treatment regime to provide a sense of control. (Date initiated: 10/11/23). Instruct on potential side effects or possible adverse effects of not taking the medications or treatments. (Date initiated: 10/11/23) Review of Resident #55's Order Summary dated 10/18/23 revealed: Ativan/Benadryl/Haldol 1/25/1mg PLO 1ml/syringe every 6 hours as needed related to palliative care/dementia with agitation/anxiety (order date 9/8/23) Acetaminophen Oral Tablet 500mg give 1 tablet orally every 6 hours as needed for pain/temp (order date 6/6/23) Acetaminophen Rectal Suppository 650mg insert 1 suppository rectally every 6 hours as needed for pain/temp *not to exceed 3 grams in 24 hours (order date 6/13/23) Fentanyl citrate injection solution 250mcg/5ml give 0.2ml sublingually every 2 hours as needed for pain (order date 9/8/23) Fentanyl citrate injection solution 250mcg/5ml give 0.4ml sublingually every 2 hours as needed for pain (order date 9/8/23) Lidocaine external ointment 5% apply topically to bilateral lower extremities two times a day related to pain (order date 10/3/23) Lidocaine external patch 5% apply to proximal left upper extremity one time a day related to pain 12 hours on and 12 hours off (order date 10/18/23) Observation and interview on 10/17/23 at 2:54 PM revealed Resident #55 walking in the hallway in the women's secured unit asking CNA B if she could have a pain patch for her arm. CNA B explained to her that the patch had been discontinued by the doctor but told Resident #55 that she would go speak with the nurse to see if there was something different she could have for the pain. Resident #55 agreed, and CNA B assisted her to her room and into her recliner to wait. When Speaking with Resident #55 in her room, she complained of pain in her left upper arm. The Surveyor asked what happened to cause the pain to her left arm and Resident #55 explained that the footrest on her recliner had become difficult to put down with her legs due to her leg pain and she had been using her arms to push it down and her left arm had started aching in the last day or so. On inspection of the resident's left arm there did appear to be a small raised area protruding from the location she was rubbing and complaining about the pain. During the interview with Resident #55 in her room, RN A entered the room holding a plastic bag in each hand; one containing pre-filled syringes and one containing a prescription bottle, and offered Resident #55 two different pain creams for her arm, stating they were fentanyl and ABH (ativan-benadryl-haldol) cream. RN A began to tell Resident #55 that one of the creams was the same cream she used on her leg earlier and resident stated that she had a patch on her leg. RN A stated that no she had cream because she refused to wear the patches and so the patches had been discontinued. RN A asked Resident #55 if she wanted the cream or not and resident said yes. RN A asked Resident #55 to rate her pain on scale of 1 to 10 and Resident #55 stated oh honey it is a 20. RN A placed the two bags of medication on the resident's bed, donned gloves and applied the ABH cream to the resident's left upper arm. RN A did not assess Resident #55's left arm for injury or cause of the pain. Further inspection of the bags revealed that the bottle of fentanyl was not a cream rather it was oral liquid fentanyl. In an interview on 10/18/23 at 9:45 AM, the DON stated that she was not aware that Resident #55 had been experiencing arm pain. She stated that RN A had not reported the new complaint of pain to her on 10/17/23. She stated that Resident #55 had constant complaints of leg pain. The DON stated that she recently had her lidocaine patches discontinued because she would refuse to wear them. She stated that Resident #55 was a very difficult resident to give medication to because of her dementia. She stated that Resident #55 often refused to take oral medications because she believed the staff was trying to poison her and keep her drugged up. The DON stated that RN A should have assessed Resident #55's left arm for a source for the pain since she had never complained of pain in that location before. The DON acknowledged that ABH cream was not prescribed for pain but for anxiety and RN A should have attempted to give Resident #55 the fentanyl because it was a pain medication. She stated that Resident #55 did have anxiety and that anxiety could manifest as pain but without properly assessing the resident and administering or attempting to administer the appropriate medication it would be impossible to tell what the cause of the pain (DON used air quotes) was. During the interview, the DON opened Resident #55's EHR and found no documentation of the administration of the ABH cream in the nurse's notes regarding a pain assessment by RN A. The DON stated she would assess Resident #55 herself to follow up. In an interview on 10/18/23 at 5:45 PM, RN A stated that Resident #55 had delusions. She stated that Resident #55's family member put her in the facility due to her not taking her medications, not eating, not going to the bathroom, and generally just not being able to care for herself. RN A stated she believed Resident #55 came in on hospice and if not was admitted to hospice services right after her admission to the facility, five or six months ago. She stated that Resident #55 did not complain of pain when she first came to the facility. When Resident #55 first started complaining of pain, she complained of severe chest pain, which they acted on quickly because she did have a history of heart problems. RN A stated that the majority of pain Resident #55 complained of was in her legs, but she refused most of the meds they had for her and walked up and down the halls as though nothing was wrong. RN A stated 10/17/23 was the first time Resident #55 had ever complained about her arm hurting. RN A stated that she chose to give her the cream instead of the pain medication because historically Resident #55 would not take anything by mouth and she had been refusing the lidocaine patches that had recently been discontinued. She stated the cream was the only thing that she would allow the staff to give her even though it was not for pain. RN A stated she understood that the medication that she gave was not indicated for pain but that she knew her residents and what would work for them and sometimes that was more important than what the medication was prescribed for. RN A stated that Resident #55 was putting on a show because of the surveyor's presence in the room, that Resident #55 knew what the meds were and what they were for because she used to be a nurse. She stated that Resident #55 had dementia and she understood that caused residents to act out. She stated she did believe that Resident #55 was in some pain but not as much as she was claiming. RN A stated when she went back into Resident #55's room approximately 30 minutes after applying the cream on her left arm to ask how her pain was, Resident #55 told her she felt much better . When asked if she documented the initial complaint of arm pain, administration of the ABH cream, and the follow up with Resident #55 on 10/17/23, RN A stated she got busy and forgot but when she was called in to speak to the surveyor by the DON, she made a late entry progress note but she had to guess at the time because she was unable to remember the exact time she administered the medication to the resident. In an interview on 10/19/23 at 1:23 PM, CNA B stated she had never heard Resident #55 complain of having arm pain before 10/17/23. She stated that Resident #55 was showered by hospice aides on Tuesday's and Thursday's. CNA B stated that the hospice aides did not leave notes but she asked about skin issues so she could document on the shower sheets, and no one reported anything unusual to her on Tuesday (10/17/23). CNA B stated that she had not noted any bruising or swelling to Resident #55's left arm but she had seen Resident #55 using a wheelchair to wheel herself around the secured unit on Monday and Tuesday (10/16/23 and 10/17/23), which she stated she did not require, and stated she believed that might be what caused the pain in her left arm since she was not used to propelling herself in the chair. She stated that Resident #55 told her she was using the wheelchair because her legs were hurting when she walked. In a follow up interview on 10/19/23 at 3:32 PM the DON stated she would expect a nurse to offer a pain medication to a resident when they asked for a pain medication, not an antianxiety medication. RN A should have told Resident #55 that the ABH cream was not for pain before she offered it to her and then asked if she still wanted it instead of just applying it. RN A should have assessed Resident #55 better before giving her anything. The DON stated that RN A told her (DON) and Regional Compliance RN that Resident #55 seemed more anxious than in pain and that when she went back to check on her 20-30 minutes later, she was fine and said her pain was gone. The DON stated she went to speak with Resident #55 the next day and assessed her with the Regional Compliance RN and did not find any abnormalities to her left arm. The DON stated they asked her how her arm was doing, and she told them it felt better, not as sore and that the cream worked well. The DON stated they advised Resident #55 that the cream was not prescribed for pain and that it was an anxiety medication and she (Resident #55) told them that was ok because it did help, and then asked if she could have the pain patch back. The DON stated an x-ray was obtained of Resident #55's left arm as ordered by her physician which showed no fracture or mass. The DON stated the Lidocaine patch was reordered as Resident #55 requested and they were waiting for an order to be approved for voltaren gel for pain since she did better with topical medication. The DON reiterated that Resident #55 was very difficult to give medication to due to her dementia and all staff had the same problem getting her to take medication. The DON stated that RN A had been written up for giving the ABH cream when she should have given pain meds and for not explaining to the resident the difference. The DON also stated that the Regional Compliance RN had started an in-service for all nurses regarding pain. Review of facility in-service Subject: Pain, dated 10/18/23, revealed: Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability need to be asked. If a resident is non-verbal, the questions will be a PAINAD assessment. When new acute pain is identified staff will complete a pain SBAR. Administer pain medication as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. Regardless of the resident cognition staff must address any c/o signs of pain and administer medication that is appropriate for the symptoms. Do not administer behavioral medication when it comes to addressing pain issues.

Based on observation, interview and record review the facility failed to assist residents in obtaining routine dental care for 1 of 1 resident (#38) reviewed for dental care. The facility failed to offer Resident #38 dental screening or services after admission to assess for dental care needs. This failure could affect all residents by placing them at risk of not receiving needed dental care resulting in decreased quality of life. Findings included: Review of Resident #38's Admission Record dated 08/31/22 indicated she was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's quarterly MDS assessment dated [DATE] indicated no cognitive deficit. She was incontinent of bowel and bladder. She required 1 - 2 people for ADL's. The dental section of the assessment was blank. Review of Resident #38's care plan revised 11/21/20 indicated she had poor oral health care. Goal was updated 03/31/22 for resident to comply with oral care at least daily. Interventions included coordinating arrangements for dental care, with transportation as needed, and providing oral care per ADL personal hygiene tasks. During an observation and interview with Resident #38 on 08/31/22 at 9:30 AM her family member came in to visit. She asked Resident #38 what happened to her teeth. Resident #38 said, another one fell out and pointed to her front teeth. She said, My teeth are disintegrating. Observation of Resident #38's teeth revealed her left lower first premolar and the two central incisors were discolored stumps. She denied pain. She said she has not had any dental services since admission to the facility but needs it. She said she told the facility she needs to be seen by a dentist but thinks there was a misunderstanding. She said she did not refuse dental services because she didn't want to pay for it. She said, I have insurance and I want to see a dentist. In an interview with the DON on 08/31/22 at 2:45 PM she said she thought Resident #38 had declined dental services in the past because she didn't want to pay for it. She said the facility has a new dental service that started this month. She said she will add Resident #38 to the list to be seen by the dentist on the next visit to the facility which will be in September. In an interview with Resident #38 on 08/31/22 at 5:15 PM she said she was happy about getting to see the dentist next month. The facility did not provide any documentation of Resident #38 receiving dental services while in the facility. Review of facility's policy/procedure, Dental Examination/Assessment, revised 12/2013 included the following: 1. Resident shall be offered dental services as needed. 2. Dental examinations will be made by the resident's personal dentist or by the facility's Consultant Dentist. 3. Records of dental care provided shall be made a part of the resident's medical record. 4. Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist.

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #1. As a result, he eloped from the facility and was picked up by a police officer 30 minutes later in 22° Fahrenheit weather approximately 2 blocks from the facility. An Immediate Jeopardy (IJ) was determined to have existed from 02/23/22 to 03/01/22. The facility remained out of compliance at an isolated level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk for elopement, accidents, falls and injury related harm. This failure could place residents at risk for elopement, accidents, falls and injury related harm. Findings included: Review of Resident #1's Admission Record indicated he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included [CONDITION(S)], alcohol-induced persisting amnesic disorder, repeated falls, malignant neoplasm of base of tongue, and acquired absence of specified parts of digestive tract. Review of Resident #'1 Admission Assessment conducted by RN A 02/23/22 at 10:46 AM indicated he arrived ambulatory from another rehab facility. He was oriented to person only and was unable to appropriately respond to questions. He had unclear speech, was sometimes understood and was sometimes able to understand others. He had adequate vision. His hearing was highly impaired, and he wore a hearing aide in the right ear. He received nutrition by mouth and enteral tube. He was continent of bowel and bladder. He was independent with ADLs. He ambulated without an assuasive device. Review of Resident #1's Elopement Risk assessment dated [DATE] at 10:46 AM indicated he was in a secured unit. Review of Resident #1's 48 Hour Baseline Care Plan dated 02/23/22 at 10:46 AM listed: Fall/Safety Risk with Goal of no falls/injury; Tube Feeding with Goal of no complications; Dehydration Risk with Goal to consume adequate fluid; Nutrition, mechanical soft diet, ST referral with Goal to achieve weight of: (blank); ADL Decline, rehab with Goal to improve ADL skills; Cancer with Goal to achieve physical and mental comfort; Cognitive Decline with Goal of establish daily routine. Review of a nurse's note dated 02/23/22 at 11:59 AM included description of report received from Resident #1's discharging facility. The resident was pleasant and at risk of elopement . Review of a nurse's note dated 02/23/22 at 12:25 PM indicated when he arrived at the facility he was taken to the men's locked unit. Resident #1's daughter arrived to sign admission paperwork. She wanted to see her dad and his room before starting the paperwork. After signing the paperwork, she became tearful and said, He will die over there, talking about the secured unit. She said he loved to walk around and talk to people and she didn't feel like it was appropriate for him to be on the unit. She said that at the other facility they had a wander guard on him, but the doors didn't even lock when he got close to them. She said he never tried to get out and that he was only looking out the front doors. She expressed that she wanted him to be outside the unit and see how he did. Review of a nurse's note dated 02/23/22 at 7:30 PM indicated Resident #1 was up and wandering hallways exit seeking and looking for his pickup keys to leave. Staff followed him for safety. Review of the Provider Investigation Report dated 02/24/22 at 10:58 AM indicated Incident Category as Missing Resident. Incident date was 02/23/22 at 11:35 PM. The report indicated Resident #1 was ambulatory, interviewable, unable to make informed decisions, and wearing a wander guard at the time of the incident. The resident had a history of elopement. (Resident #1's) daughter said he would not be returning to the facility and she is seeking placement elsewhere. Provider Action Taken Post Investigation: The facility was in process of changing the door alarms to a more distinguishable alarm. Facility staff were in-serviced on elopement, head counts, walking rounds, and taking/giving report to the oncoming/off going shift. Review of (City) Police Department Incident Sheet printed 03/03/22 indicated the incident occurred from 02/23/22 at 11:27 PM to 02/23/22 at 11:53 PM. The narrative included: On 02/23/22 I, Officer C . observed a male subject standing in the middle of the roadway near [local road names]. I initiated a stop on the subject who identified himself as (Resident #1). (Resident #1) was clearly disoriented and stated he thought he was near [local road name]. (Resident #1) could hardly hear me and had difficulty speaking. (Resident #1) was only wearing a t-shirt and pajama pants, and it was 22 degrees (Fahrenheit). (Resident #1) was eventually able to tell me that he lived with his daughter and stated that he had her number in his phone. I then contacted (daughter) on (Resident #1's) phone who advised that (Resident #1) had been staying at (nursing facility), and that he must have walked out, but nobody had called her. (Daughter) stated that (Resident #1) is in an altered mental status and advised she would be in route to pick him up. When (daughter) arrived, she was on the phone with (nursing facility). I overheard a worker tell (daughter) that the doors were locked and that no alarms had gone off. (Daughter) then stated, you haven't seen him since 7:00 PM this evening? I could not make out what the worker replied. (Daughter) made the decision to take (Resident #1) with her and bring him back to (nursing facility) in the morning. This report is being documented for the purposes of (Resident #1's) wellbeing, and the fact that he left (nursing facility) at an unknown time and was walking in the cold weather wearing only a t-shirt and pajama pants between 1900 - 2327 hours on 02/23/22, unbeknownst to and unreported by (nursing facility) staff at this time. In an interview on 02/25/22 at 9:20 AM Administrator and DON stated that (Resident #1) was admitted from (another nursing/rehab facility). He was attempting to leave there. Daughter didn't like our locked unit. She only walked into the unit, didn't go all the way in to look around. She wanted Resident #1 in general population with a wander guard. Daughter was told the wander guard system only locks the front door and she was ok with that. He was placed in room 203. Stated that when alarm sounded on 02/23/2022 at 10:53pm staff thought it was a bed alarm and went around and checked on residents with bed alarms. (Resident #1) did not have a bed alarm. Ten minutes later daughter called and asked if staff knew where he was. She said police brought him to her house. They found him walking a couple blocks from facility. It was 19 degrees outside. They said alarm on the exit doors sound but stops sounding when door closes. They said new alarms had been ordered that do not turn off automatically. They require a key to stop alarm sounding. They said they called [police department] yesterday, but they could not locate the police report. They said the previous facility did not report to them that he was exit seeking. The DON said, When our CNA went over to pick up some of his belongings, staff there said he had elopement twice over the weekend. DON said, If we had known that we wouldn't have put him on general population. In a telephone interview on 02/25/22 at 1:27 PM, CNA B said she heard what she thought was a bed alarm about 10:53 PM on 02/23/2022. Stated that she went down the 200 Hall to check residents with bed alarms. She said she checked on the two residents with bed alarms and both were asleep. She said the alarm she heard sounded like a bed alarm and only sounded for a second, like someone with a bed alarm changing position. She said she had never heard the exit door alarm before, so she didn't know what it sounded like. During an observation and interview on 02/25/22 at 3:20 PM the surveyor watched the facility's camera video from 02/23/22 . (CNA B) left Hall 200 to the rotunda at 10:53 PM. (Resident #1) walked out of his room, went to the end of the hall and exited through the door to the outside at 10:57 PM. (CNA B) came onto hall 200 from the rotunda area approximately 15 seconds later. She looked from side to side and looked into a couple of rooms. She then exited Hall 200 towards the rotunda. In an interview on 2/25/2022 at 3:50 PM, Administrator and DON stated that the resident's daughter called the facility at approx. 11:44 PM and reported her father had eloped from the facility and had been picked up by police. The administrator stated that he received a call from the facility at approximately 11:44 PM from staff reporting the elopement. (Resident #1) did not return to the facility, he stayed with his daughter. The next morning, she took him to the hospital r/t c/o of chest pain. He remains in hospital at this time. When they checked the EPIC system (Hospital software system), there was no diagnosis listed. The daughter is looking into alternative placement for her father. In an observation and interview with the DON and administrator on 02/25/22 at 4:30 PM the DON activated a bed alarm. Then, the Hall 200 exit door was opened to activate the alarm. The bed alarm and door alarm tones and volume were almost identical. The administrator said they have ordered and will install door alarms that have a louder tone and different alarm sound. In an interview with the administrator and the DON on 03/03/22 at 2:20 PM they said only the front door has a wander guard system. They said new alarms were installed on all six emergency exit doors on 03/01/22. Now the alarm remains sounding until it is turned off by staff using a key. The DON said staffing was as usual on the night (Resident #1) eloped. There were two LVNs and five CNAs, including two CNAs assigned to the two secure units. she said Resident #1 did not have orders for routine medications that night , he only had [CONDITION(S)] medication scheduled for the next morning. Review of an invoice dated 02/28/22 indicated 6 Exit Stoppers were ordered. In an interview on 3/3/22 at 3:00 PM, Regional Director and Administrator stated that the emergency exit doors had always stopped alarming when the door shuts. On Tuesday 03/01/22 the alarm company came out and all six emergency exit doors were set on a 15 second delay before opening and to not stop alarming until staff manually turns it off with a key. In an observation on 03/03/22 at 4:30 PM, without alerting staff, the surveyor opened the Hall 200 emergency exit door. After 15 seconds the door opened, and the alarm sounded very loudly. The alarm did not stop when the door closed. Staff in the rotunda at the opposite end of Hall 200 reacted immediately. More staff rushed into the rotunda. A charge nurse came to the door and used a key to reset the alarm. In an observation on 03/04/22 at 1:45 PM, surveyor went with the administrator and maintenance director and tested all emergency exit doors. All doors alarmed correctly. When the first door alarmed staff responded immediately and were informed, the door alarms were being tested . In an interview with the DON on 03/04/22 at 2:00 PM she said they were going to re-evaluate the two residents currently with wander guards, (Resident #2 and Resident #3). She said the last elopement in-service was done in September. She said maintenance checks the wander guard system daily. If a maintenance staff is not in the building a charge nurse checks the system. Investigator checked the Wander Guard check log with entries up to date/current. In an interview on 03/05/22 at 9:15 AM with the DON she said there were three staff members left to educate and they will not work until in-services are completed. She said agency staff are educated by the charge nurses at the beginning of the shift. Investigator reviewed in-service log with entries current. In an interview on 03/05/22 at 10:50 AM RN A stated that she had an in-service on wander guards and elopement and were able to describe policies and procedures. She said they do a head count of residents at every shift change, check the door alarms and wander guards every shift. She each charge nurse has a key to reset the alarms and to never leave the door alarms off. In interviews with LVN C, CNA D, CNA E, MA F, and the SW on 03/05/22 between 10:55 AM and 11:50 AM they were able to describe the in-service provided and the procedures to prevent elopement and actions to take if a resident elopes. In an interview with the administrator and DON on 03/05/22 at 11:30 AM they identified three residents (Residents #6, #7, and #8) at moderate risk of elopement. Resident #6 had a wander guard a few months ago. He is ambulatory and goes to [CONDITION(S)]. The administrator said the resident told him he wasn't going to leave the facility; if he wanted to elope, he could when he was at [CONDITION(S)]. Resident #7 is ambulatory, gets confused at times and has a BIMS of 8. Resident #8 was previously on the secure unit. He has made no comments about leaving and is not exit seeking. The DON said these residents are monitored closely. During a record reviews of Residents #6, #7, and #8 care plans revealed there were no concerns related to exit seeking or elopement. An Immediate Jeopardy was identified on 03/04/22 at 2:30 PM. The Administrator, DON, and Regional Director were notified of the Immediate Jeopardy on 03/04/22 at 2:45 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. A Plan of Removal was submitted by the administrator and was accepted on 03/05/22 at 11:45 AM. The Plan of Removal included: On 02/25/22 resident roster was audited by the Don for residents and their need for a wonder guard. The following residents who have orders for wander guard were assessed to ensure proper placement of the wander guard and the wonder guard was tested to ensure working order. Resident #2 Resident #3 All residents identified to be at risk for elopement orders have been verified and wander guard placement confirmed on 02/25/22. To remedy concerns regarding resident elopement the facility implemented the following changes: 1. Inservice f or all staff initiated 2/25/22 on residents at risk for elopement to educate staff on proper response to door alarm and to ensure resident safety when facility door alarm sounds. In service initiated by DON. Facility will print out employee roster to ensure every employee is educated and will not work until in service is completed. agency staff will also be educated on alarms and procedures prior to working by charge nurse, new hires will be educated during the employee orientation by DON/Department Head. 2. Facility implemented policy and procedure for wander guard monitoring. Wander guard check for placement and to ensure working order completed 2/25/22 by the DON and will be documented and completed by charged nurses every shift and documented on TAR. 3. The following exit doors were checked to ensure proper functioning on door alarm, mag lock, code alert or keypad: Door alarm on 100, 200, 300, 400, 500, and 600 Halls were checked by maintenance supervisor and functioning on 2/28/22. (Door alarms are checked daily for proper functioning and documented in TELS by the maintenance supervisor) Code alarm in dining room was checked by maintenance supervisor and functioning 2/28/22. Code alarm on front entrance was checked and functioning 2/28/22. Code alarm exit by kitchen storage on 400 Hall was checked and functioning 2/28/22. New keyed alarms were ordered on 2/28/22 and installed 3/1/22 on halls 100, 200, 300, 400, 500, and 600. New door alarms were installed by the maintenance director. If the exit door is opened the newly installed alarm will sound until a staff member manually shuts off the alarm with a key. The facility Medical Director was notified on 03/04/22 of facility action plan and to offer any suggestions. This plan was implemented March 4th, 2022. This action plan will be monitored through personal observation by the administrator, daily for 30 days and verbal reports to the Regional Director of Operations on a weekly basis. Verification of Plan of Removal conducted from 03/04/22 at 2:30 PM - 03/05/22 at 11 :55 AM: Reviewed inservice documentation regarding resident elopement and response to door alarms. Staff interview confirmed inservices were conducted and staff was knowledgeable of policy/procedures. Reviewed documentation of placement and working order of wander guards on TARS by charge nurses every shift. Interviews with charge nurses verified they were able to verbalize procedure and documentation of wander guard checks. All emergency exit doors (Halls 100 - 600), dining room, kitchen and front entrance were tested , and all alarms worked properly. The new alarms sounded very loudly and did not remotely resemble the sound of a bed alarm. The maintenance director verified she checks all exit doors daily for functioning alarms and documents her findings. If she is not in the building, she assigns a trained designee to do this. Staff were observed responding immediately to door alarms and demonstrating resetting the alarm. Interviews with staff indicated they had been trained on the new door alarms and understood wander guard protocols and elopement procedures. The Administrator, DON and Regional Director were notified on 03/05/22 at 12:00 PM that the IJ was removed effective 03/01/22. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record review, it was determined the facility failed to consult the resident's physician when the resident experienced a significant change in condition or a need to alter treatment for one (Residents #9 ) of twenty-two residents reviewed for notification of changes in condition. The facility failed to: 1. ensure Resident #9's primary care physician was notified when the resident had a persistent rash to her perineal area which caused the resident pain and discomfort. This failure caused Actual Harm for Resident #9 due to her suffering with pain and discomfort related to inadequate medical treatment for a red inflamed excoriated rash she had since her admission on 9/15/15. This failure placed the facility's 93 residents at risk of their physician not being notified when the resident experiences a change in condition. This failure could result in a delay in treatment or [DIAGNOSES REDACTED]. The findings included: Resident #9 Review of Resident # 9's un-dated face sheet revealed the [AGE] year-old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's initial MDS, dated [DATE], indicated the resident was alert and oriented to person, place and time. Resident # 9's BIMS score (Brief Interview for Mental Status Score) was 13, reflecting minimal cognitive impairment. Resident #9 was non ambulatory and used a wheelchair for mobility. The resident was dependent on 2 staff for ADLS such as hygiene, bathing and transfers. Resident # 9 was incontinent of bowel and bladder and used briefs. Review of Resident #9's History and Physical dated 9/15/15 indicated no documentation of the facility reporting a rash to the residents perineal area to the physician. Review of Resident #9's Physician Visit Progress Notes dated 9/25/15, 9/28/15, 10/1/15, 10/9/15, 10/15/15 indicated each note was signed by the primary care physician. There was no documentation of a rash in the perineal area. There were no [MEDICAL CONDITION] skin assessments or full skin assessments documented on the physician examinations. Review of a Care Plan dated 9/9/15 and revised 10/6/15 documented a focus problem of a stage 2 pressure area to the coccyx. The intervention for this included to notify the nurse of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. The Care Plan did not indicate a rash or redness and pain in the perineal area. Review of Weekly Skin Assessments included the following documented under the section heading note location, measurements of any moisture associated skin damage 09/15 - perineal area 10/6 - reddened area noted to peri area. Barrier cream applied 10/13 - perineal area and upper thighs 10/21 - no documentation in this section. No reference to a rash anywhere on the skin assessment. 10/27 - perineal area 11/03 - no documentation in this section. Under section heading labeled other skin findings documented redness noted to coccyx, no open areas note at this time. Review of Resident #9's Medication Administration Record [REDACTED]. During an observation on 11/10/15 at 10:30 a.m., CNA G and CNA H transferred Resident #9 from a wheelchair to bed via a mechanical lift. Incontinent care was done using disposable cleansing wipes. The resident's vulva, perineum, inner buttocks, and inner upper thighs were bright red. Resident #9 grimaced each time the CNA used a cleansing wipe to clean the resident. The resident said the area was very painful. The CNAs said the redness had been present since the resident's admission to the facility (09/15/15). During an observation of Resident #9 on 11/10/15 at 2:30 p.m., CNA I and CNA J provided incontinent care to the resident. A bright red rash was noted on the perineal area extending to the upper thighs. The resident grimaced when the CNA's wiped the perineal area with a cleansing wipe. When asked if the rash hurt, the resident stated it was very painful and uncomfortable. During an interview on 11/11/15 at 2:00 p.m., LVN K, who also completed Resident #9's current skin assessment, said the resident has had this rash on the perineal area since she was admitted . The LVN said the rash worsens and improves. LVN K said she thought the physician was aware of the rash because he saw her when she was admitted . During an interview on 11/11/15 at 3:00 p.m., the DON stated Resident #9 has had this rash since she was admitted to the facility. The DON looked in the electronic medical record and could not find any documentation that the primary care physician had been informed of the rash. When asked, the DON said she would expect the nurses to inform the physician if a rash was persisting or not improving. The DON stated she would have the nurse call the primary care physician today and suggest a fungal cream. Review of a physician phone note, faxed to the facility on [DATE], indicated LVN M called the clinic on 11/11/15 at 4:06 p.m., with the following statement: Caller states patient has some redness around her peri area. Caller states it comes and goes and they have tried creams and nothing seems to work. She would like to see about getting an antifungal cream. During an interview on 11/13/15 at 1:30 p.m., CNA L and CNA C, stated Resident #9 has had this rash since she was admitted . They stated the rash improves and worsens, but has never fully resolved since being admitted . During an interview on 11/13/15 at 1:40 p.m., LVN K, said the resident has had this rash since she was admitted and it has never gone away. When asked why three of the weekly skin assessments did not have a rash documented on them (one she had signed herself), LVN K did not have an explanation. She said again the rash has never completely gone away, but improves at times. During an interview on 11/13 at 3:37 p.m., the primary care physician said he was not aware that the resident had a rash prior to being called by the facility on 11/11/2015. The physician stated although he has seen the resident several times, he did not do a full skin assessment at every examination. He stated he would only examine the [MEDICAL CONDITION] skin if he had reason to suspect an issue. He said that he relies on the facility to report to him when there are skin issues, since they see the resident frequently during bathing, incontinent care and assessments. After describing the surveyor ' s observations of the rash, the physician stated that is not how staff described the rash on 11/11/2015. He stated for a rash of that extent that has persisted for two months, he would normally want to examine the resident. He stated for a typical perineal rash that is suspicious of yeast, he would usually prescribe a topical antifungal. He stated that he would prescribe an oral antifungal if the rash was extensive or persistent. He also stated that he would advise other methods such as air drying, mild soap, and discontinuing disposable cleansing wipes, which typically are harsh on the skin. In an interview on 11/13/15 at 4:10 p.m., Resident #9 said the red rash on her peri area has made her miserable. According to a list provided by ADON A on 11/13/15 at 3:05 pm., the facility had identified 4 residents in the facility with skin rashes. Review of the Policy and Procedure: Change in a Resident's Condition or Status revised April 2006 indicated the following: Our facility shall promptly notify the resident, his/her Attending Physician and representative of changes in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident Attending Physician or On-call physician when there has been: A significant change in the resident's physical/emotional/mental condition, A need to alter the resident's medical treatment significantly,(Refusal of treatment or medications two or more consecutive times). Review of the CMS-672 dated 11/10/15 indicated the census was 93.

Based on interviews and record review, it was determined the facility failed to consult the resident's physician when the resident experienced a significant change in condition or a need to alter treatment for one (Residents #9 ) of twenty-two residents reviewed for notification of changes in condition. The facility failed to: 1. ensure Resident #9's primary care physician was notified when the resident had a persistent rash to her perineal area which caused the resident pain and discomfort. This failure caused Actual Harm for Resident #9 due to her suffering with pain and discomfort related to inadequate medical treatment for a red inflamed excoriated rash she had since her admission on 9/15/15. This failure placed the facility's 93 residents at risk of their physician not being notified when the resident experiences a change in condition. This failure could result in a delay in treatment or [DIAGNOSES REDACTED]. The findings included: Resident #9 Review of Resident # 9's un-dated face sheet revealed the [AGE] year-old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's initial MDS, dated [DATE], indicated the resident was alert and oriented to person, place and time. Resident # 9's BIMS score (Brief Interview for Mental Status Score) was 13, reflecting minimal cognitive impairment. Resident #9 was non ambulatory and used a wheelchair for mobility. The resident was dependent on 2 staff for ADLS such as hygiene, bathing and transfers. Resident # 9 was incontinent of bowel and bladder and used briefs. Review of Resident #9's History and Physical dated 9/15/15 indicated no documentation of the facility reporting a rash to the residents perineal area to the physician. Review of Resident #9's Physician Visit Progress Notes dated 9/25/15, 9/28/15, 10/1/15, 10/9/15, 10/15/15 indicated each note was signed by the primary care physician. There was no documentation of a rash in the perineal area. There were no [MEDICAL CONDITION] skin assessments or full skin assessments documented on the physician examinations. Review of a Care Plan dated 9/9/15 and revised 10/6/15 documented a focus problem of a stage 2 pressure area to the coccyx. The intervention for this included to notify the nurse of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. The Care Plan did not indicate a rash or redness and pain in the perineal area. Review of Weekly Skin Assessments included the following documented under the section heading note location, measurements of any moisture associated skin damage 09/15 - perineal area 10/6 - reddened area noted to peri area. Barrier cream applied 10/13 - perineal area and upper thighs 10/21 - no documentation in this section. No reference to a rash anywhere on the skin assessment. 10/27 - perineal area 11/03 - no documentation in this section. Under section heading labeled other skin findings documented redness noted to coccyx, no open areas note at this time. Review of Resident #9's Medication Administration Record [REDACTED]. During an observation on 11/10/15 at 10:30 a.m., CNA G and CNA H transferred Resident #9 from a wheelchair to bed via a mechanical lift. Incontinent care was done using disposable cleansing wipes. The resident's vulva, perineum, inner buttocks, and inner upper thighs were bright red. Resident #9 grimaced each time the CNA used a cleansing wipe to clean the resident. The resident said the area was very painful. The CNAs said the redness had been present since the resident's admission to the facility (09/15/15). During an observation of Resident #9 on 11/10/15 at 2:30 p.m., CNA I and CNA J provided incontinent care to the resident. A bright red rash was noted on the perineal area extending to the upper thighs. The resident grimaced when the CNA's wiped the perineal area with a cleansing wipe. When asked if the rash hurt, the resident stated it was very painful and uncomfortable. During an interview on 11/11/15 at 2:00 p.m., LVN K, who also completed Resident #9's current skin assessment, said the resident has had this rash on the perineal area since she was admitted . The LVN said the rash worsens and improves. LVN K said she thought the physician was aware of the rash because he saw her when she was admitted . During an interview on 11/11/15 at 3:00 p.m., the DON stated Resident #9 has had this rash since she was admitted to the facility. The DON looked in the electronic medical record and could not find any documentation that the primary care physician had been informed of the rash. When asked, the DON said she would expect the nurses to inform the physician if a rash was persisting or not improving. The DON stated she would have the nurse call the primary care physician today and suggest a fungal cream. Review of a physician phone note, faxed to the facility on [DATE], indicated LVN M called the clinic on 11/11/15 at 4:06 p.m., with the following statement: Caller states patient has some redness around her peri area. Caller states it comes and goes and they have tried creams and nothing seems to work. She would like to see about getting an antifungal cream. During an interview on 11/13/15 at 1:30 p.m., CNA L and CNA C, stated Resident #9 has had this rash since she was admitted . They stated the rash improves and worsens, but has never fully resolved since being admitted . During an interview on 11/13/15 at 1:40 p.m., LVN K, said the resident has had this rash since she was admitted and it has never gone away. When asked why three of the weekly skin assessments did not have a rash documented on them (one she had signed herself), LVN K did not have an explanation. She said again the rash has never completely gone away, but improves at times. During an interview on 11/13 at 3:37 p.m., the primary care physician said he was not aware that the resident had a rash prior to being called by the facility on 11/11/2015. The physician stated although he has seen the resident several times, he did not do a full skin assessment at every examination. He stated he would only examine the [MEDICAL CONDITION] skin if he had reason to suspect an issue. He said that he relies on the facility to report to him when there are skin issues, since they see the resident frequently during bathing, incontinent care and assessments. After describing the surveyor ' s observations of the rash, the physician stated that is not how staff described the rash on 11/11/2015. He stated for a rash of that extent that has persisted for two months, he would normally want to examine the resident. He stated for a typical perineal rash that is suspicious of yeast, he would usually prescribe a topical antifungal. He stated that he would prescribe an oral antifungal if the rash was extensive or persistent. He also stated that he would advise other methods such as air drying, mild soap, and discontinuing disposable cleansing wipes, which typically are harsh on the skin. In an interview on 11/13/15 at 4:10 p.m., Resident #9 said the red rash on her peri area has made her miserable. According to a list provided by ADON A on 11/13/15 at 3:05 pm., the facility had identified 4 residents in the facility with skin rashes. Review of the Policy and Procedure: Change in a Resident's Condition or Status revised (MONTH) 2006 indicated the following: Our facility shall promptly notify the resident, his/her Attending Physician and representative of changes in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident Attending Physician or On-call physician when there has been: A significant change in the resident's physical/emotional/mental condition, A need to alter the resident's medical treatment significantly,(Refusal of treatment or medications two or more consecutive times). Review of the CMS-672 dated 11/10/15 indicated the census was 93.

Based on observation, interview and record review, the facility failed to ensure that 1 of 4 residents (Resident # 9) reviewed for skin irritation and rashes received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to: A) Assess, closely monitor, and provide adequate treatment and interventions for Resident #9's painful red perineum, inner buttocks, and upper thighs. B) Care plan interventions to treat Resident #9's skin condition and associated pain. C) Assess and provide adequate interventions to address Resident #9's pain and discomfort related to skin irritation. D) Notify and consult with resident #9's physician regarding Resident #9's painful skin condition. Resident #9 received inadequate medical and pain relieving treatment for [REDACTED]. These failures caused Actual Harm for Resident #9 due to her suffering with pain and discomfort related to inadequate medical treatment for [REDACTED].These failures could place 4 residents with identified rashes at risk of receiving inadequate medical treatment resulting in delayed healing or worsening condition and avoidable pain and discomfort. Findings Include: Review of Resident # 9's un-dated face sheet revealed the [AGE] year-old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's initial MDS, dated [DATE], indicated the resident was alert and oriented to person, place and time. Resident # 9's BIMS score (Brief Interview for Mental Status Score) was 13, reflecting minimal cognitive impairment. Resident #9 was non ambulatory and used a wheelchair for mobility. The resident was dependent on 2 staff for ADLS such as hygiene, bathing and transfers. Resident # 9 was incontinent of bowel and bladder and used briefs. Review of Resident #9's History and Physical dated 9/15/15 indicated no documentation of the facility reporting a rash of/on the residents perineal area on the physician. Review of Resident #9's Physician Visit Progress Notes dated 9/25/15, 9/28/15, 10/1/15, 10/9/15, 10/15/15 indicated each note was signed by the primary care physician. There was no documentation of a rash in the perineal area. There were no [MEDICAL CONDITION] skin assessments or full skin assessments documented on the physician examinations. Review of a Care Plan dated 9/9/15 and revised 10/6/15 documented a focus problem of a stage 2 pressure area to the coccyx. The intervention for this included to notify the nurse of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. The Care Plan did not indicate a rash or redness and pain in the perineal area. Review of Weekly Skin Assessments included the following documented under the section heading note location, measurements of any moisture associated skin damage 09/15 - perineal area 10/6 - reddened area noted to peri area. Barrier cream applied 10/13 - perineal area and upper thighs 10/21 - no documentation in this section. No reference to a rash anywhere on the skin assessment. 10/27 - perineal area 11/03 - no documentation in this section. Under section heading labeled other skin findings documented redness noted to coccyx, no open areas note at this time. Review of Resident #9's Medication Administration Record [REDACTED]. During an observation on 11/10/15 at 10:30 a.m., CNA G and CNA H transferred Resident #9 from a wheelchair to bed via a mechanical lift. Incontinent care was done using disposable cleansing wipes. The resident's vulva, perineum, inner buttocks, and inner upper thighs were bright red. Resident #9 grimaced each time the CNA used a cleansing wipe to clean the resident. The resident said the area was very painful. The CNAs said the redness had been present since the resident's admission to the facility (09/15/15). During an observation of Resident #9 on 11/10/15 at 2:30 p.m., CNA I and CNA J provided incontinent care to the resident. A bright red rash was noted on the perineal area extending to the upper thighs. The resident grimaced when the CNA's wiped the perineal area with a cleansing wipe. When asked if the rash hurt, the resident stated it was very painful and uncomfortable. During an interview on 11/11/15 at 2:00 p.m., LVN K, who also completed Resident #9's current skin assessment, said the resident has had this rash on the perineal area since she was admitted . The LVN said the rash worsens and improves. LVN K said she thought the physician was aware of the rash because he saw her when she was admitted . During an interview on 11/11/15 at 3:00 p.m., the DON stated Resident #9 has had this rash since she was admitted to the facility. The DON looked in the electronic medical record and could not find any documentation that the primary care physician had been informed of the rash. When asked, the DON said she would expect the nurses to inform the physician if a rash was persisting or not improving. The DON stated she would have the nurse call the primary care physician today and suggest a fungal cream. Review of a physician phone note, faxed to the facility on [DATE], indicated LVN M called the clinic on 11/11/15 at 4:06 p.m., with the following statement: Caller states patient has some redness around her peri area. Caller states it comes and goes and they have tried creams and nothing seems to work. She would like to see about getting an antifungal cream. During an interview on 11/13/15 at 1:30 p.m., CNA L and CNA C, stated Resident #9 has had this rash since she was admitted . They stated the rash improves and worsens, but has never fully resolved since being admitted . During an interview on 11/13/15 at 1:40 p.m., LVN K, said the resident has had this rash since she was admitted and it has never gone away. When asked why three of the weekly skin assessments did not have a rash documented on them (one she had signed herself), LVN K did not have an explanation. She said again the rash has never completely gone away, but improves at times. During an interview on 11/13 at 3:37 p.m., the primary care physician said he was not aware that the resident had a rash prior to being called by the facility on 11/11/2015. The physician stated although he has seen the resident several times, he did not do a full skin assessment at every examination. He stated he would only examine the [MEDICAL CONDITION] skin if he had reason to suspect an issue. He said that he relies on the facility to report to him when there are skin issues, since they see the resident frequently during bathing, incontinent care and assessments. After describing the surveyor ' s observations of the rash, the physician stated that is not how staff described the rash on 11/11/2015. He stated for a rash of that extent that has persisted for two months, he would normally want to examine the resident. He stated for a typical perineal rash that is suspicious of yeast, he would usually prescribe a topical antifungal. He stated that he would prescribe an oral antifungal if the rash was extensive or persistent. He also stated that he would advise other methods such as air drying, mild soap, and discontinuing disposable cleansing wipes, which typically are harsh on the skin. In an interview on 11/13/15 at 4:10 p.m., Resident #9 said the red rash on her peri area has made her miserable. According to a list provided by ADON A on 11/13/15 at 3:05 pm., the facility identified 4 residents in the facility with skin rashes.

Based on observation, interview and record review, the facility failed to ensure that 1 of 4 residents (Resident # 9) reviewed for skin irritation and rashes received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to: A) Assess, closely monitor, and provide adequate treatment and interventions for Resident #9's painful red perineum, inner buttocks, and upper thighs. B) Care plan interventions to treat Resident #9's skin condition and associated pain. C) Assess and provide adequate interventions to address Resident #9's pain and discomfort related to skin irritation. D) Notify and consult with resident #9's physician regarding Resident #9's painful skin condition. Resident #9 received inadequate medical and pain relieving treatment for [REDACTED]. These failures caused Actual Harm for Resident #9 due to her suffering with pain and discomfort related to inadequate medical treatment for [REDACTED].These failures could place 4 residents with identified rashes at risk of receiving inadequate medical treatment resulting in delayed healing or worsening condition and avoidable pain and discomfort. Findings Include: Review of Resident # 9's un-dated face sheet revealed the [AGE] year-old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's initial MDS, dated [DATE], indicated the resident was alert and oriented to person, place and time. Resident # 9's BIMS score (Brief Interview for Mental Status Score) was 13, reflecting minimal cognitive impairment. Resident #9 was non ambulatory and used a wheelchair for mobility. The resident was dependent on 2 staff for ADLS such as hygiene, bathing and transfers. Resident # 9 was incontinent of bowel and bladder and used briefs. Review of Resident #9's History and Physical dated 9/15/15 indicated no documentation of the facility reporting a rash of/on the residents perineal area on the physician. Review of Resident #9's Physician Visit Progress Notes dated 9/25/15, 9/28/15, 10/1/15, 10/9/15, 10/15/15 indicated each note was signed by the primary care physician. There was no documentation of a rash in the perineal area. There were no [MEDICAL CONDITION] skin assessments or full skin assessments documented on the physician examinations. Review of a Care Plan dated 9/9/15 and revised 10/6/15 documented a focus problem of a stage 2 pressure area to the coccyx. The intervention for this included to notify the nurse of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care. The Care Plan did not indicate a rash or redness and pain in the perineal area. Review of Weekly Skin Assessments included the following documented under the section heading note location, measurements of any moisture associated skin damage 09/15 - perineal area 10/6 - reddened area noted to peri area. Barrier cream applied 10/13 - perineal area and upper thighs 10/21 - no documentation in this section. No reference to a rash anywhere on the skin assessment. 10/27 - perineal area 11/03 - no documentation in this section. Under section heading labeled other skin findings documented redness noted to coccyx, no open areas note at this time. Review of Resident #9's Medication Administration Record [REDACTED]. During an observation on 11/10/15 at 10:30 a.m., CNA G and CNA H transferred Resident #9 from a wheelchair to bed via a mechanical lift. Incontinent care was done using disposable cleansing wipes. The resident's vulva, perineum, inner buttocks, and inner upper thighs were bright red. Resident #9 grimaced each time the CNA used a cleansing wipe to clean the resident. The resident said the area was very painful. The CNAs said the redness had been present since the resident's admission to the facility (09/15/15). During an observation of Resident #9 on 11/10/15 at 2:30 p.m., CNA I and CNA J provided incontinent care to the resident. A bright red rash was noted on the perineal area extending to the upper thighs. The resident grimaced when the CNA's wiped the perineal area with a cleansing wipe. When asked if the rash hurt, the resident stated it was very painful and uncomfortable. During an interview on 11/11/15 at 2:00 p.m., LVN K, who also completed Resident #9's current skin assessment, said the resident has had this rash on the perineal area since she was admitted . The LVN said the rash worsens and improves. LVN K said she thought the physician was aware of the rash because he saw her when she was admitted . During an interview on 11/11/15 at 3:00 p.m., the DON stated Resident #9 has had this rash since she was admitted to the facility. The DON looked in the electronic medical record and could not find any documentation that the primary care physician had been informed of the rash. When asked, the DON said she would expect the nurses to inform the physician if a rash was persisting or not improving. The DON stated she would have the nurse call the primary care physician today and suggest a fungal cream. Review of a physician phone note, faxed to the facility on [DATE], indicated LVN M called the clinic on 11/11/15 at 4:06 p.m., with the following statement: Caller states patient has some redness around her peri area. Caller states it comes and goes and they have tried creams and nothing seems to work. She would like to see about getting an antifungal cream. During an interview on 11/13/15 at 1:30 p.m., CNA L and CNA C, stated Resident #9 has had this rash since she was admitted . They stated the rash improves and worsens, but has never fully resolved since being admitted . During an interview on 11/13/15 at 1:40 p.m., LVN K, said the resident has had this rash since she was admitted and it has never gone away. When asked why three of the weekly skin assessments did not have a rash documented on them (one she had signed herself), LVN K did not have an explanation. She said again the rash has never completely gone away, but improves at times. During an interview on 11/13 at 3:37 p.m., the primary care physician said he was not aware that the resident had a rash prior to being called by the facility on 11/11/2015. The physician stated although he has seen the resident several times, he did not do a full skin assessment at every examination. He stated he would only examine the [MEDICAL CONDITION] skin if he had reason to suspect an issue. He said that he relies on the facility to report to him when there are skin issues, since they see the resident frequently during bathing, incontinent care and assessments. After describing the surveyor ' s observations of the rash, the physician stated that is not how staff described the rash on 11/11/2015. He stated for a rash of that extent that has persisted for two months, he would normally want to examine the resident. He stated for a typical perineal rash that is suspicious of yeast, he would usually prescribe a topical antifungal. He stated that he would prescribe an oral antifungal if the rash was extensive or persistent. He also stated that he would advise other methods such as air drying, mild soap, and discontinuing disposable cleansing wipes, which typically are harsh on the skin. In an interview on 11/13/15 at 4:10 p.m., Resident #9 said the red rash on her peri area has made her miserable. According to a list provided by ADON A on 11/13/15 at 3:05 pm., the facility identified 4 residents in the facility with skin rashes.

Based on observation, interview and record review, the facility Administrator and DON (Director of Nurses) failed to ensure the facility was administered in a manner which enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Administrator failed to supervise the DON to ensure the DON was monitoring nursing staff to ensure treatment and services were provided in a competent manner. The DON failed to supervise the facility's two ADONs and nursing staff to ensure: 1) Transfer policies and procedures were followed when providing care to residents. 2) The Administrator and DON failed to ensure the facility was maintained in a manner free of hazards. 3) Resident #1 was put in his motorized wheelchair via the Hoyer sling lift. The Hoyer sling straps became tangled in the wheel of his chair, causing him to fall from the chair. 4) Resident #4 was seated in her high back wheelchair with the Hoyer sling straps hanging at the level of the wheels. This failure could place the 5 residents who are transferred using a mechanical lift by placing them at risk for injury. An Immediate Jeopardy was identified on 12/18/13 at 6:04 p.m.with the Administrator and DON notified. The Immediate Jeopardy was removed on 12/20/13 at 11:30 a.m. The facility remained out of compliance at potential for harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of the corrective systems. Findings include: Resident #1 Review of Resident #1's Face Sheet dated 11/12/13 revealed he was a [AGE] year old male admitted to the facility 01/26/09 with a readmission date of [DATE]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Care Plan dated 11/26/12 revealed, "Problem/Need: Injury, risk for ...Potential for falls related to impaired mobility. Resident is paraplegic and falls forward when in wheel chair due to upper body paralysis. Goal: Have no falls with injury x next 90 days. Approaches: ...Instruct resident on appropriate use of safety device/appliance. Apply support strap to upper body when in electric wheelchair for positioning (The last statement was marked through with a date beside it 11/19/13). Review of Resident #1's Care Plan dated 11/26/12 revealed updates on 12/03/13 to include "Problem/Need: Resident plays with straps to Hoyer sling during day. Resident unhooks catheter to drain tubing. Approaches: Will make sure the straps to Hoyer are tucked in so they don't dangle. Make sure catheter is tucked." Review of Resident #1's Quarterly MDS dated [DATE] revealed he was totally dependent on staff for bed mobility, transfers, personal hygiene, had a urinary catheter and a [MEDICAL CONDITION]. Review of Resident #1's Nurse's Notes dated 12/02/13 at 4:00 p.m. revealed, "Res sent to (name of hospital) per request of mother for fall. Res at 2:45 fell out of electric wheelchair. Ambulance called to pick up and take to E.R. (emergency room ) for eval and tx. Res c/o pain in neck and back, also suprapubic catheter was pulled taught during fall ...fall occurred in dining room when pt was leaving after playing bingo." Review of Resident #1's Nurse's Notes dated 12/02/13 at 7:00 p.m. revealed, "Res returned from ER with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes dated 12/03/13 at 3:15 p.m. revealed, "Resident in bed sleeping soundly. Easily aroused to verbal stimuli...no s/s acute distress..." Review of Resident #1's Nurse's Notes dated 12/03/13 at 3:15 p.m. revealed, "...ER called and spoke with (staff name) regarding res's X-RAYs from previous night R/T (related to) recent fall ...requesting that resident return to ER d/t possible femur fx and to repeat XRAYs ..." Review of Resident #1's Nurse's Notes dated 12/04/13 at 30 minutes after midnight revealed, "...res admitted ...bilat femur fx's ..." . Review of Resident #1's hospital XRAY of the left femur dated 12/03/13 revealed, "...There is a mildly displaced comminuted spiral displaced fracture involving the distal shaft of the left femur..." Review of Resident #1's hospital XRAY of the right femur dated 12/03/13 revealed, "...There is an acute oblique fracture involving the distal shaft of the right femur..." Review of the facility's Incident/Accident Report dated 12/02/13 revealed, "...Resident was leaving bingo and fell out of his electric w/c ...Resident was leaving bingo and the straps to the Hoyer sling and catheter got tangled in the wheels. He plays with the sling at times and the straps fell down. He sometimes plays "drains" his foley tubing ...Intervention: Start using the seatbelt on the new w/c. Inservice CNA's to check thru the day to ensure straps are up out of the way..." Review of a written statement by the PTA (undated) revealed she found Resident #1 laying on the floor in the dining room with his power chair on his right side. The PTA asked Resident #1 what happened and he told her, "the Hoyer lift got caught under my wheel and I fell out". The statement revealed that Resident #1's catheter was pulled tight and caught within the Hoyer pad and under the wheel. She and another staff lifted the power chair and adjusted the Hoyer pad and catheter to decrease the tightness in the catheter line. Review of a written statement by the PTA (undated) revealed Resident #1 was trained on the use of his new wheelchair 11/20/13. The statement revealed that she educated various staff members including CNA B and LVN B briefly on the use of the wheelchair. In an interview on 12/19/13 at 9:35 a.m., the PTA said when Resident #1 got his new wheelchair, she went over its usage with CNA B and LVN B. Review of a written statement by the DON dated 12/02/13 revealed that around 2:45 p.m. that day, Resident #1 was laying on the floor in the dining room with his wheelchair beside him. The catheter strap and the strap from the Hoyer sling were wrapped around the wheels of the wheelchair. The PTA was trying to unwrap the items from the wheelchair, but they were wrapped several times around the wheel, which made it difficult to unwrap. In an interview on 12/19/13 at 5:00 p.m., the DON stated that Resident #1 was found by the PTA on the floor of the dining room. She said the belt to the Hoyer sling was wrapped around Resident #1's wheelchair, as well as his foley tubing. The DON said Resident #1 was sent by ambulance to the E.R. and returned that night with a [DIAGNOSES REDACTED].R. called and needed Resident #1 to return for more XRAY's due to a possible femur fracture. The DON stated the straps on the Hoyer pad caused Resident #1 to fall from his wheelchair. She said staff had not been in-serviced on Hoyer lifts but should have been. In an interview on 12/18/13 at 11:40 a.m., CNA B said that on 12/02/13, she assisted getting Resident #1 into his wheelchair with another staff and the Hoyer lift. CNA B said the sling was left under Resident #1 when he was up because his legs were 'dead weight' and the sling was used to get him back to bed. CNA B said when Resident #1 had his old electric wheelchair; staff used a gait belt around his chest to keep him upright because he had no trunk control. CNA B said the new electric wheelchair had the capability to lean back, so no gait belt or seat belt was used. CNA B said Resident #1 got the new chair around the middle of November. CNA B said that the Hoyer sling straps got caught in the wheelchair, causing Resident #1 to fall. In an interview on 12/18/13 at 2:45 p.m., Resident #1 said he was in the dining room at the facility 12/02/13 when the straps to the sling under him got tangled in the wheel of his chair, causing him to fall forward. Resident #1 said his catheter tubing also got tangled in the wheel. Resident #1 said staff occasionally put the sling straps behind him, but had not on the day he fell . He said his father had told staff to always keep the sling straps away from the wheels. In an interview on 12/18/13 at 4:20 p.m., Resident #1's father said when he visited, staff always left the Hoyer sling under Resident #1 when he was in his wheelchair. Resident #1's father said staff had pulled Resident #1 up in his wheelchair on the day of the fall. He said that the straps to the sling fell low, at the level of the wheels. He said he had told staff on numerous occasions to keep the straps away from the wheels because Resident #1 might fall if straps got in the wheels. In an interview on 12/19/13 at 8:45 a.m., Resident #1's step-mother said that the Hoyer sling straps to the Hoyer lift were usually hanging down by the wheels when she visited. She said she told the administrator that the Hoyer sling straps needed to be kept away from the wheels, but that he did nothing about her comment. Resident #1's step-mother said she had also told the CNA's that the Hoyer sling straps needed to be kept away from the wheels. She said only one staff member ever listened to her or put the straps behind Resident #1. She said that on 11/19/13, Resident #1 received his new wheelchair. She said staff told Resident #1 and the family that no seat belt was necessary on the chair because the chair leaned back. She said Resident #1 had no trunk control and was unable to stop a fall if he went forward. In an interview on 12/19/13 at 9:20 a.m., the Administrator said he did not recall Resident #1's family telling him that the Hoyer sling straps needed to be kept away from the wheels. He said Resident #1 was shown by therapy how to operate the new chair, and could do so independently. In an interview on 12/19/13 at 9:35 a.m., the PTA said Resident #1's new electric wheelchair reclined, the entire seat tilted back, and the feet pedals moved up and down independently. She said a representative from the wheelchair company showed Resident #1 how to operate the chair. In an interview on 12/19/13 at 2:45 p.m., the MDS Coordinator said that Resident #1's new chair leaned back. She said Resident #1 could use his hands but had no trunk control. The MDS Coordinator said the therapy department taught Resident #1 how to operate his new wheelchair. She said that staff had to leave the sling under Resident #1 or not get him up. She said on 12/02/13, staff did not notice that the Hoyer sling straps were hanging down. In an interview on 12/20/13 at 9:50 a.m., the A.D. said after bingo 12/02/13, Resident #1 was leaving the dining room when she heard the PTA yell that Resident #1 was on the floor. She said the Hoyer sling straps were caught around the right wheel of his chair at that time. In an interview on 12/20/13 at 12:45 p.m., the Administrator said Resident #1's Hoyer sling straps hanging down were not perceived as a problem until he fell . Resident #4 Review of Resident #4's clinical record revealed she was an [AGE] year old female admitted to the facility 05/12/11 with [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan dated 10/28/13 revealed she needed extensive assistance with bathing and dressing, was incontinent of bowel and bladder and needed cueing for meals with a mechanical soft diet. Review of Resident #4's Quarterly MDS dated [DATE] revealed she was incontinent of bowel and bladder, needed extensive assistance with bathing and hygiene and used a wheelchair for mobility. Observation on 12/18/13 at 10:25 a.m. revealed a hospice CNA finishing a shower on Resident #4. CNA A then assisted the hospice CNA to put the Hoyer sling under Resident #4 and lift her into her high back wheelchair. The sling was left under Resident #4. Resident #4 began self-propelling down the hall. The Hoyer sling straps on the left side were noted to be hanging off the seat at the level of the wheels. In an interview on 12/18/13 at 10:40 a.m., CNA A said Resident #4 had stopped bearing her own weight about a month prior, so staff started using the Hoyer lift to get her up. CNA A said Resident #4 was able to self-propel in her wheelchair. CNA A said she had not received training on using a Hoyer lift at the facility. In an interview on 12/18/13 at 12:11 p.m., LVN A said that around the end of October, 2013, Resident #4 was unable to bear her weight, so staff started using the Hoyer lift to get her into her wheelchair. LVN A said she had worked at the facility for 2 years, but had not been trained on how to use the Hoyer or keep the straps away from the wheels. Observation on 12/18/13 at 12:59 p.m. revealed Resident #4 in her wheelchair in her room. Resident #4 was looking in her top dresser drawer. Resident #4's Hoyer sling was under her bottom on the seat of the chair. The Hoyer sling straps were noted to be hanging down on the left side at the level of the wheels. In an interview on 12/20/13 at 10:17 a.m., ADON A said the former DON had been responsible for training nursing staff, including Hoyer lift use. ADON A said she was now responsible for Hoyer training. ADON A said no documentation on Hoyer lift training existed. An Immediate Jeopardy (IJ) was identified, and on 12/18/13 at 6:04 p.m., the Administrator and DON were notified.. The facility's Plan of Removal of Immediate Jeopardy was accepted 12/20/13 at 11:30 a.m. and included: "... 1) In-service on proper placement of cling belt straps, O2 tubing (oxygen), resident catheters or any other loose straps while resident is in wheelchair started on 12/18/13. 2) In-service with Hospice provider regarding safe placement of sling straps, O2 tubing, or any other loose straps while resident in wheelchair started 12/19/13. 3) DON (name) will be responsible to ensure all staff are in serviced on sling straps belts, O2 tubing, resident catheters, or any other loose straps while resident is in wheelchair before they are allowed to work the floor. DON will be responsible to ensure all Hospice providers receive in-service on proper placement of cling strap, O2 tubing, resident catheters, or any other loose straps while resident is in their wheelchair prior to allowing them to work with residents. 4) Administrator (name) will monitor this training to ensure all employees and hospice Providers receive in-service on proper placement of sling straps, O2 tubing, resident catheters or any other loose straps while resident is in their wheelchair before being allowed to work with residents. 5) Administrator (name) and DON (name) will discuss progress of in servicing on a daily basis until all signatures are received from employees and Hospice Providers. In addition to this discussion all new hires will receive in-service on proper placement of sling belt straps, O2 tubing, resident catheters or any other loose straps while resident is in their wheelchair. Employees who have not signed in-service will not be allowed to work the floor. 6) Facility documented Qhr (every one hour) checks beginning 12/19/13. This check was to monitor for proper placement of sling straps, O2 tubing, resident catheters or any other loose straps while resident was in their wheelchair. 7) Facility will continue to monitor safety for residents in wheelchairs, Geri-chairs or walkers be checking each resident every 2 hours and initialing form that wheel area is clear of any hazards that could get tangled in wheel causing a resident to fall, this will include (Hoyer sling straps, O2 tubing, resident catheters, purse, etc.) (Monitoring forms were provided.) 8) Nursing administration (names) began inservice 12/19/13 on Safe Transfer from Hoyer Lift from Bed to Chair as well as how to safely tuck Hoyer sling straps. 9) Return demonstrations on transfers initiated 12/19/13 for all licensed staff. 10) Manufacturing Guidelines for Hoyer Lift and Slings provided 12/20/13. 11) (Resident #1's name) power wheelchair manual was provided as well as statement from Rehab Director on new chair training that was provided ... All measures of the Plan of Removal will be completed on 12/20/13..." Observation on 12/19/13 at 11:27 a.m. revealed CNA's A and D transferred Resident #4 from a recliner to her wheelchair. The Hoyer sling ws under her. After the transfer, the CNA's put the Hoyer sling straps under Resident #4. Observations of resident transfers to wheelchairs utilizing the Hoyer lift on 12/20/13 revealed staff put the Hoyer sling straps behind the residents after the transfer. No Hoyer sling straps were noted to be hanging down on the sides of the wheelchairs. Interviews with facility staff on 12/20/13 revealed all staff had been in-serviced on proper placement of Hoyer sling straps. While the IJ was removed on 12/20/12, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness The facility provided a list of five residents transferred via the Hoyer lift.

Based on observation, interview and record review the facility failed to implement its policy to prevent neglect of 2 of 5 Residents (Residents # 1 and #4) reviewed for neglect. The facility failed to recognize, assess, and intervene timely as evidenced by: a) Resident #1 was placed in his electric wheelchair with a Hoyer sling under his bottom. Resident #1's sling straps and his foley catheter tubing became tangled in the wheel of his wheelchair, causing him to fall, resulting in fractures to both legs. 2. Resident #4 was seated in her high back wheelchair with the Hoyer sling straps hanging at the level of the wheels. 3. The facility failed to provide training on the use of Hoyer lifts to all nursing staff. An Immediate Jeopardy (IJ) was identified on 12/18/13. While the IJ was removed on 12/20/12, the facility remained out of compliance at a Severity level of Isolated at Actual Harm Harm that was not IJ with a Scope of Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. This failure could place five residents who utilize the Hoyer lift at risk of injury. The findings included: Resident #1 Review of Resident #1's Face Sheet dated 11/12/13 revealed he was a [AGE] year old male admitted to the facility 01/26/09 with a readmission date of [DATE]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Care Plan dated 11/26/12 revealed, "Problem/Need: Injury, risk for ...Potential for falls related to impaired mobility. Resident is paraplegic and falls forward when in wheel chair due to upper body paralysis. Goal: Have no falls with injury x next 90 days. Approaches: ...Instruct resident on appropriate use of safety device/appliance. Apply support strap to upper body when in electric wheelchair for positioning (The last statement was marked through with a date beside it 11/19/13). Review of Resident #1's Care Plan dated 11/26/12 revealed updates on 12/03/13 to include "Problem/Need: Resident plays with straps to Hoyer sling during day. Resident unhooks catheter to drain tubing. Approaches: Will make sure the straps to Hoyer are tucked in so they don't dangle. Make sure catheter is tucked." Review of Resident #1's Quarterly MDS dated [DATE] revealed he was totally dependent on staff for bed mobility, transfers, personal hygiene, had a urinary catheter and a [MEDICAL CONDITION]. Review of Resident #1's Nurse's Notes dated 12/02/13 at 4:00 p.m. revealed, "Res sent to (name of hospital) per request of mother for fall. Res at 2:45 fell out of electric wheelchair. Ambulance called to pick up and take to E.R. (emergency room ) for eval and tx. Res c/o pain in neck and back, also suprapubic catheter was pulled taught during fall ...fall occurred in dining room when pt was leaving after playing bingo." Review of Resident #1's Nurse's Notes dated 12/02/13 at 7:00 p.m. revealed, "Res returned from ER with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes dated 12/03/13 at 3:15 p.m. revealed, "Resident in bed sleeping soundly. Easily aroused to verbal stimuli...no s/s acute distress..." Review of Resident #1's Nurse's Notes dated 12/03/13 at 3:15 p.m. revealed, "...ER called and spoke with (staff name) regarding res's X-RAYs from previous night R/T (related to) recent fall ...requesting that resident return to ER d/t possible femur fx and to repeat XRAYs ..." Review of Resident #1's Nurse's Notes dated 12/04/13 at 30 minutes after midnight revealed, "...res admitted ...bilat femur fx's ..." . Review of Resident #1's hospital XRAY of the left femur dated 12/03/13 revealed, "...There is a mildly displaced comminuted spiral displaced fracture involving the distal shaft of the left femur ... " Review of Resident #1's hospital XRAY of the right femur dated 12/03/13 revealed, "...There is an acute oblique fracture involving the distal shaft of the right femur..." Review of the facility's Incident/Accident Report dated 12/02/13 revealed, "...Resident was leaving bingo and fell out of his electric w/c ...Resident was leaving bingo and the straps to the Hoyer sling and catheter got tangled in the wheels. He plays with the sling at times and the straps fell down. He sometimes plays "drains" his foley tubing ...Intervention: Start using the seatbelt on the new w/c. Inservice CNA's to check thru the day to ensure straps are up out of the way..." Review of a written statement by the PTA (undated) revealed she found Resident #1 laying on the floor in the dining room with his power chair on his right side. The PTA asked Resident #1 what happened and he told her, "the Hoyer lift got caught under my wheel and I fell out " . The statement revealed that Resident #1's catheter was pulled tight and caught within the Hoyer pad and under the wheel. She and another staff lifted the power chair and adjusted the Hoyer pad and catheter to decrease the tightness in the catheter line. Review of a written statement by the PTA (undated) revealed Resident #1 was trained on the use of his new wheelchair 11/20/13. The statement revealed that she educated various staff members including CNA B and LVN B briefly on the use of the wheelchair. In an interview on 12/19/13 at 9:35 a.m., the PTA said when Resident #1 got his new wheelchair, she went over its usage with CNA B and LVN B. Review of a written statement by the DON dated 12/02/13 revealed that around 2:45 that day, Resident #1 was laying on the floor in the dining room with his wheelchair beside him. The catheter strap and the strap from the Hoyer sling were wrapped around the wheels of the wheelchair. The PTA was trying to unwrap the items from the wheelchair, but they were wrapped several times around the wheel, which made it difficult to unwrap. In an interview on 12/19/13 at 5:00 p.m., the DON stated that Resident #1 was found by the PTA on the floor of the dining room. She said the belt to the Hoyer sling was wrapped around Resident #1's wheelchair, as well as his foley tubing. The DON said Resident #1 was sent by ambulance to the E.R. and returned that night with a [DIAGNOSES REDACTED].R. called and needed Resident #1 to return for more XRAY's due to a possible femur fracture. The DON stated the straps on the Hoyer pad caused Resident #1 to fall from his wheelchair. She said staff had not been in-serviced on Hoyer lifts but should have been. In an interview on 12/18/13 at 11:40 a.m., CNA B said that on 12/02/13, she assisted getting Resident #1 into his wheelchair with another staff and the Hoyer lift. CNA B said the sling was left under Resident #1 when he was up because his legs were 'dead weight' and the sling was used to get him back to bed. CNA B said when Resident #1 had his old electric wheelchair; staff used a gait belt around his chest to keep him upright because he had no trunk control. CNA B said the new electric wheelchair had the capability to lean back, so no gait belt or seat belt was used. CNA B said Resident #1 got the new chair around the middle of November. CNA B said that the Hoyer sling straps got caught in the wheelchair, causing Resident #1 to fall. In an interview on 12/18/13 at 2:45 p.m., Resident #1 said he was in the dining room at the facility 12/02/13 when the straps to the sling under him got tangled in the wheel of his chair, causing him to fall forward. Resident #1 said his catheter tubing also got tangled in the wheel. Resident #1 said staff occasionally put the sling straps behind him, but had not on the day he fell . He said his father had told staff to always keep the sling straps away from the wheels. In an interview on 12/18/13 at 4:20 p.m., Resident #1's father said when he visited, staff always left the Hoyer sling under Resident #1 when he was in his wheelchair. Resident #1's father said staff had pulled Resident #1 up in his wheelchair on the day of the fall. He said that the straps to the sling fell low, at the level of the wheels. He said he had told staff on numerous occasions to keep the straps away from the wheels because Resident #1 might fall if straps got in the wheels. In an interview on 12/19/13 at 8:45 a.m., Resident #1's step-mother said that the Hoyer sling straps to the Hoyer lift were usually hanging down by the wheels when she visited. She said she told the administrator that the Hoyer sling straps needed to be kept away from the wheels, but that he did nothing about her comment. Resident #1's step-mother said she had also told the CNA's that the Hoyer sling straps needed to be kept away from the wheels. She said only one staff member ever listened to her or put the straps behind Resident #1. She said that on 11/19/13, Resident #1 received his new wheelchair. She said staff told Resident #1 and the family that no seat belt was necessary on the chair because the chair leaned back. She said Resident #1 had no trunk control and was unable to stop a fall if he went forward. In an interview on 12/19/13 at 9:20 a.m., the Administrator said he did not recall Resident #1 ' s family telling him that the Hoyer sling straps needed to be kept away from the wheels. He said Resident #1 was shown by therapy how to operate the new chair, and could do so independently. In an interview on 12/19/13 at 9:35 a.m., the PTA said Resident #1's new electric wheelchair reclined, the entire seat tilted back, and the feet pedals moved up and down independently. She said a representative from the wheelchair company showed Resident #1 how to operate the chair. In an interview on 12/19/13 at 2:45 p.m., the MDS Coordinator said that Resident #1's new chair leaned back. She said Resident #1 could use his hands but had no trunk control. The MDS Coordinator said the therapy department taught Resident #1 how to operate his new wheelchair. She said that staff had to leave the sling under Resident #1 or not get him up. She said on 12/02/13, staff did not notice that the Hoyer sling straps were hanging down. In an interview on 12/20/13 at 9:50 a.m., the A.D. said after bingo 12/02/13, Resident #1 was leaving the dining room when she heard the PTA yell that Resident #1 was on the floor. She said the Hoyer sling straps were caught around the right wheel of his chair at that time. Resident #4 Review of Resident #4's clinical record revealed she was an [AGE] year old female admitted to the facility 05/12/11 with [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan dated 10/28/13 revealed she needed extensive assistance with bathing and dressing, was incontinent of bowel and bladder and needed cueing for meals with a mechanical soft diet. Review of Resident #4's Quarterly MDS dated [DATE] revealed she was incontinent of bowel and bladder, needed extensive assistance with bathing and hygiene and used a wheelchair for mobility. Observation on 12/18/13 at 10:25 a.m. revealed a hospice CNA finishing a shower on Resident #4. CNA A then assisted the hospice CNA to put the Hoyer sling under Resident #4 and lift her into her high back wheelchair. The sling was left under Resident #4. Resident #4 began self-propelling down the hall. The Hoyer sling straps on the left side were noted to be hanging off the seat at the level of the wheels. In an interview on 12/18/13 at 10:40 a.m., CNA A said Resident #4 had stopped bearing her own weight about a month prior, so staff started using the Hoyer lift to get her up. CNA A said Resident #4 was able to self-propel in her wheelchair. CNA A said she had not received training on using a Hoyer lift at the facility. In an interview on 12/18/13 at 12:11 p.m., LVN A said that around the end of October, 2013, Resident #4 was unable to bear her weight, so staff started using the Hoyer lift to get her into her wheelchair. LVN A said she had worked at the facility for 2 years, but had not been trained on how to use the Hoyer or keep the straps away from the wheels. Observation on 12/18/13 at 12:59 p.m. revealed Resident #4 in her wheelchair in her room. Resident #4 was looking in her top dresser drawer. Resident #4's Hoyer sling was under her bottom on the seat of the chair. The Hoyer sling straps were noted to be hanging down on the left side at the level of the wheels. In an interview on 12/20/13 at 10:17 a.m., ADON A said the former DON had been responsible for training nursing staff, including Hoyer lift use. ADON A said she was now responsible for Hoyer training. ADON A said no documentation on Hoyer lift training existed. Review of the facility's Abuse Policy, undated, revealed, "...Negligence: Failing to properly care for a resident in the manner conducive to professional care standards...Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness..." Review of the facility's policy, Preventing Accidents, undated, revealed, "Be alert to safety hazards and take extra precautions to protect the elderly and frail people from injnury...Preventing falls. Falls are the leading cause of injury...Be alert to furniture or objects that pose a hazard..." Review of the facility's policy, Accidents/Falls dated 06/04/08 revealed, "...The facility will identify each resident at risk for accidents and/or falls, and will adequately plan care and implement procedures to reduce or prevent accidents...It is the policy of (facility name) to identify residents at risk of falling and provide nursing interventions to maintain a safe environment...Identify characteristics of environment that may increase potential for falls..." An Immediate Jeopardy (IJ) was identified and on 12/18/13 at 6:04 p.m., and the Administrator and DON were informed. The facility's Plan of Removal of Immediate Jeopardy was accepted 12/20/13 at 11:30 a.m. and included: "... 1) In-service on proper placement of cling belt straps, O2 tubing (oxygen), resident catheters or any other loose straps while resident is in wheelchair started on 12/18/13. 2) In-service with Hospice provider regarding safe placement of sling straps, O2 tubing, or any other loose straps while resident in wheelchair started 12/19/13. 3) DON (name) will be responsible to ensure all staff are in serviced on sling straps belts, O2 tubing, resident catheters, or any other loose straps while resident is in wheelchair before they are allowed to work the floor. DON will be responsible to ensure all Hospice providers receive in-service on proper placement of cling strap, O2 tubing, resident catheters, or any other loose straps while resident is in their wheelchair prior to allowing them to work with residents. 4) Administrator (name) will monitor this training to ensure all employees and hospice Providers receive in-service on proper placement of sling straps, O2 tubing, resident catheters or any other loose straps while resident is in their wheelchair before being allowed to work with residents. 5) Administrator (name) and DON (name) will discuss progress of in servicing on a daily basis until all signatures are received from employees and Hospice Providers. In addition to this discussion all new hires will receive in-service on proper placement of sling belt straps, O2 tubing, resident catheters or any other loose straps while resident is in their wheelchair. Employees who have not signed in-service will not be allowed to work the floor. 6) Facility documented Qhr (every one hour) checks beginning 12/19/13. This check was to monitor for proper placement of sling straps, O2 tubing, resident catheters or any other loose straps while resident was in their wheelchair. 7) Facility will continue to monitor safety for residents in wheelchairs, Geri-chairs or walkers be checking each resident every 2 hours and initialing form that wheel area is clear of any hazards that could get tangled in wheel causing a resident to fall, this will include (Hoyer sling straps, O2 tubing, resident catheters, purse, etc.) (Monitoring forms were provided.) 8) Nursing administration (names) began inservice 12/19/13 on Safe Transfer from Hoyer Lift from Bed to Chair as well as how to safely tuck Hoyer sling straps. 9) Return demonstrations on transfers initiated 12/19/13 for all licensed staff. 10) Manufacturing Guidelines for Hoyer Lift and Slings provided 12/20/13. 11) (Resident #1's name) power wheelchair manual was provided as well as statement from Rehab Director on new chair training that was provided ... All measures of the Plan of Removal will be completed on 12/20/13..." Observation on 12/19/13 at 11:27 a.m. revealed CNA's A and D transferred Resident #4 from a recliner to her wheelchair. The Hoyer sling was under her. After the transfer, the CNA's put the Hoyer sling straps under Resident #4. Observations of resident transfers to wheelchairs utilizing the Hoyer lift on 12/20/13 revealed staff put the Hoyer sling straps behind the residents after the transfer. No Hoyer sling straps were noted to be hanging down on the sides of the wheelchairs. Interviews with facility staff on 12/20/13 revealed all staff had been in-serviced on proper placement of Hoyer sling straps. While the IJ was removed on 12/20/12, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. The facility provided a list of five residents transferred via the Hoyer lift.

Based on observations, interviews and record reviews the facility failed to develop and implement policies and procedures to prevent accidents for 2 of 5 residents (Residents #1 and #4) reviewed for the use of Hoyer lifts. 1. Resident #1 was put in his motorized wheelchair 12/02/13 with the Hoyer sling under him. The Hoyer sling strap became tangled in the front right wheel of the wheelchair. Resident #1 fell out of the chair onto the floor. Resident #1 was sent to the hospital where he was diagnosed with [REDACTED]. 2. Resident #4 was seated in her high back wheelchair with the Hoyer sling straps hanging at the level of the wheels. 3. The facility failed to provide training on the use of Hoyer lifts to all nursing staff. An Immediate Jeopardy (IJ) was identified on 12/18/13. While the IJ was removed on 12/20/12, the facility remained out of compliance at a Severity level of Isolated at Actual Harm that was not IJ with a Scope of Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. This failure could place five residents who utilize the Hoyer lift at risk of injury. The findings included: Review of the facility's Abuse Policy, undated, revealed, "...Negligence: Failing to properly care for a resident in the manner conducive to professional care standards...Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness..." Review of the facility's policy, Preventing Accidents, undated, revealed, "Be alert to safety hazards and take extra precautions to protect the elderly and frail people from injnury...Preventing falls. Falls are the leading cause of injury...Be alert to furniture or objects that pose a hazard..." Review of the facility's policy, Accidents/Falls dated 06/04/08 revealed, "...The facility will identify each resident at risk for accidents and/or falls, and will adequately plan care and implement procedures to reduce or prevent accidents...It is the policy of (facility name) to identify residents at risk of falling and provide nursing interventions to maintain a safe environment...Identify characteristics of environment that may increase potential for falls..." Resident #1 Review of Resident #1's Face Sheet dated 11/12/13 revealed he was a [AGE] year old male admitted to the facility 01/26/09 with a readmission date of [DATE]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Care Plan dated 11/26/12 revealed, "Problem/Need: Injury, risk for ...Potential for falls related to impaired mobility. Resident is paraplegic and falls forward when in wheel chair due to upper body paralysis. Goal: Have no falls with injury x next 90 days. Approaches: ...Instruct resident on appropriate use of safety device/appliance. Apply support strap to upper body when in electric wheelchair for positioning (The last statement was marked through with a date beside it 11/19/13). Review of Resident #1's Care Plan dated 11/26/12 revealed updates on 12/03/13 to include "Problem/Need: Resident plays with straps to Hoyer sling during day. Resident unhooks catheter to drain tubing. Approaches: Will make sure the straps to Hoyer are tucked in so they don't dangle. Make sure catheter is tucked." Review of Resident #1's Quarterly MDS dated [DATE] revealed he was totally dependent on staff for bed mobility, transfers, personal hygiene, had a urinary catheter and a [MEDICAL CONDITION]. Review of Resident #1's Nurse's Notes dated 12/02/13 at 4:00 p.m. revealed, "Res sent to (name of hospital) per request of mother for fall. Res at 2:45 fell out of electric wheelchair. Ambulance called to pick up and take to E.R. (emergency room ) for eval and tx. Res c/o pain in neck and back, also suprapubic catheter was pulled taught during fall ...fall occurred in dining room when pt was leaving after playing bingo." Review of Resident #1's Nurse's Notes dated 12/02/13 at 7:00 p.m. revealed, "Res returned from ER with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes dated 12/03/13 at 3:15 p.m. revealed, "Resident in bed sleeping soundly. Easily aroused to verbal stimuli...no s/s acute distress..." Review of Resident #1's Nurse's Notes dated 12/03/13 at 3:15 p.m. revealed, "...ER called and spoke with (staff name) regarding res's X-RAYs from previous night R/T (related to) recent fall ...requesting that resident return to ER d/t possible femur fx and to repeat XRAYs ..." Review of Resident #1's Nurse's Notes dated 12/04/13 at 30 minutes after midnight revealed, "...res admitted ...bilat femur fx's ..." Review of Resident #1's hospital XRAY of the left femur dated 12/03/13 revealed, "...There is a mildly displaced comminuted spiral displaced fracture involving the distal shaft of the left femur..." Review of Resident #1's hospital XRAY of the right femur dated 12/03/13 revealed, "...There is an acute oblique fracture involving the distal shaft of the right femur..." Review of the facility's Incident/Accident Report dated 12/02/13 revealed, "...Resident was leaving bingo and fell out of his electric w/c ...Resident was leaving bingo and the straps to the Hoyer sling and catheter got tangled in the wheels. He plays with the sling at times and the straps fell down. He sometimes plays "drains" his foley tubing ...Intervention: Start using the seatbelt on the new w/c. Inservice CNA's to check thru the day to ensure straps are up out of the way..." Review of a written statement by the PTA (undated) revealed she found Resident #1 laying on the floor in the dining room with his power chair on his right side. The PTA asked Resident #1 what happened and he told her, "the Hoyer lift got caught under my wheel and I fell out " . The statement revealed that Resident #1's catheter was pulled tight and caught within the Hoyer pad and under the wheel. She and another staff lifted the power chair and adjusted the Hoyer pad and catheter to decrease the tightness in the catheter line. Review of a written statement by the PTA (undated) revealed Resident #1 was trained on the use of his new wheelchair 11/20/13. The statement revealed that she educated various staff members including CNA B and LVN B briefly on the use of the wheelchair. In an interview on 12/19/13 at 9:35 a.m., the PTA said when Resident #1 got his new wheelchair, she went over its usage with CNA B and LVN B. Review of a written statement by the DON dated 12/02/13 revealed that around 2:45 that day, Resident #1 was laying on the floor in the dining room with his wheelchair beside him. The catheter strap and the strap from the Hoyer sling were wrapped around the wheels of the wheelchair. The PTA was trying to unwrap the items from the wheelchair, but they were wrapped several times around the wheel, which made it difficult to unwrap. In an interview on 12/19/13 at 5:00 p.m., the DON stated that Resident #1 was found by the PTA on the floor of the dining room. She said the belt to the Hoyer sling was wrapped around Resident #1's wheelchair, as well as his foley tubing. The DON said Resident #1 was sent by ambulance to the E.R. and returned that night with a [DIAGNOSES REDACTED].R. called and needed Resident #1 to return for more XRAY's due to a possible femur fracture. The DON stated the straps on the Hoyer pad caused Resident #1 to fall from his wheelchair. She said staff had not been in-serviced on Hoyer lifts but should have been. In an interview on 12/18/13 at 11:40 a.m., CNA B said that on 12/02/13, she assisted getting Resident #1 into his wheelchair with another staff and the Hoyer lift. CNA B said the sling was left under Resident #1 when he was up because his legs were 'dead weight' and the sling was used to get him back to bed. CNA B said when Resident #1 had his old electric wheelchair; staff used a gait belt around his chest to keep him upright because he had no trunk control. CNA B said the new electric wheelchair had the capability to lean back, so no gait belt or seat belt was used. CNA B said Resident #1 got the new chair around the middle of November. CNA B said that the Hoyer sling straps got caught in the wheelchair, causing Resident #1 to fall. In an interview on 12/18/13 at 2:45 p.m., Resident #1 said he was in the dining room at the facility 12/02/13 when the straps to the sling under him got tangled in the wheel of his chair, causing him to fall forward. Resident #1 said his catheter tubing also got tangled in the wheel. Resident #1 said staff occasionally put the sling straps behind him, but had not on the day he fell . He said his father had told staff to always keep the sling straps away from the wheels. In an interview on 12/18/13 at 4:20 p.m., Resident #1's father said when he visited, staff always left the Hoyer sling under Resident #1 when he was in his wheelchair. Resident #1's father said staff had pulled Resident #1 up in his wheelchair on the day of the fall. He said that the straps to the sling fell low, at the level of the wheels. He said he had told staff on numerous occasions to keep the straps away from the wheels because Resident #1 might fall if straps got in the wheels. In an interview on 12/19/13 at 8:45 a.m., Resident #1's step-mother said that the Hoyer sling straps to the Hoyer lift were usually hanging down by the wheels when she visited. She said she told the administrator that the Hoyer sling straps needed to be kept away from the wheels, but that he did nothing about her comment. Resident #1's step-mother said she had also told the CNA's that the Hoyer sling straps needed to be kept away from the wheels. She said only one staff member ever listened to her or put the straps behind Resident #1. She said that on 11/19/13, Resident #1 received his new wheelchair. She said staff told Resident #1 and the family that no seat belt was necessary on the chair because the chair leaned back. She said Resident #1 had no trunk control and was unable to stop a fall if he went forward. In an interview on 12/19/13 at 9:20 a.m., the Administrator said he did not recall Resident #1 ' s family telling him that the Hoyer sling straps needed to be kept away from the wheels. He said Resident #1 was shown by therapy how to operate the new chair, and could do so independently. In an interview on 12/19/13 at 9:35 a.m., the PTA said Resident #1's new electric wheelchair reclined, the entire seat tilted back, and the feet pedals moved up and down independently. She said a representative from the wheelchair company showed Resident #1 how to operate the chair. In an interview on 12/19/13 at 2:45 p.m., the MDS Coordinator said that Resident #1's new chair leaned back. She said Resident #1 could use his hands but had no trunk control. The MDS Coordinator said the therapy department taught Resident #1 how to operate his new wheelchair. She said that staff had to leave the sling under Resident #1 or not get him up. She said on 12/02/13, staff did not notice that the Hoyer sling straps were hanging down. In an interview on 12/20/13 at 9:50 a.m., the A.D. said after bingo 12/02/13, Resident #1 was leaving the dining room when she heard the PTA yell that Resident #1 was on the floor. She said the Hoyer sling straps were caught around the right wheel of his chair at that time. Resident #4 Review of Resident #4's clinical record revealed she was an [AGE] year old female admitted to the facility 05/12/11 with [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan dated 10/28/13 revealed she needed extensive assistance with bathing and dressing, was incontinent of bowel and bladder and needed cueing for meals with a mechanical soft diet. Review of Resident #4's Quarterly MDS dated [DATE] revealed she was incontinent of bowel and bladder, needed extensive assistance with bathing and hygiene and used a wheelchair for mobility. Observation on 12/18/13 at 10:25 a.m. revealed a hospice CNA finishing a shower on Resident #4. CNA A then assisted the hospice CNA to put the Hoyer sling under Resident #4 and lift her into her high back wheelchair. The sling was left under Resident #4. Resident #4 began self-propelling down the hall. The Hoyer sling straps on the left side were noted to be hanging off the seat at the level of the wheels. In an interview on 12/18/13 at 10:40 a.m., CNA A said Resident #4 had stopped bearing her own weight about a month prior, so staff started using the Hoyer lift to get her up. CNA A said Resident #4 was able to self-propel in her wheelchair. CNA A said she had not received training on using a Hoyer lift at the facility. In an interview on 12/18/13 at 12:11 p.m., LVN A said that around the end of October, 2013, Resident #4 was unable to bear her weight, so staff started using the Hoyer lift to get her into her wheelchair. LVN A said she had worked at the facility for 2 years, but had not been trained on how to use the Hoyer or keep the straps away from the wheels. Observation on 12/18/13 at 12:59 p.m. revealed Resident #4 in her wheelchair in her room. Resident #4 was looking in her top dresser drawer. Resident #4's Hoyer sling was under her bottom on the seat of the chair. The Hoyer sling straps were noted to be hanging down on the left side at the level of the wheels. In an interview on 12/20/13 at 10:17 a.m., ADON A said the former DON had been responsible for training nursing staff, including Hoyer lift use. ADON A said she was now responsible for Hoyer training. ADON A said no documentation on Hoyer lift training existed. An Immediate Jeopardy (IJ) was identified on 12/18/13 at 6:04 p.m., and the Administrator and DON were notified. The facility's Plan of Removal of Immediate Jeopardy was accepted 12/20/13 at 11:30 a.m. and included: "... 1) In-service on proper placement of cling belt straps, O2 tubing (oxygen), resident catheters or any other loose straps while resident is in wheelchair started on 12/18/13. 2) In-service with Hospice provider regarding safe placement of sling straps, O2 tubing, or any other loose straps while resident in wheelchair started 12/19/13. 3) DON (name) will be responsible to ensure all staff are in serviced on sling straps belts, O2 tubing, resident catheters, or any other loose straps while resident is in wheelchair before they are allowed to work the floor. DON will be responsible to ensure all Hospice providers receive in-service on proper placement of cling strap, O2 tubing, resident catheters, or any other loose straps while resident is in their wheelchair prior to allowing them to work with residents. 4) Administrator (name) will monitor this training to ensure all employees and hospice Providers receive in-service on proper placement of sling straps, O2 tubing, resident catheters or any other loose straps while resident is in their wheelchair before being allowed to work with residents. 5) Administrator (name) and DON (name) will discuss progress of in servicing on a daily basis until all signatures are received from employees and Hospice Providers. In addition to this discussion all new hires will receive in-service on proper placement of sling belt straps, O2 tubing, resident catheters or any other loose straps while resident is in their wheelchair. Employees who have not signed in-service will not be allowed to work the floor. 6) Facility documented Qhr (every one hour) checks beginning 12/19/13. This check was to monitor for proper placement of sling straps, O2 tubing, resident catheters or any other loose straps while resident was in their wheelchair. 7) Facility will continue to monitor safety for residents in wheelchairs, Geri-chairs or walkers be checking each resident every 2 hours and initialing form that wheel area is clear of any hazards that could get tangled in wheel causing a resident to fall, this will include (Hoyer sling straps, O2 tubing, resident catheters, purse, etc.) (Monitoring forms were provided.) 8) Nursing administration (names) began inservice 12/19/13 on Safe Transfer from Hoyer Lift from Bed to Chair as well as how to safely tuck Hoyer sling straps. 9) Return demonstrations on transfers initiated 12/19/13 for all licensed staff. 10) Manufacturing Guidelines for Hoyer Lift and Slings provided 12/20/13. 11) (Resident #1's name) power wheelchair manual was provided as well as statement from Rehab Director on new chair training that was provided ... All measures of the Plan of Removal will be completed on 12/20/13..." Observation on 12/19/13 at 11:27 a.m. revealed CNA's A and D transferred Resident #4 from a recliner to her wheelchair. The Hoyer sling ws under her. After the transfer, the CNA's put the Hoyer sling straps under Resident #4. Observations of resident transfers to wheelchairs utilizing the Hoyer lift on 12/20/13 revealed staff put the Hoyer sling straps behind the residents after the transfer. No Hoyer sling straps were noted to be hanging down on the sides of the wheelchairs. Interviews with facility staff on 12/20/13 revealed all staff had been in-serviced on proper placement of Hoyer sling straps. While the IJ was removed on 12/20/13, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. The facility provided a list of five residents transferred via the Hoyer lift.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision to prevent accidents for 2 of 5 residents (Residents #1 and #4) reviewed for the use of Hoyer lifts. 1. Resident #1 was put in his motorized wheelchair 12/02/13 with the Hoyer sling under him. The Hoyer sling strap became tangled in the front right wheel of the wheelchair. Resident #1 fell out of the chair onto the floor. Resident #1 was sent to the hospital where he was diagnosed with [REDACTED]. 2. Resident #4 was seated in her high back wheelchair with the Hoyer sling straps hanging at the level of the wheels. 3. The facility failed to provide training on the use of Hoyer lifts to all nursing staff. An Immediate Jeopardy (IJ) was identified on 12/18/13. While the IJ was removed on 12/20/12, the facility remained out of compliance at a Severity level of Isolated Actual Harm that was not IJ with a Scope of Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. This failure could place five residents who utilize the Hoyer lift at risk of injury. The findings included: Resident #1 Review of Resident #1's Face Sheet dated 11/12/13 revealed he was a [AGE] year old male admitted to the facility 01/26/09 with a readmission date of [DATE]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Care Plan dated 11/26/12 revealed, "Problem/Need: Injury, risk for ...Potential for falls related to impaired mobility. Resident is paraplegic and falls forward when in wheel chair due to upper body paralysis. Goal: Have no falls with injury x next 90 days. Approaches: ...Instruct resident on appropriate use of safety device/appliance. Apply support strap to upper body when in electric wheelchair for positioning (The last statement was marked through with a date beside it 11/19/13). Review of Resident #1's Care Plan dated 11/26/12 revealed updates on 12/03/13 to include "Problem/Need: Resident plays with straps to Hoyer sling during day. Resident unhooks catheter to drain tubing. Approaches: Will make sure the straps to Hoyer are tucked in so they don't dangle. Make sure catheter is tucked." Review of Resident #1's Quarterly MDS dated [DATE] revealed he was totally dependent on staff for bed mobility, transfers, personal hygiene, had a urinary catheter and a colostomy. Review of Resident #1's Nurse's Notes dated 12/02/13 at 4:00 p.m. revealed, " Res sent to (name of hospital) per request of mother for fall. Res at 2:45 fell out of electric wheelchair. Ambulance called to pick up and take to E.R. (emergency room ) for eval and tx. Res c/o pain in neck and back, also suprapubic catheter was pulled taught during fall ...fall occurred in dining room when pt was leaving after playing bingo." Review of Resident #1's Nurse's Notes dated 12/02/13 at 7:00 p.m. revealed, "Res returned from ER with [DIAGNOSES REDACTED]. Review of Residint #1's Nurse's Notes dated 12/03/13 at 3:15 p.m. revealed, "Resident in bed sleeping soundly. Easily aroused to verbal stimuli...no s/s acute distress..." Review of Resident #1's Nurse's Notes dated 12/03/13 at 3:15 p.m. revealed, "...ER called and spoke with (staff name) regarding res's X-RAYs from previous night R/T (related to) recent fall ...requesting that resident return to ER d/t possible femur fx and to repeat XRAYs ..." Review of Resident #1's Nurse's Notes dated 12/04/13 at 30 minutes after midnight revealed, "...res admitted ...bilat femur fx's ..." . Review of Resident #1's hospital XRAY of the left femur dated 12/03/13 revealed, " ...There is a mildly displaced comminuted spiral displaced fracture involving the distal shaft of the left femur ... " Review of Resident #1's hospital XRAY of the right femur dated 12/03/13 revealed, "...There is an acute oblique fracture involving the distal shaft of the right femur..." Review of the facility's Incident/Accident Report dated 12/02/13 revealed, "...Resident was leaving bingo and fell out of his electric w/c ...Resident was leaving bingo and the straps to the Hoyer sling and catheter got tangled in the wheels. He plays with the sling at times and the straps fell down. He sometimes plays "drains" his foley tubing ...Intervention: Start using the seatbelt on the new w/c. Inservice CNA's to check thru the day to ensure straps are up out of the way..." Review of a written statement by the PTA (undated) revealed she found Resident #1 laying on the floor in the dining room with his power chair on his right side. The PTA asked Resident #1 what happened and he told her, "the Hoyer lift got caught under my wheel and I fell out ". The statement revealed that Resident #1's catheter was pulled tight and caught within the Hoyer pad and under the wheel. She and another staff lifted the power chair and adjusted the Hoyer pad and catheter to decrease the tightness in the catheter line. Review of a written statement by the PTA (undated) revealed Resident #1 was trained on the use of his new wheelchair 11/20/13. The statement revealed that she educated various staff members including CNA B and LVN B briefly on the use of the wheelchair. In an interview on 12/19/13 at 9:35 a.m., the PTA said when Resident #1 got his new wheelchair, she went over its usage with CNA B and LVN B. Review of a written statement by the DON dated 12/02/13 revealed that around 2:45 that day, Resident #1 was laying on the floor in the dining room with his wheelchair beside him. The catheter strap and the strap from the Hoyer sling were wrapped around the wheels of the wheelchair. The PTA was trying to unwrap the items from the wheelchair, but they were wrapped several times around the wheel, which made it difficult to unwrap. In an interview on 12/19/13 at 5:00 p.m., the DON stated that Resident #1 was found by the PTA on the floor of the dining room. She said the belt to the Hoyer sling was wrapped around Resident #1's wheelchair, as well as his foley tubing. The DON said Resident #1 was sent by ambulance to the E.R. and returned that night with a [DIAGNOSES REDACTED].R. called and needed Resident #1 to return for more XRAY's due to a possible femur fracture. The DON stated the straps on the Hoyer pad caused Resident #1 to fall from his wheelchair. She said staff had not been in-serviced on Hoyer lifts but should have been. In an interview on 12/18/13 at 11:40 a.m., CNA B said that on 12/02/13, she assisted getting Resident #1 into his wheelchair with another staff and the Hoyer lift. CNA B said the sling was left under Resident #1 when he was up because his legs were 'dead weight' and the sling was used to get him back to bed. CNA B said when Resident #1 had his old electric wheelchair; staff used a gait belt around his chest to keep him upright because he had no trunk control. CNA B said the new electric wheelchair had the capability to lean back, so no gait belt or seat belt was used. CNA B said Resident #1 got the new chair around the middle of November. CNA B said that the Hoyer sling straps got caught in the wheelchair, causing Resident #1 to fall. In an interview on 12/18/13 at 2:45 p.m., Resident #1 said he was in the dining room at the facility 12/02/13 when the straps to the sling under him got tangled in the wheel of his chair, causing him to fall forward. Resident #1 said his catheter tubing also got tangled in the wheel. Resident #1 said staff occasionally put the sling straps behind him, but had not on the day he fell . He said his father had told staff to always keep the sling straps away from the wheels. In an interview on 12/18/13 at 4:20 p.m., Resident #1's father said when he visited, staff always left the Hoyer sling under Resident #1 when he was in his wheelchair. Resident #1's father said staff had pulled Resident #1 up in his wheelchair on the day of the fall. He said that the straps to the sling fell low, at the level of the wheels. He said he had told staff on numerous occasions to keep the straps away from the wheels because Resident #1 might fall if straps got in the wheels. In an interview on 12/19/13 at 8:45 a.m., Resident #1's step-mother said that the Hoyer sling straps to the Hoyer lift were usually hanging down by the wheels when she visited. She said she told the administrator that the Hoyer sling straps needed to be kept away from the wheels, but that he did nothing about her comment. Resident #1's step-mother said she had also told the CNA's that the Hoyer sling straps needed to be kept away from the wheels. She said only one staff member ever listened to her or put the straps behind Resident #1. She said that on 11/19/13, Resident #1 received his new wheelchair. She said staff told Resident #1 and the family that no seat belt was necessary on the chair because the chair leaned back. She said Resident #1 had no trunk control and was unable to stop a fall if he went forward. In an interview on 12/19/13 at 9:20 a.m., the Administrator said he did not recall Resident #1 ' s family telling him that the Hoyer sling straps needed to be kept away from the wheels. He said Resident #1 was shown by therapy how to operate the new chair, and could do so independently. In an interview on 12/19/13 at 9:35 a.m., the PTA said Resident #1's new electric wheelchair reclined, the entire seat tilted back, and the feet pedals moved up and down independently. She said a representative from the wheelchair company showed Resident #1 how to operate the chair. In an interview on 12/19/13 at 2:45 p.m., the MDS Coordinator said that Resident #1's new chair leaned back. She said Resident #1 could use his hands but had no trunk control. The MDS Coordinator said the therapy department taught Resident #1 how to operate his new wheelchair. She said that staff had to leave the sling under Resident #1 or not get him up. She said on 12/02/13, staff did not notice that the Hoyer sling straps were hanging down. In an interview on 12/20/13 at 9:50 a.m., the A.D. said after bingo 12/02/13, Resident #1 was leaving the dining room when she heard the PTA yell that Resident #1 was on the floor. She said the Hoyer sling straps were caught around the right wheel of his chair at that time. Resident #4 Review of Resident #4's clinical record revealed she was an [AGE] year old female admitted to the facility 05/12/11 with [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan dated 10/28/13 revealed she needed extensive assistance with bathing and dressing, was incontinent of bowel and bladder and needed cueing for meals with a mechanical soft diet. Review of Resident #4's Quarterly MDS dated [DATE] revealed she was incontinent of bowel and bladder, needed extensive assistance with bathing and hygiene and used a wheelchair for mobility. Observation on 12/18/13 at 10:25 a.m. revealed a hospice CNA finishing a shower on Resident #4. CNA A then assisted the hospice CNA to put the Hoyer sling under Resident #4 and lift her into her high back wheelchair. The sling was left under Resident #4. Resident #4 began self-propelling down the hall. The Hoyer sling straps on the left side were noted to be hanging off the seat at the level of the wheels. In an interview on 12/18/13 at 10:40 a.m., CNA A said Resident #4 had stopped bearing her own weight about a month prior, so staff started using the Hoyer lift to get her up. CNA A said Resident #4 was able to self-propel in her wheelchair. CNA A said she had not received training on using a Hoyer lift at the facility. In an interview on 12/18/13 at 12:11 p.m., LVN A said that around the end of October, 2013, Resident #4 was unable to bear her weight, so staff started using the Hoyer lift to get her into her wheelchair. LVN A said she had worked at the facility for 2 years, but had not been trained on how to use the Hoyer or keep the straps away from the wheels. Observation on 12/18/13 at 12:59 p.m. revealed Resident #4 in her wheelchair in her room. Resident #4 was looking in her top dresser drawer. Resident #4's Hoyer sling was under her bottom on the seat of the chair. The Hoyer sling straps were noted to be hanging down on the left side at the level of the wheels. In an interview on 12/20/13 at 10:17 a.m., ADON A said the former DON had been responsible for training nursing staff, including Hoyer lift use. ADON A said she was now responsible for Hoyer training. ADON A said no documentation on Hoyer lift training existed. An Immediate Jeopardy (IJ) was identified and on 12/18/13 at 6:04 p.m., the Administrator and DON were informed. The facility's Plan of Removal of Immediate Jeopardy was accepted 12/20/13 at 11:30 a.m. and included: "... 1) In-service on proper placement of cling belt straps, O2 tubing (oxygen), resident catheters or any other loose straps while resident is in wheelchair started on 12/18/13. 2) In-service with Hospice provider regarding safe placement of sling straps, O2 tubing, or any other loose straps while resident in wheelchair started 12/19/13. 3) DON (name) will be responsible to ensure all staff are in serviced on sling straps belts, O2 tubing, resident catheters, or any other loose straps while resident is in wheelchair before they are allowed to work the floor. DON will be responsible to ensure all Hospice providers receive in-service on proper placement of cling strap, O2 tubing, resident catheters, or any other loose straps while resident is in their wheelchair prior to allowing them to work with residents. 4) Administrator (name) will monitor this training to ensure all employees and hospice Providers receive in-service on proper placement of sling straps, O2 tubing, resident catheters or any other loose straps while resident is in their wheelchair before being allowed to work with residents. 5) Administrator (name) and DON (name) will discuss progress of in servicing on a daily basis until all signatures are received from employees and Hospice Providers. In addition to this discussion all new hires will receive in-service on proper placement of sling belt straps, O2 tubing, resident catheters or any other loose straps while resident is in their wheelchair. Employees who have not signed in-service will not be allowed to work the floor. 6) Facility documented Qhr (every one hour) checks beginning 12/19/13. This check was to monitor for proper placement of sling straps, O2 tubing, resident catheters or any other loose straps while resident was in their wheelchair. 7) Facility will continue to monitor safety for residents in wheelchairs, Geri-chairs or walkers be checking each resident every 2 hours and initialing form that wheel area is clear of any hazards that could get tangled in wheel causing a resident to fall, this will include (Hoyer sling straps, O2 tubing, resident catheters, purse, etc.) (Monitoring forms were provided.) 8) Nursing administration (names) began inservice 12/19/13 on Safe Transfer from Hoyer Lift from Bed to Chair as well as how to safely tuck Hoyer sling straps. 9) Return demonstrations on transfers initiated 12/19/13 for all licensed staff. 10) Manufacturing Guidelines for Hoyer Lift and Slings provided 12/20/13. 11) (Resident #1's name) power wheelchair manual was provided as well as statement from Rehab Director on new chair training that was provided ... All measures of the Plan of Removal will be completed on 12/20/13..." Observation on 12/19/13 at 11:27 a.m. revealed CNA's A and D transfered Resident #4 from a recliner to her wheelchair. The Hoyer sling was under her. After the transfer, the CNA's put the Hoyer sling straps under Resident #4. Observations of resident transfers to wheelchairs utilizing the Hoyer lift on 12/20/13 revealed staff put the Hoyer sling straps behind the residents after the transfer. No Hoyer sling straps were noted to be hanging down on the sides of the wheelchairs. Interviews with facility staff on 12/20/13 revealed all staff had been in-serviced on proper placement of Hoyer sling straps. On 12/20/12 at 11:30 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. The facility provided a list of five residents transferred via the Hoyer lift.

Based on record reviews and interviews, it was determined that the facility failed to ensure residents received adequate fluid to maintain adequate health and prevent infection. This failure affected one (Resident ID #2) of 2 residents evaluated for dehydration risk and recent hospitalization s. The facility failed to: A) monitor Resident #2's fluid intake and output while the resident had a catheter from 05/02/13 until it was removed on 05/08/13, B) monitor Resident #2's fluid intake and output after the catheter was removed from 05/08/13 through 06/01/13 (the date the resident was hospitalized with a [DIAGNOSES REDACTED]. C) assess Resident #2's fluid needs since admission and dehydration risk as care planned (until 05/26/13) and, D) failed to follow the facility's current policy for I&O monitoring for a resident with a foley catheter. As a result of this failure, Resident #2 experienced a lack of fluid monitoring which was needed to ensure adequate oral intake and urinary output and was subsequently admitted to ICU with urosepsis. The facility currently had 52 of 91 residents at risk of dehydration (at varying degrees), but no other resident outcomes had been experienced. There was no other facility resident (except for Resident #2) identified to be hospitalized with urosepsis or any other condition due to a lack of fluid monitoring. The findings included: 1. Review of the current clinical record (admission face sheet) for totally dependent Resident #2 revealed she had been originally admitted to the facility on [DATE] and was currently [AGE] years of age. (The resident was currently in a local hospital). Admission [DIAGNOSES REDACTED]. The resident had also been admitted with several pressure sore areas and a foley catheter (drains the urinary bladder) in place for a [MEDICAL CONDITION] bladder (a bladder that does not function and empty well due to a lack of muscle tone). Further review of Resident #2's record revealed the resident had been readmitted to the facility on [DATE] after surgery (left above the knee amputation) and hospitalizatiion which began around 04/11/13. The resident had been readmitted to the facility on [DATE] with a foley catheter. Review of physician orders [REDACTED]. 2. Further review of Resident #2's current clinical record revealed the resident had a care plan developed dated 03/21/13 that documented the resident had a potential to develop dehydration due to cognitive impairment related to dementia. The goal of this care plan documented the resident would be well hydrated for the next 90 days (and consequently urine output would be adequate). The approaches listed to reach this goal was to do a hydration risk assessment per protocol and monitor I&O if ordered and document. Review of the facility's policy for I&O measurement -effective date unknown-revealed all residents with indwelling catheters to be monitored for a minimum of the first 30 days..., it did not address how a resident's output was to be monitored after removal of a foley catheter to ensure adequate output. Review of the clinical record revealed Resident #2 had never been assessed for dehydration risk and the resident's daily fluid needs had never been calculated by any of the facility's dietary or nursing staff. In an interview with the facility DON on 06/05/13 at 2:50 p.m. it was revealed that he agreed with these findings and on 05/26/13 he realized no assessments had been done for any resident concerning dehydration risk, so he did one for Resident #2 and most of the other residents on 05/26/13. 3. Review of the I&O record for Resident #2 from 05/02/13 through 05/08/13 (the resident had a foley catheter in place to measure output) revealed multiple shifts left blank on urinary/catheter output and no 24 hour totals. The same was true for the resident's oral fluid intake during the same time period (multiple shifts left blank and no 24 hour totals). Review of the I&O record from 05/09/13 through 05/26/13 (that was as far as the record went) also revealed multiple shift blanks for oral fluid intake and no 24 hour totals and multiple shift blanks for numbers of times voided/urinated and no 24 hour totals. This made it impossible to determine if Resident #2 had been adequately hydrated and monitored for adequate urinary output. Further review of Resident #2's current clinical record revealed she had a sudden change in her mental status the morning of 06/01/13 and so was sent to a local hospital for further evaluation. The resident was seen in the emergency department and hospitalized . 4. In an interview done via telephone on 06/04/13 at 4:00 p.m. with an emergency department nurse who catheterized Resident #2 upon arrival to a local hospital on [DATE], it was revealed that the nurse immediately obtained 700 cc's of urine loaded with blood and pus and the resident had a rectal temperature of 105 degrees Fahrenheit. The nurse also stated Resident #2 had been admitted to ICU with severe urosepsis. Review of the hospital history and physical dated 06/01/13 done by the resident's attending physician revealed "patient noted to have significant pyuria. The patient was felt to be septic from urinary source." "Impression: 1. [MEDICAL CONDITION] from urinary source, present on admission". (Pyuria is pus in the urine). 5. In an interview with the facility DON in the facility on 06/05/13 at 5:22 p.m. , it was revealed that when he had assessed residents for dehydration risk on 05/26/13 it was discovered that there were currently 52 of 91 residents in the facility at risk for dehydration (at differing levels) but he had not yet had time to develop care plans for these residents for the prevention of such.

Based on observation, record review and interview it was determined the administration failed to administer the facility in a manner that enabled the facility to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 6 residents (#2, #6, #7, #8, #9, and #10) of 12 residents reviewed for smoking safety and supervision to prevent accidents. 1) The administrator failed to ensure staff supervised residents and failed to provide appropriate safety devices to protect Resident #6 from cigarette [MEDICAL CONDITION] his clothing and Ace bandage wrap to his left arm. 2) The administrator failed to put into place effective facility fire safety precautions when Resident #2 was observed with his cigarette and lighter at his bedside, following incidents in which he was found smoking in his room. 3) The administration failed to provide an adequate staff supervision to ensure Resident's (#2, #6, #7, #8, #9, and #10) were assessed for smoking safety each quarter per facility policy and care plans were updated in regards to residents smoking safety needs. 4) The administrator failed to implement the facility policy's and procedures regarding resident smoking supervision and safety devices. This deficient practice resulted in an Immediate Jeopardy (IJ) on 10/19/12. While the IJ was removed on 10/20/12, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern because the facility did not have time to monitor the Plan of Removal for effectiveness or to train all staff. These deficient practices had the potential to place 6 residents identified by the facility as unsupervised smokers at risk for cigarette related burns, fires and/or death. The findings included: Resident #6 During an observation on 10/18/12 at 9:30 a.m. Resident #6 was observed sitting in his wheelchair on the walkway in front of the facility. The resident was observed to be bent at the waist, with his chest resting on his thighs. The resident's head was observed hanging over his knees and the resident had his eyes closed. Resident #6 was observed to have two lit cigarettes in his right hand. The resident's hand and lit cigarettes were observed dangling near the residents right pants leg. No staff was observed outside the facility, supervising the resident. (No smoking safety apron or positioning safety devices were observed.) Review of Resident #6's Face Sheet indicated the resident was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #6, a male, was [AGE] years old at the time of the investigation. Review of Resident #6's Social Service Update dated 4/07/11 indicated the social worker had discussed the smoking policy with Resident #6 and his mother regarding the resident not having a lighter in his possession and the resident requiring supervised smoking. Review of the facility's Policy and Procedure; Smoking Policy- Residents dated as revised April 2006 indicated the following: --Ashtrays- Metal containers with self closing cover devices shall be available in all smoking areas. -- Smoking Restrictions- 1) The attending Physician and Director of Nursing shall have the authority to make the determination as to which residents are responsible and non-responsible, prior to or upon admission, and what restrictions, if any, will need to be placed on the residents smoking privileges. 2) Any restrictions placed on smoking privileges shall be noted on the care plan so all personnel may be alert to smoking restrictions. 3) Should a resident, who has been classified as a responsible person, be at a later date reclassified as a non-responsible person, the requirements as outlined above shall apply. -- Review of Smoking Restriction- 1) Smoking restrictions concerning the classification of residents as responsible and non-responsible shall be made at least quarterly by the Director of Nursing Services, Attending Physician, and/or Care Planning Team. 2) Reclassification deemed necessary for the safety and well-being of the resident may be made at any time by the attending Physician and/or Director of Nursing Services. --Smoking Articles- 1) Residents who have been classified as responsible shall be permitted to retain cigarettes, pipes, tobacco, and other smoking articles within their possession. 2) Smoking shall not be permitted in bed at any time, unless under direct supervision. 3) Residents classified as non-responsible shall not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc. either on his or her person or within his/her living or sleeping area, at any time other than when the resident is under direct supervision. --Purchasing of Smoking Articles for Residents- 1) Only those articles, as approved within these policies, shall be permitted and only those residents classified as responsible shall be permitted to retain such smoking articles. 2) Resident's classified as non-responsible shall not be permitted to retain any type of smoking articles on his/her person or within the resident living or sleeping areas. All such articles must be left with the on-duty charge nurse. Review of Resident #6's quarterly Minimum (MDS) data set [DATE] indicated the following: Resident #6 was identified to require physical assistance of one person for bed mobility, transfers, dressing and bathing. Resident #6 was identified with functional range of motion limitation for one side of his upper extremities and both sides of his lower extremities. Review of Resident #6's clinical record indicated no documented quarterly smoking review or any care planning with regards to the resident smoking safety needs. During an interview on 10/19/12 at 3:42 p.m. the ADON confirmed Resident #6 had not had a smoking assessment for his safety. Review of Resident #6's Nurses Notes dated 9/11/12 at 11:25 p.m. indicated the following, Resident #6 came up to the nurses desk and stated ' I am going out to smoke without a babysitter whether you or the administrator likes it. I'm tired of being babysat on my smoke breaks and you can report me to whomever you want.' According to the note LVN G documented; Resident #6 had the tendency to fall asleep while smoking outside therefore may cause self-harm and is in need of supervision. At that time all aides were making rounds and the other nurse was busy, therefore the staff was unable to go out to supervise the resident to smoke. LVN G advised the patient the last smoke break for the day was 10:30 p.m. and he replied, he didn't care and was going out anyway. During an interview on 10/19/12 at 1:30 p.m. a confidential resident said he/she was aware that Resident #6 was not supposed to be outside smoking unsupervised. He/she said Resident #6 would frequently "sneak" outside to smoke in front of the building, and would also go to the designated smoking area during designated smoke breaks in order to double his smoke times. He/she said he/she felt the alert residents had to watch Resident #6 when he smoked outside in front of the building due to his condition in which he would lay his torso on top of his thighs, hang his head over his knees and fall asleep while smoking his cigarettes. He/she said there had been occasions in which the staff had been unavailable to supervise Resident #6 when he smoked in front of the building and had asked alert residents to watch the resident. During an observation on 10/19/12 at 2:50 p.m. Resident #6 was observed sitting in his wheelchair near the nurse desk wearing a long sleeve orange shirt. The shirt was observed to have multiple burn holes in the left sleeve. During an interview/observation in Resident #6's room on 10/19/12 at 3:35 p.m. LVN F was observed to inspect Resident #6's long sleeved hooded jacket and one of the residents long sleeved blue sweatshirts. While inspecting the residents clothing, LVN F said she identified two burn holes in the hood of the residents jacket, four burn holes in the left sleeve of the residents jacket and one burn hole in the left arm of the residents sweatshirt. She said she felt her findings were "alarming" due to the resident having burn holes in the hood of his jacket. She said one of the burn holes in the resident ' s jacket had burned through the fabric and melted the jackets inner lining. She said Resident #6 usually went to the smoking area during designated smoking times; however she had found him out in front of the building smoking on multiple occasions and had to redirect him back in due to not being supervised. During an interview on 10/19/12 at 10:32 a.m. Resident #9 said Resident #6 smoked two cigarettes at one time and often dropped them on the ground while smoking unsupervised on the front porch. She said she had never been asked by staff to watch Resident #6 but she heard another resident had been asked by staff to watch the resident. During an observation of a smoke break on the back patio of the facility on 10/20/12 at 11:30 a.m. Resident #6 was observed smoking two cigarettes at one time. The staff and DON had to redirect the resident multiple times to sit up straight. Resident #6 was observed to have multiple burn holes in an Ace bandage wrapped on his left arm. During an interview on 10/20/12 at 11:50 a.m. the Maintenance Director said he could not definitely say; however he thought the holes in Resident #6's Ace bandage wrap were burn holes. He said he felt Resident #6 presented a safety hazard due to the way the resident sits bent over. He said the resident smoked two to three cigarettes at one time. He said he had observed the resident fall asleep and drop his cigarettes three times during the morning smoke break. He said the staff had to continuously ask Resident #6 to sit up while he was smoking. During an observation on the back patio of the facility on 10/22/12 at 11:53 a.m. Resident #6 was smoking two cigarettes at the time. The resident was wearing a smoking apron and a large amount of ashes were on the apron. The Maintenance Director removed the resident's apron after he finished his cigarettes and told the resident it was a good thing he had the apron on because all of the ashes would have been in his lap. During an interview on 10/22/12 at 11:19 a.m. LVN G said she had reported concerns with Resident #6 to the ADON regarding the resident's non-compliance with smoking while supervised. She said she had known Resident #6 to sneak outside for a cigarette when the staff was busy with other residents. She said she had attempted on multiple occasions to encourage Resident #6 to wait until staff was available to supervise him; however she said the resident would not listen. She said Resident #6 could not go outside without supervision due to being a safety risk. She said she was fearful the resident was going to sneak outside to smoke a cigarette, fall asleep and catch himself on fire. She said she had not asked any of the alert residents to watch Resident #6 while outside smoking; however she was aware of other staff members doing so. She said she had redirected the staff members due to feeling it was not the other residents responsibility to watch Resident #6. During an observation/ interview in Resident #6's room on 10/22/12 at 11:10 a.m. LVN B was observed to inspect Resident #6's long sleeved plaid hooded jacket. LVN B said the holes in the resident's hood and left arm sleeve were burn holes. She said she felt Resident #6 had a tendency to bend and fall asleep while smoking and was not aware of his own safety needs. During an interview on 10/22/12 at 11:56 a.m. CNA H said sometimes she was available to go out and watch the residents smoke and sometimes she wasn't. She said Resident #6 worried her due to the way he bends over in his wheelchair and falls asleep while smoking. She said she had reported her concerns to the charge nurses on multiple occasions and they would disregard her concerns and say they had already informed the resident to sit up. She said there had been times when she had reported to the charge nurse that Resident #6 had gone outside the front entrance to smoke unsupervised and had been told by the charge nurse the resident could be seen out the window from the nursing desk. She said there had been instances when she had told alert residents to help the staff watch Resident #6 due to him wanting to stay out for 30 minutes at a time to smoke. She said Resident #6 was very difficult to redirect and felt he had no self-awareness regarding his safety while smoking. Resident #2 Resident #2's admission MDS dated [DATE] indicated the male resident was admitted to the facility on [DATE] from the hospital. The resident had short-term and long-term memory problems. The resident was moderately impaired-decisions poor; cues/supervision required. The resident had signs and symptoms of [MEDICAL CONDITION] which included inattention and disorganized thinking. The resident had signs and symptoms of [MEDICAL CONDITION] which included [MEDICAL CONDITION]. The resident had behavioral symptoms which interfered with his care and the resident rejected care 4 to 6 days during the assessment period. The resident required limited assistance of one person for transfers, toilet use and dressing. The resident required extensive assistance of one person for bathing and personal hygiene. The resident was not ambulatory. The resident's [DIAGNOSES REDACTED]. The resident was [AGE] years old at the time of this survey. Resident #2's Skilled Daily Nurses Note dated 6/03/12 indicated the resident was alert in bed and awake. The smell of smoke was coming from the resident's room. A cup full with water and 3 cigarette butts and ashes were noted on the floor bedside the resident's bed. The nurse explained to the resident that smoking was not allowed in the building and the resident told the nurse "you need to provide a facility you can smoke in just as much as you want". The nurse explained the city ordinance regarding healthcare facilities and the resident looked at the television and ignored the nurse. The nurse asked for the resident's cigarettes and the resident continually ignored the nurse. The Administrator was contacted and he advised the nurse to inform the resident if he was caught smoking again he could possibly be discharged from the facility. The Administrator informed the nurse to continue to monitor and ask the resident to relinquish his lighter but if the resident was not co-operative just continue to monitor for smoke. The Administrator informed the nurse to call him back if smoke was noted coming out of the resident's room again. The nurse informed the resident of the information and the resident refused to relinquish his lighter by saying, "nope". Resident #2's Social Services Progress Notes indicated on 6/04/12 the social worker received a referral that the resident was smoking in his room over the weekend (6/03/12). The social worker spoke to the resident and he did not deny that he was smoking in his room. The resident told the social worker he understood the smoking policy. The social worker documented she would provide the resident a copy of the smoking policy and conduct a smoking assessment. Resident #2's Resident Smoking assessment dated [DATE], completed by the social worker, indicated the resident was oriented to person, time and place, able to demonstrate dexterity to manage small objects with both hands, able to hold a cigarette without dropping it, aware of the facility smoking policy, accepted the responsibility to refrain from smoking in bed, agreed to hold the facility harmless for injuries, damage, or accidents caused by smoking activities, able to verbalize the request for smoking materials, able to inform family to purchase additional smoking materials, able to verbalize location of designated smoking areas and a signed "Smoking Disclosure" was on file. The assessment indicated resident did not have a signed doctor's order permitting smoking. Review of Resident #2's clinical record indicated a signed Smoking Disclosure dated 6/05/12. Review of the facility Smoking Disclosure indicated the following: The facility is committed to quality care of all residents. In an effort to provide optimal care, it is necessary to build a partnership between physicians, family members and facility staff to best serves the resident. In that endeavor, family involvement in the treatments, interventions and approaches is an integral part of the over-all approach. The resident's desire to smoke may present hazardous conditions to the resident, staff and visitors. Examples:[MEDICAL CONDITION] clothing, [MEDICAL CONDITION] self,[MEDICAL CONDITION] property, and respiratory disorders. There was no care plan in the resident's clinical record regarding his smoking regimen or smoking precautions and no documentation the resident's physician was notified regarding the resident smoking in bed on 6/03/12. Resident #2's psychiatric assessment dated [DATE] indicated the resident had cognitive impairments and was oriented to person only. The resident had a depressed mood with decreased energy and motivation. The resident's insight and judgment was impaired. Resident #2's Nurses Notes dated 7/20/12 indicated the resident was found smoking while in bed by a CNA. The resident was observed putting out a cigarette in a cup of juice next to his bed. The nurse notified the DON and then went to the resident's room to remind him of the importance of not smoking in the facility due to residents on oxygen and the city ordinance. The nurse asked the resident for his personal lighter that was on his bedside table and the nurse placed the lighter on the nurses' cart. The nurse informed the resident that he needed to go smoke outside and to let the staff know and they could give him his lighter. Review of Resident #2's clinical record indicated the resident's ability to smoke safely was not re-assessed to determine the level of supervision he required and there was no care plan regarding the resident's smoking regimen or documentation the physician was consulted regarding the resident smoking in bed on 7/20/12. Resident #2's quarterly MDS dated [DATE] indicated the resident scored a 6 on his Brief Interview for Mental Status. A score of 0-7 indicated severe cognitive impairment. During a telephone interview on 10/19/12 at 8:35 a.m. Resident #2's physician said he was not informed the resident was observed smoking in his room on 6/03/12 or 7/20/12. During observation and interview on 10/19/12 at 12:15 p.m. Resident #2 was observed in bed resting. The resident's cigarettes and lighter were sitting on the resident's bedside dresser within reach of the resident. The resident said he had smoked in his room, but the staff told him he would be kicked out of the facility if he did it again. During an interview on 10/19/12 at 12:18 p.m. the Administrator said he was aware Resident #2 had been observed smoking in his room on 6/03/12 and 7/20/12. He said he was aware the resident had his cigarettes and lighter in his room. He said the resident had not smoked in his room since 7/20/12 and it was okay for the resident to have his cigarettes and lighter. During an observation on 10/19/12 at 12:40 p.m. Resident #2 was observed resting in his bed. The resident's cigarettes and a lighter were observed sitting on the resident's bedside dresser within reach of the resident. The Administrator was observed in the resident's room visiting with him. During an interview on 10/19/12 at 12:45 p.m. the Administrator said Resident #2 had been assessed regarding his smoking safety after he was found smoking in his room on 6/05/12; however the resident had not been re-assessed regarding his smoking safety on 7/20/12. He said the resident had not smoked in his room since 7/20/12 but he removed the resident's cigarettes and lighter from the resident's room today after his discussion with the resident. Immediate Jeopardy Identified On 10/19/12 at 12:45 p.m. the Administrator and Director of Nursing were informed an Immediate Jeopardy had been identified. A list received from the administrator on 10/19/12 at 1:45 p.m. indicated the facility had identified 12 residents who smoked, 5 residents on the list were identified as requiring supervised smoke breaks. Resident's #2, #6, #7, #8,#9 and #10 were identified on the list to be unsupervised independent smokers. During an interview on 10/19/12 at 2:00 p.m. the ADON said Resident #2's smoking regimen and smoking safety had not ever been care planned. Resident #2's Skilled Daily Nurses Note dated 10/19/12 indicated the resident was sent to the emergency room and admitted to the hospital for evaluation and treatment due to nausea, vomiting, fever, elevated pulse and low blood pressure. Resident #10 Resident #10's quarterly MDS dated [DATE] indicated the female resident was admitted to the facility on [DATE]. The resident scored a 15 on her Brief Interview for Mental Status. A score of 12-15 indicated the resident was cognitively intact. The resident was independent for ambulation and activities of daily living. The resident's [DIAGNOSES REDACTED]. The resident was [AGE] years old at the time of this survey. Resident #10's Nurse's Notes dated 5/09/12 indicated the resident no longer presented with wander seeking behavior and did not express a desire to leave the facility un-attended. The resident was moved from the locked dementia unit to the main building. Resident #10's Nurse's Notes dated 5/12/12 the resident was upset and demanding to be allowed to go to the store to get cigarettes. The resident was re-directed but remained upset. The resident returned to the nurses' station and said she found half a pack of cigarettes in her stuff. The resident refused to allow staff to secure her cigarettes and said she could go smoke herself. The nurse documented the resident would be monitored closely. Resident #10's Social Services Progress Notes indicated: --on 7/13/12 the resident was smoking outside the front door and the social worker asked the resident to move to the smoking area. The social worker documented the resident wanted to argue about smoking anywhere she wanted and finally moved. --7/21/12 the resident was smoking outside the nursing home door where smoking was not allowed. The social worker asked her to move or put out her cigarette and the resident continued to smoke. The social worker reminded the resident of the city smoking law and the facility's policy but the resident continued smoking. Review of Resident #10's clinical record indicated no documentation of quarterly smoking assessments per facility policy or care planning with regards to the resident smoking safety needs. No documented smoking disclosure was located. During an observation on 10/18/12 at 6:00 a.m. Resident #10 was alone on the front porch smoking. Resident #10's Nurses Notes dated 10/22/12 at 5:20 a.m.indicated the resident went outside around 4:45 a.m. and was sitting on the front porch, around 5:20 a.m. a staff member from the other nursing home facility (located several feet away) called and said the resident was at their facility smoking. During an interview on 10/22/12 at 11:10 a.m. the Administrator said he was not aware Resident #10 was at the other facility this morning smoking. He said a smoking assessment should have been completed on the resident and in her clinical record. During an interview on 10/22/12 at 11:20 a.m. the ADON said she was aware Resident #10 was seen over at the other facility smoking. She said she was not sure how the resident got cigarettes. She said no smoking assessment or care plan was completed for Resident #10. During an interview on 10/22/12 at 12:48 p.m. the Administrator said the smoking assessments should have been completed on residents who smoked independently and it had been the former social worker's responsibility to conduct the assessments. He said there had been issues with the social worker getting all of her assessments done and her last date of employment was 9/12/12. He said the new social worker started today (10/22/12). Resident #7 Resident #7's quarterly MDS dated [DATE] indicated the male resident was admitted to the facility on [DATE]. The resident had short-term and long-term memory problems. The resident was moderately impaired-decisions poor; cues/supervision required. The resident had signs/symptoms of [MEDICAL CONDITION] which included inattention and disorganized thinking which were continuous and did not fluctuate. The resident was independent for ambulation and activities of daily living. The resident's [DIAGNOSES REDACTED]. The resident was [AGE] years old at the time of this survey. The facility's Smoking Disclosure was signed by Resident #7 and dated 12/09/09. Review of Resident #7's Resident Smoking assessment dated [DATE], completed by the social worker, indicated the resident was not oriented to person, time and place, the resident was able to demonstrate dexterity to manage small objects with both hands, able to hold a cigarette without dropping it, aware of the facility smoking policy, accepted the responsibility to refrain from smoking in bed, agreed to hold the facility harmless for injuries, damage, or accidents caused by smoking activities, able to verbalize the request for smoking materials, able to inform family to purchase additional smoking materials, able to verbalize location of designated smoking areas and a signed "Smoking Disclosure" was on file. According to this assessment, the resident's smoking regimen was included in the care plan. The assessment indicated resident did not have a signed doctor's order permitting smoking. Resident #7's Smoking Care Plan dated 8/22/12 indicated the resident had the potential for injury related to smoking. The goal was for the resident to remain free of injury related to smoking for the next 90 days. The interventions included social services to complete a smoking assessment to determine safety and all smoking material will be kept in the medication room and cigarettes will be distributed by the nurses. During an interview on 10/19/12 at 3:42 p.m. the ADON said Resident #7's smoking assessment had not been updated since 1/26/10. During an interview on 10/19/12 at 3:44 p.m. the Activity Director said Resident #7 had a personal lighter and smoked on the front porch un-supervised. She said the resident often smoked cigarette butts he found in the trash. She said the resident's lighter was now locked up as of today (10/19/12). Resident #8 Review of Resident # 8's Face Sheet indicated the resident was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #8, a female, was [AGE] years old at the time of the investigation. Review of Resident #8's quarterly Minimum (MDS) data set [DATE] indicated Resident #8 was identified as being independent for bed mobility, transfers, locomotion on an off the unit, dressing, toileting and personal hygiene. Resident #8 had no functional range of motion limitations. Resident #8 was continent of bowel and bladder. Review of Resident # 8's Resident Smoking assessment dated [DATE] indicated the resident was identified with the following; Oriented to person, time and place, Demonstrate dexterity to manage small objects with both hands, Able to hold a cigarette without dropping it, Aware of the facility smoking policy, accepts the responsibility to refrain from smoking in bed, Agrees to hold the facility harmless for injuries, damage, or accidents caused by smoking activities, Able to store smoking materials to prevent access by other residents, Able to verbalize the request for smoking materials, Able to inform family to purchase additional smoking materials, Able to verbalize location of designated smoking areas, Resident smoking regimen is included in the care plan, and a signed Smoking Disclosure is on file. Review of Resident #8's Smoking Disclosure dated 1/26/10 indicated the resident signed the disclosure on 2/08/10. Review of Resident #8's clinical record indicated no documentation of quarterly smoking assessments per facility policy or care planning with regards to the resident smoking safety needs. During an observation on 10/18/12 at 8:35 a.m. Resident #8 was smoking independently on the front porch. Resident #9 Review of Resident #9's Face Sheet indicated the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #9, a female, was [AGE] years old at the time of the investigation. Review of Resident #9's quarterly Minimum (MDS) data set [DATE] indicated Resident #9 was identified as being independent for bed mobility, transfers, locomotion on an off the unit, dressing, toileting and personal hygiene. Resident #9 had no functional range of motion limitations. Resident #9 was continent of bowel and bladder. Review of Resident # 9's Resident Smoking assessment dated [DATE] indicated the resident was identified with the following; Oriented to person, time and place, Demonstrate dexterity to manage small objects with both hands, Able to hold a cigarette without dropping it, Aware of the facility smoking policy, accepts the responsibility to refrain from smoking in bed, Agrees to hold the facility harmless for injuries, damage, or accidents caused by smoking activities, Able to store smoking materials to prevent access by other residents, Able to verbalize the request for smoking materials, Able to inform family to purchase additional smoking materials, Able to verbalize location of designated smoking areas, and A signed Smoking Disclosure is on file. Review of Resident #9's clinical record indicated no documentation of quarterly smoking assessments per facility policy or care planning with regards to the resident smoking safety needs. No documented smoking disclosure was located. During an observation on 10/18/12 at 9:24 a.m. Resident #9 was smoking independently on the front porch. Plan to Lift Immediate Jeopardy On 10/19/12 at 4:52 p.m. the facility provided a Plan to Lift Immediate Jeopardy. Review of this plan indicated the facility planned to: 1) Identify all residents who smoke. 2) Interview all identified residents who smoke. 3) Have identified residents who smoke volunteer (relinquished) all smoking paraphernalia. ( Resident's #2, #6, #7, #8, #9, and #10 were noted to have volunteered their smoking paraphernalia) 4) Label and place all resident's smoking paraphernalia and place in the facility's "smoking box" to keep in the facility's possession. 5) Assess all identified residents who smoke for safety during smoking. The following care plan updates were made as a result of these assessments: 1) Resident #6 will be reminded to sit upright and will be required to wear a smoking apron. To remedy concerns regarding unsafe smoking practices the facility implemented changes to the smoking policy. Those changes are as follows: 1) All residents, regardless of cognitive status or physical function will be supervised when smoking to ensure safety for the facility as a whole. 2) A single designated resident smoking area will be established on the back patio. A fire extinguisher has been installed in this area. 3) The facility will maintain its current smoking schedule at the following times: 6:30 a.m.-with Laundry staff supervision, 8:30 a.m. - with Activity staff supervision, 10:30 a.m.- with Kitchen staff supervision, 11:30 a.m. - with Housekeeping staff supervision, 1:30 p.m. - with Activity staff supervision, 3:30 p.m. - with Kitchen staff supervision, 4:30 p.m. - with Medication Aide supervision, 6:30 p.m. - with Nursing staff supervision, 8:30 p.m. - with Nursing staff supervision, 10:30 p.m. - with Nursing staff supervision. 4) a zero tolerance clause will be implemented. Any resident who viola

Based on observation, interview and record review the facility failed to ensure 6 residents (#2, #6, #7, #8, #9, and #10) of 12 residents reviewed for smoking safety received adequate supervision and safety devices to prevent accidents. The facility failed to: 1) ensure appropriate supervision and safety devices were in place to protect Resident #6 from cigarette related burns to his clothing and Ace bandage wrap to his left arm. 2) ensure appropriate facility fire safety precautions were in place when Resident #2 had access to his cigarette and lighter at his bedside, following incidents in which he was found smoking in his room. 3) ensure Resident's (#2, #6, #7, #8, #9, and #10) were reviewed for smoking safety each quarter per facility policy and had appropriate and individualized care plans regarding the residents smoking safety needs. This deficient practice resulted in an Immediate Jeopardy (IJ) on 10/19/12. While the IJ was removed on 10/20/12, the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a Scope of Pattern related to continued need by the facility to monitor their plan for effectiveness. These failures had the potential to place 6 residents identified by the facility as unsupervised smokers at risk for cigarette related burns, fires and/or death. The findings included: Resident #6 During an observation on 10/18/12 at 9:30 a.m. Resident #6 was observed sitting in his wheelchair on the walkway in front of the facility. The resident was observed to be bent at the waist, with his chest resting on his thighs. The resident's head was observed hanging over his knees and the resident had his eyes closed. Resident #6 was observed to have two lit cigarettes in his right hand. The resident's hand and lit cigarettes were observed dangling near the residents right pants leg. No staff was observed outside the facility, supervising the resident. (No smoking safety apron or positioning safety devices were observed.) Review of Resident #6's Face Sheet indicated the resident was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #6, a male, was [AGE] years old at the time of the investigation. Review of Resident #6's Social Service Update dated 4/07/11 indicated the social worker had discussed the smoking policy with Resident #6 and his mother regarding the resident not having a lighter in his possession and the resident requiring supervised smoking. Review of the facility's Policy and Procedure; Smoking Policy- Residents dated as revised April 2006 indicated the following: --Ashtrays- Metal containers with self closing cover devices shall be available in all smoking areas. -- Smoking Restrictions- 1) The attending Physician and Director of Nursing shall have the authority to make the determination as to which residents are responsible and non-responsible, prior to or upon admission, and what restrictions, if any, will need to be placed on the residents smoking privileges. 2) Any restrictions placed on smoking privileges shall be noted on the care plan so all personnel may be alert to smoking restrictions. 3) Should a resident, who has been classified as a responsible person, be at a later date reclassified as a non-responsible person, the requirements as outlined above shall apply. -- Review of Smoking Restriction- 1) Smoking restrictions concerning the classification of residents as responsible and non-responsible shall be made at least quarterly by the Director of Nursing Services, Attending Physician, and/or Care Planning Team. 2) Reclassification deemed necessary for the safety and well-being of the resident may be made at any time by the attending Physician and/or Director of Nursing Services. --Smoking Articles- 1) Residents who have been classified as responsible shall be permitted to retain cigarettes, pipes, tobacco, and other smoking articles within their possession. 2) Smoking shall not be permitted in bed at any time, unless under direct supervision. 3) Residents classified as non-responsible shall not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc. either on his or her person or within his/her living or sleeping area, at any time other than when the resident is under direct supervision. --Purchasing of Smoking Articles for Residents- 1) Only those articles, as approved within these policies, shall be permitted and only those residents classified as responsible shall be permitted to retain such smoking articles. 2) Resident's classified as non-responsible shall not be permitted to retain any type of smoking articles on his/her person or within the resident living or sleeping areas. All such articles must be left with the on-duty charge nurse. Review of Resident #6's quarterly Minimum (MDS) data set [DATE] indicated the following: Resident #6 was identified to require physical assistance of one person for bed mobility, transfers, dressing and bathing. Resident #6 was identified with functional range of motion limitation for one side of his upper extremities and both sides of his lower extremities. Review of Resident #6's clinical record indicated no documented quarterly smoking review or any care planning with regards to the resident smoking safety needs. During an interview on 10/19/12 at 3:42 p.m. the ADON confirmed Resident #6 had not had a smoking assessment for his safety. Review of Resident #6's Nurses Notes dated 9/11/12 at 11:25 p.m. indicated the following, Resident #6 came up to the nurses desk and stated ' I am going out to smoke without a babysitter whether you or the administrator likes it. I'm tired of being babysat on my smoke breaks and you can report me to whomever you want.' According to the note LVN G documented; Resident #6 had the tendency to fall asleep while smoking outside therefore may cause self-harm and is in need of supervision. At that time all aides were making rounds and the other nurse was busy, therefore the staff was unable to go out to supervise the resident to smoke. LVN G advised the patient the last smoke break for the day was 10:30 p.m. and he replied, he didn't care and was going out anyway. During an interview on 10/19/12 at 1:30 p.m. a confidential resident said he/she was aware that Resident #6 was not supposed to be outside smoking unsupervised. He/she said Resident #6 would frequently "sneak" outside to smoke in front of the building, and would also go to the designated smoking area during designated smoke breaks in order to double his smoke times. He/she said he/she felt the alert residents had to watch Resident #6 when he smoked outside in front of the building due to his condition in which he would lay his torso on top of his thighs, hang his head over his knees and fall asleep while smoking his cigarettes. He/she said there had been occasions in which the staff had been unavailable to supervise Resident #6 when he smoked in front of the building and had asked alert residents to watch the resident. During an observation on 10/19/12 at 2:50 p.m. Resident #6 was observed sitting in his wheelchair near the nurse desk wearing a long sleeve orange shirt. The shirt was observed to have multiple burn holes in the left sleeve. During an interview/observation in Resident #6's room on 10/19/12 at 3:35 p.m. LVN F was observed to inspect Resident #6's long sleeved hooded jacket and one of the residents long sleeved blue sweatshirts. While inspecting the residents clothing, LVN F said she identified two burn holes in the hood of the residents jacket, four burn holes in the left sleeve of the residents jacket and one burn hole in the left arm of the residents sweatshirt. She said she felt her findings were "alarming" due to the resident having burn holes in the hood of his jacket. She said one of the burn holes in the resident ' s jacket had burned through the fabric and melted the jackets inner lining. She said Resident #6 usually went to the smoking area during designated smoking times; however she had found him out in front of the building smoking on multiple occasions and had to redirect him back in due to not being supervised. During an interview on 10/19/12 at 10:32 a.m. Resident #9 said Resident #6 smoked two cigarettes at one time and often dropped them on the ground while smoking unsupervised on the front porch. She said she had never been asked by staff to watch Resident #6 but she heard another resident had been asked by staff to watch the resident. During an observation of a smoke break on the back patio of the facility on 10/20/12 at 11:30 a.m. Resident #6 was observed smoking two cigarettes at one time. The staff and DON had to redirect the resident multiple times to sit up straight. Resident #6 was observed to have multiple burn holes in an Ace bandage wrapped on his left arm. During an interview on 10/20/12 at 11:50 a.m. the Maintenance Director said he could not definitely say; however he thought the holes in Resident #6's Ace bandage wrap were burn holes. He said he felt Resident #6 presented a safety hazard due to the way the resident sits bent over. He said the resident smoked two to three cigarettes at one time. He said he had observed the resident fall asleep and drop his cigarettes three times during the morning smoke break. He said the staff had to continuously ask Resident #6 to sit up while he was smoking. During an observation on the back patio of the facility on 10/22/12 at 11:53 a.m. Resident #6 was smoking two cigarettes at the time. The resident was wearing a smoking apron and a large amount of ashes were on the apron. The Maintenance Director removed the resident's apron after he finished his cigarettes and told the resident it was a good thing he had the apron on because all of the ashes would have been in his lap. During an interview on 10/22/12 at 11:19 a.m. LVN G said she had reported concerns with Resident #6 to the ADON regarding the resident's non-compliance with smoking while supervised. She said she had known Resident #6 to sneak outside for a cigarette when the staff was busy with other residents. She said she had attempted on multiple occasions to encourage Resident #6 to wait until staff was available to supervise him; however she said the resident would not listen. She said Resident #6 could not go outside without supervision due to being a safety risk. She said she was fearful the resident was going to sneak outside to smoke a cigarette, fall asleep and catch himself on fire. She said she had not asked any of the alert residents to watch Resident #6 while outside smoking; however she was aware of other staff members doing so. She said she had redirected the staff members due to feeling it was not the other residents responsibility to watch Resident #6. During an observation/ interview in Resident #6's room on 10/22/12 at 11:10 a.m. LVN B was observed to inspect Resident #6's long sleeved plaid hooded jacket. LVN B said the holes in the resident's hood and left arm sleeve were burn holes. She said she felt Resident #6 had a tendency to bend and fall asleep while smoking and was not aware of his own safety needs. During an interview on 10/22/12 at 11:56 a.m. CNA H said sometimes she was available to go out and watch the residents smoke and sometimes she wasn't. She said Resident #6 worried her due to the way he bends over in his wheelchair and falls asleep while smoking. She said she had reported her concerns to the charge nurses on multiple occasions and they would disregard her concerns and say they had already informed the resident to sit up. She said there had been times when she had reported to the charge nurse that Resident #6 had gone outside the front entrance to smoke unsupervised and had been told by the charge nurse the resident could be seen out the window from the nursing desk. She said there had been instances when she had told alert residents to help the staff watch Resident #6 due to him wanting to stay out for 30 minutes at a time to smoke. She said Resident #6 was very difficult to redirect and felt he had no self-awareness regarding his safety while smoking. Resident #2 Resident #2's admission MDS dated [DATE] indicated the male resident was admitted to the facility on [DATE] from the hospital. The resident had short-term and long-term memory problems. The resident was moderately impaired-decisions poor; cues/supervision required. The resident had signs and symptoms of delirium which included inattention and disorganized thinking. The resident had signs and symptoms of psychosis which included delusions. The resident had behavioral symptoms which interfered with his care and the resident rejected care 4 to 6 days during the assessment period. The resident required limited assistance of one person for transfers, toilet use and dressing. The resident required extensive assistance of one person for bathing and personal hygiene. The resident was not ambulatory. The resident's [DIAGNOSES REDACTED]. The resident was [AGE] years old at the time of this survey. Resident #2's Skilled Daily Nurses Note dated 6/03/12 indicated the resident was alert in bed and awake. The smell of smoke was coming from the resident's room. A cup full with water and 3 cigarette butts and ashes were noted on the floor bedside the resident's bed. The nurse explained to the resident that smoking was not allowed in the building and the resident told the nurse "you need to provide a facility you can smoke in just as much as you want". The nurse explained the city ordinance regarding healthcare facilities and the resident looked at the television and ignored the nurse. The nurse asked for the resident's cigarettes and the resident continually ignored the nurse. The Administrator was contacted and he advised the nurse to inform the resident if he was caught smoking again he could possibly be discharged from the facility. The Administrator informed the nurse to continue to monitor and ask the resident to relinquish his lighter but if the resident was not co-operative just continue to monitor for smoke. The Administrator informed the nurse to call him back if smoke was noted coming out of the resident's room again. The nurse informed the resident of the information and the resident refused to relinquish his lighter by saying, "nope". Resident #2's Social Services Progress Notes indicated on 6/04/12 the social worker received a referral that the resident was smoking in his room over the weekend (6/03/12). The social worker spoke to the resident and he did not deny that he was smoking in his room. The resident told the social worker he understood the smoking policy. The social worker documented she would provide the resident a copy of the smoking policy and conduct a smoking assessment. Resident #2's Resident Smoking assessment dated [DATE], completed by the social worker, indicated the resident was oriented to person, time and place, able to demonstrate dexterity to manage small objects with both hands, able to hold a cigarette without dropping it, aware of the facility smoking policy, accepted the responsibility to refrain from smoking in bed, agreed to hold the facility harmless for injuries, damage, or accidents caused by smoking activities, able to verbalize the request for smoking materials, able to inform family to purchase additional smoking materials, able to verbalize location of designated smoking areas and a signed "Smoking Disclosure" was on file. The assessment indicated resident did not have a signed doctor's order permitting smoking. Review of Resident #2's clinical record indicated a signed Smoking Disclosure dated 6/05/12. Review of the facility Smoking Disclosure indicated the following: The facility is committed to quality care of all residents. In an effort to provide optimal care, it is necessary to build a partnership between physicians, family members and facility staff to best serves the resident. In that endeavor, family involvement in the treatments, interventions and approaches is an integral part of the over-all approach. The resident's desire to smoke may present hazardous conditions to the resident, staff and visitors. Examples: Burns in clothing, accidental burns to self, burns to property, and respiratory disorders. There was no care plan in the resident's clinical record regarding his smoking regimen or smoking precautions and no documentation the resident's physician was notified regarding the resident smoking in bed on 6/03/12. Resident #2's psychiatric assessment dated [DATE] indicated the resident had cognitive impairments and was oriented to person only. The resident had a depressed mood with decreased energy and motivation. The resident's insight and judgment was impaired. Resident #2's Nurses Notes dated 7/20/12 indicated the resident was found smoking while in bed by a CNA. The resident was observed putting out a cigarette in a cup of juice next to his bed. The nurse notified the DON and then went to the resident's room to remind him of the importance of not smoking in the facility due to residents on oxygen and the city ordinance. The nurse asked the resident for his personal lighter that was on his bedside table and the nurse placed the lighter on the nurses' cart. The nurse informed the resident that he needed to go smoke outside and to let the staff know and they could give him his lighter. Review of Resident #2's clinical record indicated the resident's ability to smoke safely was not re-assessed to determine the level of supervision he required and there was no care plan regarding the resident's smoking regimen or documentation the physician was consulted regarding the resident smoking in bed on 7/20/12. Resident #2's quarterly MDS dated [DATE] indicated the resident scored a 6 on his Brief Interview for Mental Status. A score of 0-7 indicated severe cognitive impairment. During a telephone interview on 10/19/12 at 8:35 a.m. Resident #2's physician said he was not informed the resident was observed smoking in his room on 6/03/12 or 7/20/12. During observation and interview on 10/19/12 at 12:15 p.m. Resident #2 was observed in bed resting. The resident's cigarettes and lighter were sitting on the resident's bedside dresser within reach of the resident. The resident said he had smoked in his room, but the staff told him he would be kicked out of the facility if he did it again. During an interview on 10/19/12 at 12:18 p.m. the Administrator said he was aware Resident #2 had been observed smoking in his room on 6/03/12 and 7/20/12. He said he was aware the resident had his cigarettes and lighter in his room. He said the resident had not smoked in his room since 7/20/12 and it was okay for the resident to have his cigarettes and lighter. During an observation on 10/19/12 at 12:40 p.m. Resident #2 was observed resting in his bed. The resident's cigarettes and a lighter were observed sitting on the resident's bedside dresser within reach of the resident. The Administrator was observed in the resident's room visiting with him. During an interview on 10/19/12 at 12:45 p.m. the Administrator said Resident #2 had been assessed regarding his smoking safety after he was found smoking in his room on 6/05/12; however the resident had not been re-assessed regarding his smoking safety on 7/20/12. He said the resident had not smoked in his room since 7/20/12 but he removed the resident's cigarettes and lighter from the resident's room today after his discussion with the resident. Immediate Jeopardy Identified On 10/19/12 at 12:45 p.m. the Administrator and Director of Nursing were informed an Immediate Jeopardy had been identified. A list received from the administrator on 10/19/12 at 1:45 p.m. indicated the facility had identified 12 residents who smoked, 5 residents on the list were identified as requiring supervised smoke breaks. Resident's #2, #6, #7, #8,#9 and #10 were identified on the list to be unsupervised independent smokers. During an interview on 10/19/12 at 2:00 p.m. the ADON said Resident #2's smoking regimen and smoking safety had not ever been care planned. Resident #2's Skilled Daily Nurses Note dated 10/19/12 indicated the resident was sent to the emergency room and admitted to the hospital for evaluation and treatment due to nausea, vomiting, fever, elevated pulse and low blood pressure. Resident #10 Resident #10's quarterly MDS dated [DATE] indicated the female resident was admitted to the facility on [DATE]. The resident scored a 15 on her Brief Interview for Mental Status. A score of 12-15 indicated the resident was cognitively intact. The resident was independent for ambulation and activities of daily living. The resident's [DIAGNOSES REDACTED]. The resident was [AGE] years old at the time of this survey. Resident #10's Nurse's Notes dated 5/09/12 indicated the resident no longer presented with wander seeking behavior and did not express a desire to leave the facility un-attended. The resident was moved from the locked dementia unit to the main building. Resident #10's Nurse's Notes dated 5/12/12 the resident was upset and demanding to be allowed to go to the store to get cigarettes. The resident was re-directed but remained upset. The resident returned to the nurses' station and said she found half a pack of cigarettes in her stuff. The resident refused to allow staff to secure her cigarettes and said she could go smoke herself. The nurse documented the resident would be monitored closely. Resident #10's Social Services Progress Notes indicated: --on 7/13/12 the resident was smoking outside the front door and the social worker asked the resident to move to the smoking area. The social worker documented the resident wanted to argue about smoking anywhere she wanted and finally moved. --7/21/12 the resident was smoking outside the nursing home door where smoking was not allowed. The social worker asked her to move or put out her cigarette and the resident continued to smoke. The social worker reminded the resident of the city smoking law and the facility's policy but the resident continued smoking. Review of Resident #10's clinical record indicated no documentation of quarterly smoking assessments per facility policy or care planning with regards to the resident smoking safety needs. No documented smoking disclosure was located. During an observation on 10/18/12 at 6:00 a.m. Resident #10 was alone on the front porch smoking. Resident #10's Nurses Notes dated 10/22/12 at 5:20 a.m.indicated the resident went outside around 4:45 a.m. and was sitting on the front porch, around 5:20 a.m. a staff member from the other nursing home facility (located several feet away) called and said the resident was at their facility smoking. During an interview on 10/22/12 at 11:10 a.m. the Administrator said he was not aware Resident #10 was at the other facility this morning smoking. He said a smoking assessment should have been completed on the resident and in her clinical record. During an interview on 10/22/12 at 11:20 a.m. the ADON said she was aware Resident #10 was seen over at the other facility smoking. She said she was not sure how the resident got cigarettes. She said no smoking assessment or care plan was completed for Resident #10. During an interview on 10/22/12 at 12:48 p.m. the Administrator said the smoking assessments should have been completed on residents who smoked independently and it had been the former social worker's responsibility to conduct the assessments. He said there had been issues with the social worker getting all of her assessments done and her last date of employment was 9/12/12. He said the new social worker started today (10/22/12). Resident #7 Resident #7's quarterly MDS dated [DATE] indicated the male resident was admitted to the facility on [DATE]. The resident had short-term and long-term memory problems. The resident was moderately impaired-decisions poor; cues/supervision required. The resident had signs/symptoms of delirium which included inattention and disorganized thinking which were continuous and did not fluctuate. The resident was independent for ambulation and activities of daily living. The resident's [DIAGNOSES REDACTED]. The resident was [AGE] years old at the time of this survey. The facility's Smoking Disclosure was signed by Resident #7 and dated 12/09/09. Review of Resident #7's Resident Smoking assessment dated [DATE], completed by the social worker, indicated the resident was not oriented to person, time and place, the resident was able to demonstrate dexterity to manage small objects with both hands, able to hold a cigarette without dropping it, aware of the facility smoking policy, accepted the responsibility to refrain from smoking in bed, agreed to hold the facility harmless for injuries, damage, or accidents caused by smoking activities, able to verbalize the request for smoking materials, able to inform family to purchase additional smoking materials, able to verbalize location of designated smoking areas and a signed "Smoking Disclosure" was on file. According to this assessment, the resident's smoking regimen was included in the care plan. The assessment indicated resident did not have a signed doctor's order permitting smoking. Resident #7's Smoking Care Plan dated 8/22/12 indicated the resident had the potential for injury related to smoking. The goal was for the resident to remain free of injury related to smoking for the next 90 days. The interventions included social services to complete a smoking assessment to determine safety and all smoking material will be kept in the medication room and cigarettes will be distributed by the nurses. During an interview on 10/19/12 at 3:42 p.m. the ADON said Resident #7's smoking assessment had not been updated since 1/26/10. During an interview on 10/19/12 at 3:44 p.m. the Activity Director said Resident #7 had a personal lighter and smoked on the front porch un-supervised. She said the resident often smoked cigarette butts he found in the trash. She said the resident's lighter was now locked up as of today (10/19/12). Resident #8 Review of Resident # 8's Face Sheet indicated the resident was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #8, a female, was [AGE] years old at the time of the investigation. Review of Resident #8's quarterly Minimum (MDS) data set [DATE] indicated Resident #8 was identified as being independent for bed mobility, transfers, locomotion on an off the unit, dressing, toileting and personal hygiene. Resident #8 had no functional range of motion limitations. Resident #8 was continent of bowel and bladder. Review of Resident # 8's Resident Smoking assessment dated [DATE] indicated the resident was identified with the following; Oriented to person, time and place, Demonstrate dexterity to manage small objects with both hands, Able to hold a cigarette without dropping it, Aware of the facility smoking policy, accepts the responsibility to refrain from smoking in bed, Agrees to hold the facility harmless for injuries, damage, or accidents caused by smoking activities, Able to store smoking materials to prevent access by other residents, Able to verbalize the request for smoking materials, Able to inform family to purchase additional smoking materials, Able to verbalize location of designated smoking areas, Resident smoking regimen is included in the care plan, and a signed Smoking Disclosure is on file. Review of Resident #8's Smoking Disclosure dated 1/26/10 indicated the resident signed the disclosure on 2/08/10. Review of Resident #8's clinical record indicated no documentation of quarterly smoking assessments per facility policy or care planning with regards to the resident smoking safety needs. During an observation on 10/18/12 at 8:35 a.m. Resident #8 was smoking independently on the front porch. Resident #9 Review of Resident #9's Face Sheet indicated the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #9, a female, was [AGE] years old at the time of the investigation. Review of Resident #9's quarterly Minimum (MDS) data set [DATE] indicated Resident #9 was identified as being independent for bed mobility, transfers, locomotion on an off the unit, dressing, toileting and personal hygiene. Resident #9 had no functional range of motion limitations. Resident #9 was continent of bowel and bladder. Review of Resident # 9's Resident Smoking assessment dated [DATE] indicated the resident was identified with the following; Oriented to person, time and place, Demonstrate dexterity to manage small objects with both hands, Able to hold a cigarette without dropping it, Aware of the facility smoking policy, accepts the responsibility to refrain from smoking in bed, Agrees to hold the facility harmless for injuries, damage, or accidents caused by smoking activities, Able to store smoking materials to prevent access by other residents, Able to verbalize the request for smoking materials, Able to inform family to purchase additional smoking materials, Able to verbalize location of designated smoking areas, and A signed Smoking Disclosure is on file. Review of Resident #9's clinical record indicated no documentation of quarterly smoking assessments per facility policy or care planning with regards to the resident smoking safety needs. No documented smoking disclosure was located. During an observation on 10/18/12 at 9:24 a.m. Resident #9 was smoking independently on the front porch. Plan to Lift Immediate Jeopardy On 10/19/12 at 4:52 p.m. the facility provided a Plan to Lift Immediate Jeopardy. Review of this plan indicated the facility planned to: 1) Identify all residents who smoke. 2) Interview all identified residents who smoke. 3) Have identified residents who smoke volunteer (relinquished) all smoking paraphernalia. ( Resident's #2, #6, #7, #8, #9, and #10 were noted to have volunteered their smoking paraphernalia) 4) Label and place all resident's smoking paraphernalia and place in the facility's "smoking box" to keep in the facility's possession. 5) Assess all identified residents who smoke for safety during smoking. The following care plan updates were made as a result of these assessments: 1) Resident #6 will be reminded to sit upright and will be required to wear a smoking apron. To remedy concerns regarding unsafe smoking practices the facility implemented changes to the smoking policy. Those changes are as follows: 1) All residents, regardless of cognitive status or physical function will be supervised when smoking to ensure safety for the facility as a whole. 2) A single designated resident smoking area will be established on the back patio. A fire extinguisher has been installed in this area. 3) The facility will maintain its current smoking schedule at the following times: 6:30 a.m.-with Laundry staff supervision, 8:30 a.m. - with Activity staff supervision, 10:30 a.m.- with Kitchen staff supervision, 11:30 a.m. - with Housekeeping staff supervision, 1:30 p.m. - with Activity staff supervision, 3:30 p.m. - with Kitchen staff supervision, 4:30 p.m. - with Medication Aide supervision, 6:30 p.m. - with Nursing staff supervision, 8:30 p.m. - with Nursing staff supervision, 10:30 p.m. - with Nursing staff supervision. 4) a zero tolerance clause will be implemented. Any resident who violates this policy will be given a 30 day notice of discharge from the facility. The Facility Medical Director was contacted to be made aware of the immediate jeopardy and offer any suggestions on the plan to remove. Review of the revised Smoking Policy for Resident's; amended 10/19/12 indicated the following: Policy and Interpretation: --Assignment of rooms; 1) Prior to or upon admission, residents shall be informed that smoking is permitted in designated

Based on observation, interview, and record review the facility failed to ensure 4 residents (Resident #1, #15, #18, and #24) of 9 residents sampled for accidents resulting in injury received adequate supervision to prevent accidents. The facility failed to: 1. ensure Resident #1 had a functioning bed alarm, as was ordered by the resident's physician, on the night of 10/12/11-10/13/11. On that night, the resident got out of bed without supervision or assistance, fell , and suffered a hip fracture. 2. ensure Resident #1 had a functioning bed alarm on 11/9/11 when the resident was resting in his room. 3. ensure Resident #18 had a functioning chair alarm, received assistance when he called using his call light and received attention when his bed alarm sounded to decrease the risk of falling and potential serious injury. 4. ensure Resident #15 had been assessed for the use of and provided appropriate assistive devices to prevent falling out of his wheelchair on several occasions. 5. ensure Resident #24 had a functioning bed alarm on 11/9/11 when she was resting in bed. These failures resulted in severe harm for Resident #1, but could have affected 36 residents who had physician orders [REDACTED]. These facility failure could result in avoidable falls with injury for 36 residents who had physician orders [REDACTED]. The findings include: Resident #1 Review of Resident #1's medical record face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old at the time of this survey. Review of Resident #1's consolidated physician orders [REDACTED]. According to these orders, the resident was to have an alarm on his bed. Review of Resident #1's admission orders [REDACTED]. Review of Resident #1's admission MDS dated [DATE] revealed the resident had both short-term and long-term memory problems. His cognitive skills for daily decision making were severely impaired. He experienced periods of inattention and disorganized thinking. The resident had daily wandering behavior. The resident needed only supervision for bed mobility. He needed staff assistance for transfers. He needed limited help for toilet use and personal hygiene. He was unsteady when moving from a seated to a standing position, when walking, and when turning around. He normally used a walker for ambulation. He was occasionally incontinent of bladder and bowel. Record review of Resident #1's Careplan dated 08/29/11 revealed that Resident #1 was at risk for falls related to impaired mobility due to increased weakness. Bed alarm was listed as an approach. Review of the facility's Provider Investigation Report dated 10/13/11 revealed on 10/13/11 at 2:30 a.m. Resident #1 got out of bed and fell . The report documented the resident suffered a fractured hip as a result of this fall. According to this report, the resident had a physician order [REDACTED]. In a written statement included with the Provider Investigation Report, LVN 'D' documented she was at the nurse's station when she heard a loud thump (the LVN did not document she heard a bed alarm). She documented she went to Resident #1's room (which was close to the nurse's station) and found the resident on his back on the floor. She documented the resident was complaining of severe pain in his right hip, so he was transferred to a local hospital for evaluation. The Provider Investigation Report did not include any interviews from the staff who assisted Resident #1 to bed on the evening of 11/12/11, to determine whether the staff ensured the resident had a functioning bed alarm in place. In an interview on 10/27/11 at 8:15 a.m. the administrator said at the time Resident #1 was found on the floor on 10/13/11, staff found the resident's bed alarm was not on the resident's bed as it was supposed to be, but was in a dresser drawer in the resident's room. In an interview on 11/8/11 at 3:35 p.m. CNA A said she had worked at the facility about 2 ? years. She said she had worked on the unit where Resident #1 resided and said she knew Resident #1. She said she had always worked on the 2:00 p.m. to 10:00 p.m. shift. She said she had never seen Resident #1 disable or remove his bed alarm, and had never heard any report of the resident doing this. In an interview on 11/8/11 at 5:15 p.m. LVN 'A' said she did not recall any staff ever reporting Resident #1 had removed or turned off his bed alarm. Observation on 11/9/11 at 9:45 a.m. revealed Resident #1 was resting in bed. The resident was awake and alert. LVN 'C' and CNA 'B' came into the resident ' s room to change a dressing on a small wound on the resident ' s coccyx. The resident had a bed alarm on the bed, but it was not turned on. LVN 'C' said she and a hospice aide put the resident into bed about 10 minutes before she returned to change the dressing and failed to ensure the resident's bed alarm was activated. In a telephone interview on 11/10/11 at 4:24 p.m. Administrator 'A' said he did not investigate whether the evening staff ensured Resident #1 had a bed alarm when they put the resident in bed on 10/12/11. At this time the facility's RN consultant said Administrator 'A' should have interviewed the evening shift staff about Resident #1's bed alarm. The RN consultant said he did not feel the facility ' s investigation of Resident #1's fall and injury was completed. In an interview on 11/10/11 at 3:02 p.m. LVN 'B' said she was the 2-10 nurse on the unit where Resident #1 resided. She said since about 10/1/11 she normally worked Tuesday through Saturday each week. She said none of the aides had ever reported to her Resident #1 had removed or turned off his bed alarm. Review of Resident #1's reentry MDS dated [DATE] revealed this assessment was completed when the resident was readmitted to the facility from an acute hospital on [DATE]. According to this MDS following his hospital stay (related to his hip fracture which resulted from his fall on 10/13/11), Resident #1 had significantly declined in his physical functioning, even in areas not directly related to his hip fracture, such as eating. This MDS documented the resident, following his return to the facility, needed extensive physical assistance for bed mobility, and required total care from 2 staff members for transfers. He was unable to walk in his room or in the corridor, needed extensive assistance from 2 staff members for dressing, required physical help for eating, needed total care for toileting, and needed extensive help for personal hygiene. He was totally dependent for bathing. In an interview on 11/8/11 at 10:55 a.m. the facility's OTR (registered occupational therapist) said it could take Resident #1 as long as 8 weeks of therapy to recover his physical functionality to the level it was prior to his fall and hip fracture. Resident #18 Review of Resident #18's medical record face sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. Review of Resident #18's consolidated physician orders [REDACTED]. According to these orders, Resident #18 was to have a bed alarm and a chair alarm for safety. Review of Resident #18's comprehensive plan of care dated 02/28/11 and last updated on 05/26/11, revealed a problem of risk for falls related to the resident's prescribed psychotropic medications and impaired mobility. The approaches for staff to follow included: "Ensure that call light is within reach and answer promptly when used", and "the completion of fall risk assessment and update quarterly". Review of a facility Incident/Accident report dated 10/03/11, revealed Resident #18 was found on the floor at 8:45 AM, lying on his left side with a copious amount of blood to the left side of his face and head. The resident had a 5 cm laceration to his left eyebrow and abrasions to his chin. Review of Resident #18's Fall Risk assessment dated [DATE] (this was the most recent in the medical record) revealed a score of 15. According to this assessment form, a score of 10 or higher represented a high risk for falls. In an interview on 11/10/11 at 8:00 AM, MDS Coordinator "A" revealed the facility nurses were supposed to be doing the fall risk assessments quarterly, after a fall and with any significant change in a resident's condition. An observation on 11/10/11 at 1:34 p.m. revealed #18 was in the bathroom. The resident's wheelchair was in the doorway of the bathroom, and the resident had been transferred or had transferred himself to the toilet. There was an alarm on his wheelchair but it was not turned on. CNA "C" reported the resident had an alarm on his wheelchair to alert staff when the resident got up unassisted. In an interview on 11/10/11 at 2:29 PM, LVN "F" revealed resident #18 should not be left alone on the toilet. In an interview on 11/10/11 at 3:14 PM resident #18 stated it took the staff a long time to come when he used his call light. He stated he would turn off his alarm by pushing the button. Observation on 11/10/11 at 3:14 PM revealed resident #18 turned on the call light for assistance to go to the bathroom and turned on his bed alarm to demonstrate how it worked. At 3:27 PM (13 minutes later) CNA "F" entered the resident's room to see what he needed. Resident #18 had a yellow star attached to his wall behind his bed with his name and "assist x 1" written on it. Resident #15 Review of Resident #15's medical record face sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. Review of Resident #15's consolidated physician orders [REDACTED]. According to these orders, Resident #15 was to have a self releasing seatbelt on wheelchair due to resident leaned forward frequently and had an unsteady balance. Review of Resident #15's comprehensive plan of care dated 03/03/11 and last updated on 10/31/11, revealed a problem of risk for falls related to the resident's Diagnosis: [REDACTED]. The plan of care also included a problem of "Inappropriate/disruptive behavior: Leans over in chair and sleeps anywhere". The approaches included: "place resident in area where constant observation is possible", and "assist to bed as needed". In an observation on 11/09/11 at 3:05 PM revealed resident #15 had a seat belt on his wheelchair. The belt was attached to an alarm but the alarm was not sounding when the resident unhooked the seat belt. The seat belt was very loose while he was in the wheelchair. In an interview on 11/09/11 at 3:05 PM resident #15 revealed the seat belt did not "buzz" like it was supposed to. In an interview on 11/10/11 at 8:00 AM the facility's ADON revealed it was not safe for resident #15 to go outside by himself because he "falls asleep at the drop of a hat". She stated resident #15 had been found on the ground a few times and he would say he just laid down. She stated resident #15 "had broken his seatbelt alarm twice and it does not work now". She revealed the facility had not had the therapist look at positioning for resident #15 to help keep his trunk positioned in the wheelchair. She revealed she had wanted to try a wedge cushion but the resident refused. She revealed resident #15 had told the nursing staff his back and hips hurt and was the reason he leaned forward in his wheelchair. She revealed he was being seen by the local pain clinic for chronic pain associated with his back and hips. Review of resident #15's clinical record including assessments by nursing staff, therapy, and social services revealed there was no assessment and intervention regarding the residents inability to keep the trunk of his body in an upright position related to pain. Review of resident #15's assessments revealed the last fall risk assessment documented was dated 02/18/11. There were no fall risk assessments documented after the resident fell on [DATE], 07/11/11, and 08/12/11. Resident #24 Review of Resident #24's medical record face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old at the time of this survey. Review of Resident #24's consolidated physician orders [REDACTED]. According to these orders, Resident #24 was to have a bed alarm and a chair alarm for safety. Review of Resident #24's Fall Risk assessment dated [DATE] (this was the most recent in the medical record) revealed a score of 14. According to this assessment form, a score of 10 or higher represented a high risk for falls. Review of Resident #24's annual MDS dated [DATE] revealed she had both short-term and long-term memory problems. Her cognitive ability for daily decision making was severely impaired. She experienced periods of inattention and disorganized thinking. According to this assessment, Resident #24 needed supervision for transfers. She was unable to walk, needed limited help for dressing and personal hygiene, and supervision for toilet use. Resident #24 was not steady when moving from a seated to a standing position, when walking, when turning around, and when moving on and off the toilet, and was not able to stabilize herself without staff assistance. Her functional range of motion was limited in both her lower extremities. She used a wheelchair for mobility. She was frequently incontinent of bladder. Review of Resident #24's comprehensive plan of care dated 11/1/11 revealed a problem of risk for falls related to the resident's impaired mobility and seizure disorder. A random observations on 11/10/11 at 1:27 p.m. revealed Resident #24 was resting in bed. Her bed alarm was not turned on at that time. According to a list provided by the DON, there were 36 residents who had a physician order [REDACTED].

Base on observation, interview, and record review the facility failed to ensure 8 residents (Resident #15, 18, 24, 26, 27, 29, 31, and 32) of 14 residents reviewed for falls received adequate supervision and assistive devices to prevent accidents . The facility failed to: 1. ensure Resident #27's physician ordered alarm was in place and properly functioning on [DATE] at 7:30 p.m. On that date and time the resident fell in her room and fractured her finger. The alarm did not sound to alert the staff the resident was attempting to get up without the required staff assistance. 2. ensure Resident #31 had his physician ordered alarm in place and properly functioning on [DATE] at 8:10 p.m. On that date and time the resident fell in his room sustaining a laceration to his forehead and bilateral suborbital bruising (black eyes). The resident's alarm did not sound to alert the staff the resident was attempting to get up without the required staff assistance. 3. ensure Resident #15 had his physician ordered alarm in place and properly functioning on [DATE] at 8:55 a.m. On that date and time the resident fell without his alarm sounding to alert the staff. 4. ensure Resident #31 had his physician ordered alarm properly placed on [DATE] at 11:15 a.m. On that date and time the resident was resting in bed, however his alarm was lying loosely on the bed in such a manner that it would not have sounded had the resident got up without the required staff assistance. 5. ensure Resident #32 had his physician ordered lap buddy (a type of cushion which acted as a physical restraint) on his wheelchair on [DATE] at 10:20 p.m. On that date and time the resident fell out of his wheelchair. 6. ensure Resident #29 had his physician ordered alarm in place and properly functioning on [DATE] at 5:15 p.m. On that date and time the resident fell in his room. The resident's alarm did not sound to alert the staff the resident had got up without the required staff assistance. 7. ensure Resident #26 had her physician ordered alarm in place and properly functioning on [DATE] at 9:50 p.m. On that date and time the resident fell in her room. The resident's alarm did not sound to alert the staff the resident had got up without the required staff assistance. 8. ensure Resident #18 had his physician ordered alarm in place and properly functioning on [DATE] at 3:30 p.m. On that date and time the resident fell in his room. The resident's alarm did not sound to alert the staff the resident had got up without the required staff assistance. 9. ensure Resident #24 had her physician ordered alarm in place and properly functioning on [DATE] at 2:08 p.m. On that date and time the resident had got up without the required staff assistance and had taken herself to the bathroom. The alarm did not sound to alert the staff the resident had got up without assistance. On [DATE] at 11:50 a.m. the administrator was informed an Immediate Jeopardy had been identified. The Immediate Jeopardy was lifted effective [DATE]. The facility remained out of compliance at a level of actual harm at a pattern due to the residents who suffered injury as a result of the facility failure to ensure alarms were in place and functioning properly. These failure could have resulted in injury from falls for all 36 residents who had physician orders [REDACTED]. Findings include: Resident #27 Review of Resident #27's medical record Face Sheet revealed the resident was readmitted to the facility on [DATE]. She was [AGE] years old at the time of the survey. Review of Resident #27's consolidated physician orders [REDACTED]. Review of Resident #27's Physician orders [REDACTED]. Review of Resident #27's Fall Risk assessment dated [DATE] revealed the facility had identified Resident #27's score = 11. Instructions for the Fall Risk Assessment included: When residents total score is 10 or more, interventions should promptly be put in place. Review of a facility Incident and Accident Report dated [DATE] at 7:30 p.m. revealed the following information: --- Location of incident: Resident #27's bedroom ---Condition before incident: Normal ---Restraints/Devices in use: No ---Fall: Occurred while standing ---Skin Tear: Laceration, unsure, found during care ---Injury: Fourth and Fifth fingers on left hand. ---Care Provided: Sent to hospital --- Statement: "Went to #6 hall and heard resident yell 'Please help me'. Ran to door and resident states she had to use the bathroom. Resident never used call light. Resident had a blanket on the floor next to bed and fell to floor breaking left pinky. Resident states she fell on Right side of hip with complaints of pain as well." Review of Resident #27's Physician orders [REDACTED]." Review of Resident #27's Nursing Note dated [DATE] at 10:00 p.m. revealed Resident #27 had been transported to the hospital where her left little finger was found to have a fracture and laceration which required sutures. In an interview on [DATE] at 1:35 p.m. LVN 'A' stated on [DATE] she heard Resident #27 yelling from her room. Resident #27's alarm was not sounding. She stated Resident #27 told her she had removed her alarm due to needing to go to the bathroom. LVN 'A' stated she had redirected the resident about removing her alarm and not using her call light. She stated Resident #27 had sustained a fracture of her left little finger during the fall. She stated Resident #27's finger was "mangled" and it "made her cringe" to look at it. Review of Resident #27's Nursing Notes dated [DATE] at 2:10 a.m. revealed "Bed alarm intact, resident removes alarm at times. Call light in reach." Review of Resident #27's Nursing Notes dated [DATE] at 2:00 a.m. revealed "Up to bathroom via wheelchair, encouraged to use the call light for assistance with transfers. Disables personal alarm at times." Review of Resident #27's Nursing Notes dated [DATE] at 4:05 a.m. revealed "Up to bathroom via wheelchair without assistance, encouraged to use call light for assistance, disarms personal alarm. Call light in reach." Review of Resident #27's Nursing Notes dated [DATE] at 4:45 a.m. revealed "Continue to remind to use call light for assistance with transferring. Resident is non-compliant with call light use most of the time." An observation/interview on [DATE] at 8:40 a.m. CNA 'C' stated Resident #27 frequently moves from her bed to the wheelchair without notifying staff. Resident #27 observed resting in bed with eyes closed. Resident #27's personal alarm was observed attached to her wheelchair and not connected to the resident. In an interview on [DATE] at 1:45 p.m. Administrator stated there had been no investigation done regarding Resident #27's fall on [DATE] due to Resident #27 being able to tell them what had happened. In an interview on [DATE] at 1:45 p.m. DON and ADON stated no follow-up investigation or care plan updates had been completed regarding Resident #27's fall on [DATE]. In an interview on [DATE] at 11:15 a.m. LVN 'B' stated she had to frequently monitor Resident #27 due to her taking off her personal alarm. She stated she had spoken to the DON and ADON regarding Resident #27 taking off her personal alarms, however it was more like a "in passing" conversation. She stated she had not documented any concerns and given to the ADON or DON. She stated CNA's had reported to her on occasion regarding Resident #27 taking off her personal alarm. She stated she felt Resident #27 was not actually trying to remove her alarm, however she felt Resident #27 fidgeted around with the cord and the clip to the alarm system and sometimes it came off. Review of Resident #27's Nursing Notes dated [DATE] at 1:45 p.m. revealed " continues to remove personal alarm." Review of Resident #27's Condition Change Form dated [DATE] at 2:45 p.m. revealed Resident continues to remove her personal alarm- New orders to 1) discontinue personal alarm. 2) Seatbelt with alarm to wheelchair 3) Pressure alarm to wheelchair. 4) Pressure alarm to bed. Review of Resident #27's Care Plan updated [DATE] revealed the following: ---Problem: At risk for falls related to impaired mobility due to arthritis ---Goal: Will not sustain injury from falls within the next 90 days ---Approaches: Seatbelt with alarm to wheelchair, Pressure alarm to wheelchair, Pressure alarm to bed. An observation on [DATE] at 5:35 p.m. revealed Resident #27 sitting in the dining room in her wheelchair. A self release alarm seat belt and pressure alarm were observed in place. In an interview on [DATE] at 6:10 p.m. ADON stated the nurses and CNA's had not been passing on information regarding residents taking off their personal alarms. She stated the nurses have not been documenting important information in the residents clinical record as they should, therefore the concern of residents taking off their personal alarms was not reaching the proper people. Resident #31 Review of Resident #31's medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. He was [AGE] years old at the time of this survey. Review of Resident #31's consolidated physician orders [REDACTED]. The resident's medications included Lexapro (an antidepressant) and Avapro (used to treat hypertension). According to these orders, the facility was to provide the resident with a personal alarm at all times, in bed and in the wheelchair. Review of Resident #31's quarterly MDS assessment dated [DATE] revealed the resident had both short-term and long-term memory problems. His cognitive ability for daily decision making was moderately impaired. The resident normally used a wheelchair for mobility. Review of Resident #31's Fall Risk assessment dated [DATE] revealed the resident was not able to stand without physical assistance. The resident's fall risk score was documented to be 14. According to this assessment, a score of 10 or higher indicated the resident was at risk for falls. Review of Resident #31's Comprehensive Plan of Care dated [DATE] revealed: -- the problem of a risk for falls related to the resident's impaired mobility due to a [DIAGNOSES REDACTED]. -- the problem of possible adverse consequences of antidepressant medication use (Lexapro), which included dizziness and a risk for falls. -- the problem of possible adverse consequences of anti-hypertensive drugs (Avapro), which included dizziness, postural hypotension, fatigue, and a risk for falls. Review of a facility Incident/Accident Report dated [DATE] at 6:30 p.m. revealed Resident #31 fell in a hall. According to this report, the fall was not witnessed by any staff. Review of Resident #31's Care Plan Update dated [DATE] revealed the facility was to provide the resident a personal alarm for his bed and wheelchair. Review of an Incident/Accident Report dated [DATE] at 8:10 p.m. revealed Resident #31 fell in his room. The report documented the resident sustained [REDACTED]. In an interview on [DATE] at 8:20 a.m. LVN 'A' said she worked on the 2:00 p.m. to 10:00 p.m. shift on [DATE]. She said at about 8:10 p.m. on that day she was not working on the hall where Resident #31 lived. She said there were no staff on that hall at that time, so another resident came to her and said Resident #31 had fallen in his room. LVN 'A' said she went to Resident #31's room and saw him on the floor. She said there was no alarm sounding at that time. She said the resident had a head laceration and there was quite a bit of blood on the floor. She said shortly afterward, the resident also had 2 black eyes from the fall. On [DATE] at 11:15 a.m. the surveyor and LVN 'B' entered Resident #31's room. The resident was resting on his bed. On the resident's forehead were Steristrips (a type of wound dressing) through which was visible an area of dried blood about 1.5 inches in diameter. The resident had bilateral suborbital bruising, and a small laceration on the bridge of his nose. At this time the resident had an alarm string clipped to his clothing, however the alarm box was lying on the bed next to the resident. This type of alarm was designed to sound when the resident moved away from the alarm box far enough so that the alarm string released the magnetic switch on the alarm box. For this to function properly, the alarm box had to be secured to the resident's bed. Since the resident's alarm box was at this time lying unsecured on the bed, it was unlikely to sound had the resident got up from his bed at that time. LVN 'B' said it took some effort to activate the alarm. She picked up the alarm box by suspending it from the string; the alarm box failed to activate. Immediate Jeopardy Identified On [DATE] at 11:50 a.m. the administrator was informed an Immediate Jeopardy had been identified. Resident #15 Review of Resident #15's medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. He was [AGE] years old at the time of the survey. Review of Resident #15's consolidated physician orders [REDACTED]. Review of Resident #15's Physician order [REDACTED]. 2) Personal Alarm at all times. Review of Resident #15's Fall Risk assessment dated [DATE] revealed the facility had identified Resident #15's score = 18. Instructions for the Fall Risk Assessment included: When residents total score is 10 or more, interventions should promptly be put in place. Review of Resident #15's quarterly assessment dated [DATE] revealed Resident 15 was identified as requiring limited assistance of one person for transfers,bed mobility and personal hygiene. Resident #15 required extensive assistance of one person for dressing, toilet use and bathing. Resident #15 was identified as having functional range of motion limitation with impairment of both sides of his upper extremities and one side of his lower extremities. A review of Resident #15's Nursing Notes dated [DATE] at 2:30 a.m. revealed "To bathroom ad lib, despite encouragement to alert staff for assistance." An observation on [DATE] at 8:55 a.m. revealed Resident #15 on the floor in front of his recliner. Resident #15 was positioned with his face down on the floor, his right leg bent underneath him and his buttocks/hips at a higher angle. The surveyor alerted staff that Resident #15 was on the floor. There was no alarm sounding at the time. Further observation revealed Resident #15's alarm was attached to his wheelchair which was located near his recliner, however the alarm system was not connected to the resident. CNA 'C', CNA 'D' and LVN 'C' assisted Resident #15 back into his recliner. Resident #15 stated to CNA 'C' and LVN 'C' he had "slid out of his recliner" and denied any injuries. An observation on [DATE] at 9:10 a.m. revealed Resident #15 sitting across his recliner with his head laying on the arm rest. Resident #15's alarm continued to be attached to his wheelchair and was not connected to the resident. In an interview on [DATE] at 10:25 a.m. Director of Nursing (DON) stated Resident #15's alarm had been discontinued earlier in the day. He stated Resident #15 frequently bends, leans or lays on objects and frequently places himself in the floor. In an interview on [DATE] at 11:45 a.m. Assistant Director of Nursing (ADON) stated an order had been written earlier in the day discontinuing Resident #15's alarm due to Resident #15 not having any falls for the last 60 days. She stated there had not been an incident report done following finding Resident #15 on the floor at 8:55 a.m. due to Resident #15 telling the staff he had placed himself on the floor. Review of Resident #15's Care Plan updated [DATE] revealed the following: --- Problem: 1) At risk for falls related to impaired mobility due to osteoporosis, and left above the knee amputation. 2) Resident will place himself in the floor occasionally 3) Sleeps in recliner instead of bed 4) Falls asleep in chair frequently, will lean forward in chair. --- Goal: Will not sustain injury from falls for next 90 days. Resident will be transferred safely for the next 90 days. --- Approaches: Resident uses electric and manual wheelchair. Does not ask for assistance occasionally, staff to check resident every 2 hours and when needed (PRN). When staff notices resident sleeping in his chair, tap and wake him for repositioning. Review of Resident #15's Physician order [REDACTED]. Checks every 15 minutes. Review of Resident #15's Condition Change Form dated [DATE] at 9:25 a.m. revealed; order received for resident to wear a Personal Alarm at all times due to risk for falls. Alarm in place and functional. Resident educated by DON and ADON regarding proper use of alarm. Resident verbalized understanding. Review of Resident #15's Care Plan updated [DATE] revealed the following: --- Problem : Potential for injury related to: impaired mobility, fall risk, impaired safety awareness, unable to ambulate, impaired vision, balance problems, limited range of motion, limited endurance due to side effects of hypertension medication, psychotropic medications, above the knee amputation, fractured tibia, osteoporosis and transfers himself to the floor without calling for assistance. --- Goals: Resident will be free of injury, resident will maintain ability to transfer safely with supervision, resident will accept assistance, resident will not exhibit side effects from pain/hypertension/psychotropic medications, and resident will maintain current level of function. All goals for the next 90 days. --- Approaches: Keep call light and items used most within reach and answer call light promptly, maintain pathway free of clutter, personal alarm at all times which will be kept in place with a safety pin, 15 minute checks for 72 hours to establish routine, glasses cleaned and replaced while awake, frequent reminder to reposition while in wheelchair, assist with ADL's when needed, monitor for signs and symptoms of hypertension, provide assistance with transfers when needed, allow resident to do as mush as he can independently, and provide frequent reminders to call for assistance. An observation on [DATE] at 5:35 p.m. revealed Resident #15 sitting in the dining room in his wheelchair. An alarm was in place and alarm's string was safety pinned to his shirt. Resident #32 Review of Resident #32's medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. He was [AGE] years old at the time of the survey. Review of Resident #32's consolidated physician orders [REDACTED]. An order dated [DATE] revealed the facility was to provide a personal alarm at all times for Resident #32. Review of Resident #32's admission MDS assessment dated [DATE] revealed the resident had both short-term and long-term memory problems. His cognitive ability for daily decision making was severely impaired. The resident required extensive physical assistance for bed mobility and for transfers. During transitions and walking the resident was unsteady, and was only able to stabilize with human assistance. The resident normally used a wheelchair for mobility. Review of Resident #32's Fall Risk assessment dated [DATE] revealed a score was 30. Instructions for the Fall Risk Assessment included: When residents total score is 10 or more, interventions should promptly be put in place. Review of Resident #32's Physician order [REDACTED]. The [DATE] order for personal alarm at all times remained in place. Review of Resident #32's Care Plan update dated [DATE] revealed: ---Problem: Fall with personal alarm ---Goal: No falls with injury for the next 90 days ---Approach: Lap buddy while in wheelchair Review of Resident #32's Nursing Notes dated [DATE] at 5:00 p.m. revealed "Personal alarm in place. Unable to find wheelchair for lap buddy. Reported to supply agent and DON." Review of an Incident and Accident report dated [DATE] at 10:20 p.m. revealed the following: --- Location of incident: Doorway of Rm #206 ---Condition before incident: Confused ---Restraints/Devices in use: No ---Fall: Transferring ---Injury: None ---Care Provided: None ---Statement: " Notified by a resident that Resident #32 was on the floor on 200 Hall. Found Resident #32 on the floor near his wheelchair facing the opposite to sitting position, trying to get up. Resident #32 assisted to stand and sit in wheelchair. Denies pain or discomfort and stated 'It just scared me'. No injuries noted." ---Follow up: "On [DATE] at 10:20 p.m. Resident was noted to have fallen on the floor in the 200 Hall. Resident was noted to be in the sitting position on the floor. Resident verbalized no pain or discomfort. No other signs of trauma or injury. Vital signs within normal range. Family and Physician notified. Resident educated on the importance of requesting assistance for transfers, Resident verbalized understanding. Resident wheelchair was changed in order to properly accommodate a lap buddy. A lap buddy was added to aid in prevention of future falls." In an interview via telephone on [DATE] at 10:45 a.m. LVN 'C' stated on [DATE] at 10:20 p.m. she had been receiving report when a resident alerted her there was a resident on the floor on 200 Hall. She stated Resident #32 was on the floor in an odd position, facing his wheelchair. She stated he was "tangled" in his catheter tubing and was attempting to get up from the floor. LVN 'C' stated Resident #32's personal alarm was not sounding at the time of the fall. She stated she believed Resident #32 had taken his alarm off, however had not observed Resident #32 taking the alarm off. LVN 'C' stated she could not recall seeing a lap buddy during the incident and did not recall replacing a lap buddy to Resident #32's wheelchair when she assisted him back to the wheelchair. In an interview via telephone on [DATE] at 1:45 p.m. LVN 'D' stated on [DATE] at 10:20 p.m. she had been giving report when a resident alerted her there was a resident on the floor on 200 Hall. LVN 'D' stated Resident #32's personal alarm was not sounding at the time of the fall. She stated Resident #32 frequently removed his personal alarm and tries to get up from his wheelchair. LVN 'D' stated she could not recall seeing a lap buddy, therefore "could not say one way or another if a lap buddy had been in place". She stated she could not remember specifically reporting concerns to the ADON or DON regarding Resident #32's frequently removal of his personal alarm. She stated when she had any concerns regarding the residents, information was passed on to the on-coming nurse. Review of Resident #32's Nursing Notes dated [DATE] through [DATE] revealed no documentation regarding the facility providing a lap buddy for Resident #32. Review of Resident #32's Care Plan updated [DATE] revealed the following: ---Problem: Potential for fall ---Goals: Blank ---Approaches: Personal Alarm at all times, Lap buddy to wheelchair, Clip personal alarm to clothing with a safety pin. An observation on [DATE] at 2:15 p.m. revealed Resident #32 sitting in his wheelchair in the lobby. A Self release alarm seat belt was in place. In an interview/observation on [DATE] at 2:20 p.m. ADON stated Resident #32's physician orders [REDACTED].#32 now having a self release alarm seat belt. DON and ADON requested Resident #32 to take off his self release alarm seat belt, the alarm sounded and it was placed back on Resident #32. Resident #29 Review of Resident #29's medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. He was [AGE] years old at the time of this survey. Review of Resident #29's consolidated physician orders [REDACTED]. Review of Resident #29's quarterly MDS assessment dated [DATE] revealed the resident had both short-term and long-term memory problems. His cognitive ability for daily decision making was moderately impaired. The resident normally used a walker for mobility. Review of Resident #29's Comprehensive Plan of Care dated [DATE] revealed the problem of a risk for falls related to impaired mobility due to increased weakness Review of an Incident/Accident Report dated [DATE] at 8:33 a.m. revealed Resident #29 fell in his room. A staff statement included with this report documented the staff member went to the resident's room to pick up the resident's meal tray, and found the resident on the floor. Review of Resident #29's Care Plan Update dated [DATE] revealed the facility was to provide the resident a personal alarm at all times. Review of Resident #29's physician order [REDACTED]. Review of an Incident/Accident Report dated [DATE] at 5:15 p.m. revealed Resident #29 fell in his room. The report documented the staff found the resident sitting on the floor next to his bed. This report did not document whether or not the resident's alarm was sounding at that time. In an interview on [DATE] at 2:20 p.m. CNA 'A' said on [DATE] at about 5:15 p.m. she was passing meal trays on the hall where Resident #29 lived. CNA 'A' said at that time she heard a noise and went to investigate. She said she went to Resident #29's room to check on him and found him on the floor. She said there was no alarm sounding at that time. Resident #26 Review of Resident #26's medical record Face Sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old at the time of this survey. Review of Resident #26's consolidated physician orders [REDACTED]. Her medications included Aricept (use to treat Alzheimer's disease), Prinivil and Norvasc (both used to treat hypertension), and Effexor, Abilify, and Trazadone (all used to treat depression). Review of Resident #26's physician order [REDACTED]. Review of Resident #26's quarterly MDS assessment dated [DATE] revealed she had both short-term and long-term memory loss. Her cognitive ability for daily decision making was moderately impaired. This assessment documented Resident #26 required extensive physical assistance from 2 staff members for transfers. She was able to balance during transitions and walking only with human assistance. She normally used a wheelchair for mobility. This assessment documented the resident had a fall within the prior ,[DATE] month period. Review of Resident #26's Comprehensive Plan of Care dated [DATE] revealed the problem of: -- a risk for falls related to impaired mobility due to dementia and neuropathy. -- risk for adverse effects of certain medications including antihypertensive,antidepressants, Aricept drug use, including dizziness, postural hypotension, fatigue, and falls Review of Resident #26's Comprehensive Plan of Care dated [DATE] revealed the problem of falls. The care plan required the facility to provide the resident a personal alarm for her recliner. Review of an Incident/Accident Report dated [DATE] at 9:50 p.m. revealed Resident #26 fell in her room. The report documented the resident sustained [REDACTED]. According to this report, the resident fell from her recliner. This report did not document whether or not the resident's alarm was sounding at that time. In an interview on [DATE] at 2:46 p.m. CNA 'B' said on [DATE] around supper time she was working on the hall where Resident #26 lived when she heard the resident yelling for help. CNA 'B' said she went to the resident's room and saw the resident on the floor in front of her recliner. CNA 'B' said at that time the resident was bleeding from one arm. CNA 'B' said there was no alarm sounding at that time. Resident #18 Review of Resident #18's closed medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. The resident's Record of Death documented he died on [DATE]. He was [AGE] years old at the time of his death. Review of Resident #18's consolidated physician orders [REDACTED]. Review of Resident #18's physician order [REDACTED]. Review of Resident #18's quarterly MDS assessment dated [DATE] revealed the resident had long-term memory loss. He had some difficulty with decision making in new situations. When walking, the resident was unsteady and able to stabilize only with human assistance. Review of Resident #18's Fall Risk assessment dated [DATE] revealed the resident was unable to maintain his balance while sitting and while standing without physical help. His fall risk score was documented to be 17. According to this assessment, a score of 10 or higher indicated the resident was at risk for falls. Review of Resident #18's Care Plan Update dated [DATE] revealed the problem of potential for falls. This care plan update required the facility to provide the resident a personal alarm when in bed and when in a wheelchair. Review of an Incident/Accident Report dated [DATE] at 3:20 a.m. revealed Resident #18 fell in his room. The report documented the resident sustained [REDACTED]. Review of an Incident/Accident Report dated [DATE] at 11:00 a.m. revealed Resident #18 fell from his wheelchair. The report documented the resident's wheelchair alarm sounded and alerted the staff who were unable to prevent the resident from falling. According to this report, the resident sustained [REDACTED]. This report did not document whether the resident's alarm was sounding at that time. Review of an Incident/Accident Report dated [DATE] at 3:30 p.m. revealed Resident #18 fell in his room. The report documented the resident's bed was tipped over to the side and the resident was on the floor. The report did not document whether or not the resident's bed alarm was sounding at that time. In an interview on [DATE] at 3:05 p.m. CNA 'A' said on [DATE] at about 3:30 p.m. Resident #18's roommate came to her and told her Resident #18 was on the floor in his room. CNA 'A' said she went to Resident #18's room and saw him sitting on the floor. CNA 'A' said there was