Every finding on record at Chase City Health And Rehab Center

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the accurate representation of the resident experiences were documented in the clinical record for 1 out of 30 sampled residents, Resident #2 (R2). The findings included:The facility staff failed to accurately document R2's behaviors in the medical record.On 8/18/26 at 4:00 pm, an observation made of R2 in her room yelling and cursing at the staff. R2 was yelling out in the hallway at visitors, staff, and other residents and using profanity. The staff had one staff member to stay with her in her room.On 8/19/26 at 3:30 pm, there was an observation of R2 out in the hallway on the unit yelling at staff and other residents as the residents walked by her. She was using profanity and refusing to accept medications from the nurse. During this observation staff tried to redirect the residents and offer activities. On 8/19/26 at 11:00 am, a review of R2's clinical record was completed. During the review of the progress notes there were notes that were not completed or not accurate with R2's behaviors at the time. During the review there were behaviors noted on the medication administration record but were not documented in the medical record. Several observations were noted of R2 with behaviors during the initial tour and the following day. The behaviors were not documented in R2's progress notes.On 8/19/26 at 11:30 am, an interview was conducted with the Director of Nursing (DON). She stated that she didn't feel R2 was treated any differently than any other residents at the facility. DON stated she handles the facility related business for R2. She stated that R2's daughter had not refused medications that she was aware of but she would ask questions about the medications. The DON said, I have not had any staff discuss anything about being disciplined for documenting on her [R2].On 8/20/26 at 9:25 am, an interview was conducted with a licensed practical nurse, LPN3. LPN3 stated that the floor staff had discussed R2's behaviors and documentation among themselves and decided not to document all her behaviors in the medical record. LPN3 stated that staff were afraid that they would lose their job over the documentation of R2's behaviors. She stated that the Administrator nor the Director of Nursing never instructed the staff not to document but the staff felt some of the changes that were made with staffing on the memory care unit were done because the staff that were moved charted too much about R2's behaviors. LPN3 said, for a long time I didn't chart on her [R2] fearful I would lose my job and I need it. LPN3 felt that family refuses medications for her behaviors. She stated that R2 was one on one supervision for a long time. She stated that family members had voiced concerns about R2's behavior and her concern was other residents hitting back. She stated she was concerned other residents were going to be made to move because of the altercations. LPN3 stated that a nurse practitioner that used to be employed was trying to give orders for medication for behaviors and that R2's family member stated no, no you are not. On 8/20/26 at 9:45 am, an interview was conducted with a certified nursing assistant, CNA4. She stated that R2 was aggressive, agitated, and cursed sometimes. She stated that she had to sit with her one on one sometimes. CNA4, she reports behaviors to the nurse in charge. She stated, the nurse says they chart it, but some do and some don't. She stated that the nurse practitioner was going to prescribe medications for behavior and her family refused the medications. CNA4 stated, I feel it is a conflict of interest because she [R2] hits other residents and it's the other residents that was moved or redirected.On 8/20/26 at 11:00 am, a facility documentation review was conducted. The policy titled, Documentation in Medical Record, read in part, .Each resident's medical record should contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.On 8/20/26 at 3:30 PM, an end of day meeting was conducted with the Director of Nursing, Administrator, Regional Director of Clinical Services, and Clinical Service Specialist. They were informed of the above concerns.No additional information was provided to the exit of the survey.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to accurately code a minimum data set (MDS) assessment for one resident (Resident #2-R2) in a survey sample of 3 residents. The findings included: For R2, the facility staff failed to accurately code a MDS assessment to capture the resident's behavior. On 12/3/24 and 12/4/24, a closed record review was conducted of R2's chart. This review revealed a behavior progress note entry dated 4/29/24, that read in part, resident observed playing in poop . According to a progress note entry from the nurse practitioner dated 4/30/24, which read in part, .She does not answer questions appropriately and seems confused. Staff has reported that she has been found playing in her own feces . According to the MDS with an assessment reference date of 4/29/24, section E for behaviors coded that R2 had no behaviors. According to R2's care plan, an entry dated 4/30/24, noted the behavior as a focus area with interventions. On 12/4/24 at 9:35 a.m., an interview was conducted with the care plan coordinator, who completed R2's MDS assessment. When asked about MDS assessments, the care plan coordinator stated that behaviors have a 7 day look back and we have to go by what is documented in CNA [certified nursing assistant] documentation and nursing notes. When asked if a resident smearing or playing in feces is a behavior that would be captured on the MDS, the care plan coordinator stated, That I would code under E200C. During the above interview with the care plan coordinator, the surveyor asked the staff to access R2's chart. The care plan coordinator reviewed the behavior note dated 4/29/24, that indicated R2 was playing in feces. The care plan coordinator then accessed R2's admission MDS with an ARD of 4/29/24 and said, You are right, I don't see it coded. When asked if the behavior should have been coded, the care plan coordinator confirmed it should have been coded on the MDS. The MDS coordinator confirmed that the facility follows the RAI [resident assessment instrument] manual for coding instructions and guidance. According to the facility policy titled, Comprehensive Care Planning Process it read in part, 1. A comprehensive resident assessment (MDS) is completed for each patient within fourteen (14) days of the patient's admission to the center, annually according to OBRA guidelines or when the patient meets criteria for a Significant Change in status assessment The policy did not speak to the accuracy of the assessments. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, dated October 2023, was reviewed. It read in part on page 1-4, . The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status . On 12/4/24, at approximately 10:30 a.m., the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to notify the resident and/or resident representative in writing of a room change for two residents (Resident #1 - R1 and Resident #2 - R2) in a survey sample of 3 residents. The findings included: 1. For R1, who had a room change, the facility staff failed to have evidence that the resident and family were made aware of the room change and failed to provide notice of the room change in writing. On 12/3/24, a closed record review was conducted of R1's clinical chart. According to the census tab of the chart, R1 had a room change on 6/15/23. There was no documentation within the clinical record as to the reason for the room change, nor that the resident and/or family were made aware of the room change. On 12/3/24, in the afternoon, the facility administrator and director of nursing were made aware of the above findings. On 12/3/24 at 3:30 p.m., the facility administrator and director of nursing (DON) reported that they did not find documentation within R1's chart of the room change, but did find within their daily stand-up meeting notes that the room change was done due to roommate incapability. 2. For R2, who had a room change, the facility staff failed to notify the resident and/or family in writing of the room change. On 12/3/24, a closed record review was conducted of R2's chart. According to the census tab of the chart, R2 was admitted to the facility on [DATE], and on 4/27/24 a room change was conducted. According to a nursing progress note dated 4/27/24, it read, Resident has been moved to room [ROOM NUMBER]W. Spouse is aware. No questions or concerns. There was no indication within the clinical record the reason for the room changes, nor that written notification was provided. On 12/3/24 at 1:20 p.m., an interview was conducted with the facility's social worker (SW). When asked about room changes, the SW stated she and the clinical team work together on room changes. When asked about the process and if the reason for the room change is documented, the SW said that she doesn't always document the reason. When asked if written notice is given, the social worker said, I have not been issuing anything in writing. The regional said we would be starting that first of the year during a call we had last month. She went on to say that they [the company] is working on the form that will be used for this communication. During the interview with the SW she was asked about R1 and R2's room changes and was unable to recall why the residents were moved. According to the facility policy titled, Patient/Resident Room Changes, which read in part, . 6. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. 7. A copy of the room change progress note will be provided to the resident or responsible party and will include the reason(s) why the move or change is required . On 12/3/24, during an end of day meeting with the facility administrator and DON, they were made aware of the above concerns. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one resident (Resident #2- R2), in a survey sample of 5 residents. The findings included: For R2, the facility staff failed to maintain an accurate and complete clinical record with regards to medication administration, physician notification, skin condition, and change in bowel consistency. On 3/14/24 and 3/15/24, a closed record review was conducted of R2's chart. R2 was not a resident of the facility at the time of survey and therefore was not able to be interviewed. 1a. According to the March 2023 MAR (medication administration record), R2 was scheduled to receive Glimepiride, Protonix, and Bactrim on 3/9/24 at 6:30 a.m. All three entries for the administration of these medications were blank. There was no progress note entries on 3/9/24, with regards to medications not being administered, or that documented the physician had been notified. On the afternoon of 3/14/24, an interview was conducted with LPN #1. When asked about the documentation of administered medications, LPN #1 stated that medications are documented on the MAR. When asked what a blank means, LPN #1 said, it has not been given. When asked what the protocol is when a medication is not given, LPN #1 said, if not given, contact the provider and notify the family. When asked to explain why the provider (doctor or nurse practitioner) is notified, LPN #1 said, to keep up with continuity of care and so they can monitor for side effects and/or give an alternate order. On 3/14/24 at 4 p.m., during an end of day meeting, the facility Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the above concerns. On 3/15/24 at approximately 9:20 a.m., the DON (director of nursing) notified the survey team that she had spoken with RN #2, who was the assigned nurse to R2 on 3/9/24. The DON reported that RN #2 reported that she had given R2 the medications but failed to document. The DON had RN #2 come to the facility and correct the documentation and presented the survey team with a copy of the MAR that had each of the medications signed off as being administered on 3/9/24. During the above interview, the DON also confirmed that documentation of medications administered is to be done immediately following the administration and as a result she had provided RN #2 with a disciplinary action. On 3/15/24 at 1:10 p.m., an interview was conducted with LPN #2. LPN #2 was asked about medication administration and the documentation of medications being administered. LPN #2 said, medications are documented as being administered as soon as they are given. When asked what a blank on the MAR indicates, she stated, they weren't given. When asked if she must notify anyone when medications are refused or not administered, LPN #2 stated, I put a note in and let the nurse practitioner know, because medications are important. 1b. According to the nursing progress note dated 3/11/24, R2 had open area noted to scrotum, Calazinbc [sic] applied, NP [nurse practitioner] made aware. There was no clinical assessment or description of the area documented. The notification to the NP was noted in the communication book at the nursing station and gave no additional details. Therefore there was no documentation of the size or depth of the site, if there were any signs or symptoms of infection, if pain was present, or anything that might indicate etiology or treatment indicators. On the morning of 3/15/24, during an interview with the DON, the DON confirmed that the documentation was lacking and was not complete. The DON provided the survey team with evidence that a physician order for Calazinc cream to bilateral buttocks/scrotum/groin q [every] shift for redness was obtained on 2/29/24. 1c. According to a nursing progress note entered in R2's record on 3/11/24 at 10:18 a.m., resident noted to have a watery discharge from his buttock. There were no additional details of this to indicate if the discharge was coming from a wound, pustule, or any other assessment detail. This same detail was noted in a physician communication book to the provider serving as notification on their next visit to the facility. On 3/14/24, during an end of day meeting, the surveyor questioned the director of nursing regarding this entry and asked for any additional information to be provided. On 3/15/24 at approximately 9:20 a.m., the DON reported to the survey team that she had spoken with LPN #2 who made the entry and reported that it had been a jelly/watery discharge from R2's rectum. The DON further confirmed that the documentation was not complete and didn't accurately provide the needed information, noting that the buttock and rectum are two anatomically different parts of the body. The DON also clarified that the medical provider's communication book is used for .non-urgent needs that can be addressed on their next visit. Anything immediate needs to be called to the provider. The facility policy titled, Documentation in medical record was reviewed. This policy read in part, 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation should be completed at the time of service but should be no later than the shift in which the assessment, observation, or care service occurred unless authorized . 3b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care . During an end of day meeting held with the facility administrator, DON and regional clinical director, the above concerns were shared. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents receive treatment and care in accordance with professional standards of nursing practice for one resident (Resident #2- R2), in a survey sample of 5 residents. The findings included: For R2, the facility staff failed to administer medications in accordance with physician orders and failed to notify the ordering provider when medications were not administered. On 3/14/24-3/15/24, a closed record review was conducted of R2's chart which included physician orders, medication administration records (MAR), hospital records and progress notes. This review revealed that on 3/11/24, R2 was not administered two medications that were ordered to be administered at 6:30 a.m. The medications included Glimepiride and Protonix. The reason documented was coded as a 7, which according to the chart codes noted 7=sleeping. Review of the progress notes revealed an entry dated 3/11/24 at 6:38 a.m., that read, Resident has been resting quietly in bed this shift. Resident appears to be comfortable. Resident will talk to staff when you talk to him. He denied pain. Resident noted holding solids in his mouth. Resident requesting cold water and he tolerated water with no issues. There was another note on the same day that indicated the nursing staff requested an order to crush medications for R2. Review of the hospital discharge summary dated 2/22/24, revealed the following statement which read in part, Speech saw patient due to concern for aspiration and recommended . crush medications in applesauce/pudding/yogurt. This order had not been carried out when R2 was readmitted to the facility. According to the MAR, on 3/9/24, R2 did not receive the Bactrim antibiotic as ordered at 4:30 p.m. The code on the MAR was noted as 9, which according to the chart code indicated other/see nurse notes. According to the nurse note dated 3/9/24, it read, medication not given, with no further explanation. On 3/14/24, in the afternoon, an interview was conducted with LPN #1. When asked about the documentation of medications administered, LPN #1 stated that medications are documented on the MAR. When asked what a blank means, LPN #1 said, it has not been given. When asked what the protocol is when a medication is not given, LPN #1 said, if not given contact the provider and notify the family. When asked to explain why the provider (doctor or nurse practitioner) is notified, LPN #1 said, to keep up with continuity of care and so they can monitor for side effects and/or give an alternate order. On 3/14/24 at 4 p.m., during an end of day meeting, the facility Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the above concerns. On 3/15/24 at 1:10 p.m., an interview was conducted with LPN #2. LPN #2 was asked about medication administration and the documentation of medications being administered. LPN #2 said, medications are documented as being administered as soon as they are given. When asked what a blank on the MAR indicates, she stated, they weren't given. When asked if she must notify anyone when medications are refused or not administered, LPN #2 stated, I put a note in and let the nurse practitioner know, because medications are important. On 3/15/24, during an interview, the director of nursing (DON) was presented with the above findings. The DON confirmed that documentation doesn't support that the doctor was made aware of R2 not being administered the associated medications. The DON went on to say that with regards to the Bactrim, the nurse noted that R2 was receiving intravenous antibiotics and attempted to call the nurse practitioner to question the order for the Bactrim and was not able to reach the provider, so the nurse decided to hold the medication. Review of the facility policy titled; Medication Administration was conducted. This policy read in part, medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with accepted standards of practice . The Lippincott Manual of Nursing Practice, eighth edition, was reviewed. On page 18, in box 2-3, Common Legal Claims for Departure from Standards of Care were noted to include, but not limited to: . Failure to implement a physician/NP/PA order properly or in a timely fashion, failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately On 3/15/24 at 1:45 p.m., during an end of day meeting, the survey team shared the above concerns. No additional information was provided.

Based on staff interview and clinical record review, the facility staff failed to follow physicians orders for one of 26 residents in the survey sample: Resident # 99. Findings include: Facility staff failed to follow physician's orders for fluid restriction for Resident # 99. Resident # 99 was admitted to the facility 11/3/22, with a readmitted [DATE]. Diagnoses for Resident # 99 included, but were not limited to, atrial fibrillation, COPD, heart failure, congestive heart failure, and GERD. The most recent MDS (minimum data set) was an admission assessment dated [DATE]. Resident # 99 was assessed as having severe impairment in cognition in the area of daily decision making skills, with a total summary score of 07 out of 15. During review of the clinical record on 2/15/23, beginning at approximately 9:00 a.m., a physician order dated 12/6/22 and carried forward directed 1800 cc (cubic centimeters) fluid restriction as follows: 1440 cc provided on trays with meals by dietary. 360 cc provided by nursing as follows: 7-3 can give 150 cc, 3-11 can give 150 cc, 11-7 can give 60 cc every 8 hours for fluid volume maintenance. And encourage resident to comply with Physician prescribed order. Further review of the MAR (medication administration record) for December 2022, January 2023, and February 2023 revealed that staff documentation often exceeded or did not meet the prescribed amount of fluid per shift. On 2/15/23 at approximately 10:25 a.m., the dietary manager, identified as other staff (OS) # 2, was interviewed. When asked about the prescribed amount per dietary, OS #2 stated, I give what the resident wants for fluids; like for breakfast, coffee is 6 oz, etc, and nursing does the calculations. I usually get an order if a resident is on a fluid restriction . OS # 2 presented an order dated 11/3/22 which only directed the amount of fluid restriction, but did not have the amounts separated out as reflected in the current order. When OS # 2 was shown current order for dietary to provide 1440 cc on meal trays, OS # 2 stated No, I didn't get that order dated 12/6/22. That is specific for dietary; the way that's written I'd need to calculate each tray . On 2/15/23 at approximately 10:55 a.m., the corporate nurse consultant, identified as registered nurse (RN) # 2 stated, So, the resident has had multiple orders; the current order did not get shared with dietary. So currently the resident is getting 1530 cc of fluids on meal trays .We are going to audit all the fluid restrictions to make sure they are getting the correct orders . On 2/15/23 at 3:45 p.m., during an end of day meeting with the administrator, DON (director of nursing), and RN # 2, the facility staff were informed of the above findings. RN # 2 stated, What you are seeing documented by staff is correct; either too much or too little fluid per shift per the order. There was ambiguity over the order; dietary did not receive the order with the amount they were to provide on the meal trays. They had the order from 11/3/22 and the new order was not given. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review, facility document review and during a complaint investigation, the facility staff failed to provide supervision to prevent accidents for one of nine in the survey sample, Resident #9. Resident #9 sustained a second degree burn while eating tomato soup unsupervised. The findings include: Resident #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastro-[CONDITION(S)] reflux disease (GERD), [CONDITION(S)], dysphasia, depression, anxiety, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], stage 4 chronic kidney disease, and type 2 diabetes. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #9 as moderately impaired for daily decision making with a score of 9 out of 15. Under Section G - Functional Status the MDS assessed Resident #9 as requiring extensive assistance for dressing, eating, personal hygiene, and bed mobility, each requiring one person physical assistance and total dependent for toileting and bathing with one person physical assistance. The MDS dated [DATE] was a quarterly assessment and assessed Resident #9 as severely impaired for daily decision making with a score of 7 out of 15. Under Section G - Functional Status the MDS assessed Resident #9 as requiring set-up with one person physical assistance for eating; extensive assistance for dressing, personal hygiene, and bed mobility each requiring one personal physical assistance, and total dependent for toileting and bathing with one personal physical assistance. A review of Resident #9's care plans documented the following. Focus [Resident #9] requires assistance with ADLS (activities of daily living) r/t (related to) weakness, pain Dated Initiated: 12/22/2012. Created on: 12/22/2012. Interventions/Tasks [Resident #9] prefers to eat meals in her bed. Staff offer to get her up to chair but she refuses. Date Initiated 05/25/2021. Created on: 05/26/2021 . Provide clothing protector for meals. Date Initiated: 05/26/2021. Created on 05/26/2021 Requires supervision to limited one staff assistance with meals. She sometimes becomes fatigued when feeding herself and requires staff assistance to complete her meal. Date Initiated: 05/28/2021. Created on: 05/28/2021 Focus Resident with burn to chest and right elbow from spilled hot soup. Revision on: 05/28/2021. Interventions/Tasks May use 2 handled cup with lid for hot liquids. Date Initiated: 11/14/2019. Created on: 11/14/2019. Revision on 08/11/2021 . The care plans did not document Resident #9 requiring one person physical assistance with eating prior to 05/28/2021 despite the 04/22/2021 MDS assessment documenting Resident #9 required set up with one person physical assistance for eating. Observed in the progress notes were the following: 5/18/2021 18:16 Note Text: Writer walked into room to give scheduled insulin and noted resident to have spilled the entire bowl of tomato soup that came with dinner tray on self. Writer immediately called CNA (certified nursing assistant) to room to assist in getting resident cleaned up. Assessment of body was done by the writer, noted to have burn to upper right chest and right elbow noted to be red and skin blistered. Resident is c/o (complain of) pain and discomfort at this time. Resident gets scheduled Tylenol per order. [Medical Director] was called and made aware of situation. Gave the okay to apply in house Sooth and Cool Barrier moisture barrier ointment with aloe to affected areas. To monitor areas closely and will see resident tomorrow No signs of SOB (shortness of breath) or dyspnea noted. RP (responsible party) made aware. Will continue to monitor. 5/18/2021 18:34 Note Text: F/u (follow-up) with resident on incident. Resident states she is okay. She does not remember what happen. Area to upper right chest and right elbow noted to still be red and blistered. C/o (complain of) minimal pain at this time. Will continue to monitor and pass on to night shift to monitor and document. 05/18/2021 22:50 Note Text: Writer in room to assess [CONDITION(S)] as CNA called writer into room. Burn noted to right arm just about the elbow, blisters and about an inch and a half in circumference. Resident complaining of mild pain at this time. Barrier cream applied. Will continue to monitor. Burn to right clavicle area, red and peeling, barrier cream also applied here. Wound 2.5 inches in length. No drainage noted at this time. 05/18/2021 08:02 Note Text: Writer called (Medical Director) on clarification of wound. Described wound to MD as red with areas of closed fluid filled blisters on both right upper chest and right elbow. Per MD burn is stages as a second degree burn. Current treatment left in place. Per MD will be in the facility later today to assess the resident. 05/19/2021 10:28 Note Text: Writer in to check on resident. Resident currently sitting in bed with [NAME] (head of bed elevated), call bell within reach. Writer assessed [CONDITION(S)] to right side of chest and right elbow. Areas are raised and red around the sites. Resident denies any pain/discomfort to area. Cream being applied per MD order. Phone call placed to RP to update her . 05/19/2021 14:57 Note Text: MD in to assess [CONDITION(S)] to chest and right elbow, new orders as follows: [MEDICATION(S)] Cream 1%. Apply to right chest/right elbow topically three times a day for Altered skin integrity. Clean with NS (normal saline) apply Silvadine cover elbow with Kerlix and Right chest with ABD (abdominal wound dressing) and tape edges leave loosely. Start Date: 05/20/2021 . A review of the physician and physician assistant notes documented the following regarding the burn wounds. 05/20/2021 The bullous wounds from her burn is now ruptured. We will start treatment with Silvadine and keep the wounds covered with clean bandages. Patient is not having any systemic symptoms. Pain is improved. 05/24/2021 . The patient is seen today to follow-up on [MEDICATION(S)] for elbow and chest. Was wrapped in gauze today, did not unwrap at this time. Nurse states it is healing well Continue current treatment until it resolves . 05/25/2021 Wound evaluation . She has been having the [MEDICATION(S)] cream applied daily Wound to right upper chest is healing well. There is good granulation tissue. There is a small amount of epidermis in the lateral aspect, which we will remove. The right elbow is healing well as well. There is no induration, erthema, or purulent draining. Good granulation tissue appreciated Appears to be healing well without any signs of infection. We will continue [MEDICATION(S)] for next 3 days and then we will stop the [MEDICATION(S)] in order to alleviate some of the moisture. We will continue to monitor daily . 05/31/2021 . The patient is seen today for follow-up of right chest and elbow burn. Wound care has continued to treat with [MEDICATION(S)] and cover with gaze. Wish to discontinue [MEDICATION(S)] as this point to let dry. We will consult with wound care nurse. Appears to be healing well. We will continue to follow daily . 06/22/2021 . The patient is seen today with wound nurse for follow-up of her right chest and elbow wounds from [CONDITION(S)]. Wounds are now completely scabbed over. We will discontinue dry dressings and continue to monitor . A review of the clinical record weekly body audits documented the following: 05/18/2021 18:09 . Chest - right upper chest noted to be red and blistered. 1st degree burn noted. Right elbow - blistered, redness noted. A review of the clinical record documented an Area(s) of Care Concern assessment completed on 05/19/2021 by the wound nurse (LPN #5) documented the following: Identify all areas to be discussed: A10 - Other - [CONDITION(S)] .Resident noted with burn to right upper chest and right elbow Recommendations/Interventions: Treatment in place as orders by MD. Monitor for s/s (signs/symptoms) of infection. A review of the clinical record documented a Hot Liquid Safety Evaluation dated 05/20/2021 completed by the unit manager (LPN #10) that assessed Resident #9 has having muscle weakness in her upper extremities, and determined to be at risk for spilling hot liquids. There was no other hot liquid safety evaluations documented in the clinical record. A review of the facility's follow-up letter to the state agency dated May 26, 2021 documented the soup was temped at 135 degrees prior to leaving the kitchen. The investigation documented Resident #9 stated she was trying to drink her soup and just dropped it. Per the follow-up letter, the meal trays were delivered to the unity shortly before 5 p.m. and a CNA delivered the tray to the room and set up the resident for her meal. At 5:09 p.m. the unit nurse entered the room to administer Resident #9's medication and observed Resident #9 picking up her bowl of soup to drink it and spilled it on her chest and arm. The follow-up letter documented the nurse assessed the area, rendered first aid to the burn areas and notified the physician for further orders. The physician saw Resident #9 on the next day and initiated treatment changes. On May 25, 2021, the physician reassessed and stated the second-degree [CONDITION(S)] were healing without infection. A review of the facility's investigation working document completed by previous ADON (assistant director of nursing/RN #2) included interviews with staff on duty the day of the incident. The investigation documented the soup was temped at 135 degrees prior to leaving the kitchen with an acceptable range of 140-150 degrees Fahrenheit. The investigation documented the trays arrived on the floor shortly before 5 p.m. The investigation documented CNA#7 delivered and set up the tray in Resident #9's room. The nurse on duty, LPN #11 entered the room with her hands full to administer medication and witnessed Resident #9 pick up the bowl of soup and drink it. According to the investigation document, LPN #11 witnessed Resident #9 spilling soup on her chest and removed the soup from Resident #9 and observed her chest was red. LPN #11 then asked CNA #6 to come and clean up Resident #9 due to the spilled soup. The ADON's investigation documented LPN #11 came to CNA #6 while she was providing care in another room. CNA #6 stated she was instructed by LPN #11 to clean up Resident #9 due to spilled soup. CNA #6 stated she was told Resident #9 had a red area on her chest. CNA #6 stated she informed LPN #11 that she was in the middle of providing resident care and she would go when she completed the care which would take about 10 minutes. CNA #6 stated she finished her task with the other resident and went directly to Resident #9's room. CNA #6 stated that was about 10-15 minutes elapsed from time she was instructed by LPN #11 until the time she walked into Resident #9's room. Per CNA #6 upon entering Resident #9's room, she observed the resident still had on soiled blankets, clothing, and soup was still on the resident. CNA #6 stated Resident #9 had on a normal t-shirt and upon removal she noted redness to the chest and elbow. CNA #6 stated she told LPN #11 about the blisters and placed a loose gown on the resident to avoid friction to the wound. A review of the facility's witness statements for staff members working/involved with the incident documented that CNA #7 who was identified as delivering and setting-up Resident #9's tray stated she did not witness the incident because she was feeding during this time CNA #6 who was identified as cleaning up Resident #9 stated she did not witness the incident, but she did witness the resident had [CONDITION(S)] on her right chest and right elbow. LPN #11 who witnessed the incident stated Resident #9 spilled soup on self during supper. The ADON's (RN #2) interview with Resident #9 documented Resident #9 as stating, I spilled my soup., I think I tried to drink it. Additional review of the ADON's investigation documented the following: Clothing protector not in place Resident in OT (occupational therapy) from August to November. Findings during OT eval were resident needs mod to max assist with supervised meals. One person assist with set-up. Noted that resident fatigues easily during meals and leans to right. Needs assistance to maintain proper position for feeding. Resident expresses wishes to continue to self feed A review of the OT Discharge Summary for the period of 09/01/2020 through 11/13/2020 assessed Resident #9 as requiring partial/moderate assistance for eating. On 08/11/2021 at approximately 11:45 a.m., the unit manager (LPN#10) was interviewed regarding incident. LPN #10 stated she was not directly involved in the investigation; however, she did monitor Resident #9 after the incident and completed the Hot-Liquid assessment. LPN #10 was asked for any hot liquid assessments dated prior to the incident on 05/18/2021. LPN #10 stated there isn't one. As far as I'm aware we were not doing them until this incident happened. LPN #10 was asked what type of assistance did Resident #9 require with eating. LPN #10 stated, [Resident #9] has a fluctuating poor oral intake. She prefers to eat/feed herself, but she is weak in her upper extremities. She has had a decline and is on comfort care. She prefers to stay in the bed. I know the staff normally set-up her meal trays and they will then go back and forth to check on her to offer cueing and encouragement for her to eat more. I don't think they actually feed her. LPN # stated, I can get one our CNA's who works with her often & has been here a long time to give you more information. On 08/11/2021 at approximately 12:30 p.m., CNA #5 was interviewed regarding Resident #9's assistance with eating. CNA #5 stated, I will set up her meal tray and get her set up in the bed. She eats very slowly and eats a little. She prefers to feed herself. CNA #5 was asked if she assisted feeding Resident #9. CNA #5 stated, no not all the time because she wants to be independent and feed herself. I'll go in/out of the room to check on her during meal times. A lot of times she needs cueing and encouragement to take more bites or maybe to drink/eat something else on her tray, but I rarely actually feed her. CNA #5 was asked if clothing protectors were provided to all residents. CNA #5 stated, we have always offered them but if a resident refuses then we don't use them. It seems we are using them more often now since [Resident #9] burned herself. On 08/11/2021 at 2:25 p.m., the occupational therapist (OS #5) was interviewed regarding Resident #9's self-feeding ability. OS #5 reviewed the OT notes and discharge summary for the period of 09/01/2020 through 11/13/2020 and stated at that time Resident #9 did require partial to moderate assistance for eating. On 02:50 p.m. the above findings were discussed with the facility's administrator, director of nursing (DON), and corporate consultant. The facility's administrative staff was advised that Resident #9 had been burned resulting in harm because the facility staff failed to provide supervision during meals. The facility's administrative team was asked if they had been completing hot liquid assessments prior to the incident with Resident #9. The DON stated, no, we weren't unless it was indicated or observed there was a need to do so. A copy of the facility's policy on clothing protectors was requested. The administrator stated after the incident, the facility determined there were some areas of opportunity for improvement and implemented an action plan and would provide supporting documentation of the plan to the survey team. On 08/11/2021 at 4:00 p.m., the MDS coordinator (RN #1) was responsible for completing the quarterly assessment dated [DATE] was interviewed regarding Resident #9's ADL assistance for eating. RN #1 stated the coding was determined from a variety of documentation including therapy notes, CNA documentation of ADL tasks, as well as nursing observations/notes. RN #1 stated from her understanding Resident #1 required, supervision that including watching, not necessarily hands on for eating/feeding assistance. She stated this would include staff being able to go in/out of the room and monitor the resident during meals, but not necessarily feeding Resident #9. RN #1 stated, [Resident #9] eating fluctuates for eating assistance, she does requires supervision with eating because she fatigues with meals and may need some assistance with cueing and feeding. RN #1 was asked to if this should have been documented on Resident #9's care plans prior to the incident. RN #1 reviewed the care plans and stated, yes, you're right it should have been included. It's on there now, but it wasn't before she was burned. RN #1 stated she had recently completed an in-service training with all staff on how to properly identify/code residents who need ADL assistance for eating/feeding. LPN #11 who witnessed Resident #9 spilling the soup was on vacation and unavailable for interview during the survey. CNA #6 was a PRN (as needed) staff; an attempt to contact CNA #6 via telephone on 08/11/2021 was unsuccessful. CNA #7 who delivered and set up Resident #9's meal tray on the day of the incident was no longer employed by the facility, therefore no interview was completed. The ADON (RN #2) who completed the investigation at the time of the incident was no longer employed by the facility, therefore no interview was completed. On 08/11/2021 at 12:30 p.m., 2:30 p.m., and 3:30 p.m., attempts were made to interview Resident #9. At 12:30 p.m., Resident #9 was unable to communicate, her speech was unintelligible; at 2:30 p.m. and 3:30 p.m., Resident #9 was observed in her room sleeping in her bed. A review of the facility's Dining Room Meal Service policy documented: 5. Residents have the option of using a clothing protector at their request A review of the facility's plan of correction action plan dated 05/25/21 documented the following: 1. Audit and hot liquid assessment for all residents. 2. Staff education on mealtime protocol including setting residents up, providing mealtime cueing and supervision, offering clothing protectors to all residents, and center's policy on identifying patients who require supervision/cueing., etc. 3. Staff education for nurses on center's policy on [CONDITION(S)]. 4. Mealtime observation rounds for 8 weeks. 5. Updated QA monthly for three months to assess for other recommendations. On 08/11/2021 at 4:12 p.m., the administrator was asked the date of completion for the action plan. The administrator stated the plan was completed as of June 10, 2021 with continued mealtime rounds currently in place During the current survey, staff were observed providing appropriate supervision and assistance during mealtime. No other information was provided to the survey team prior to exit on 08/11/2021 at 5:15 p.m. This deficiency was cited as past non-compliance. This was a complaint deficiency.

Based on observation, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to ensure one of nine residents was free from neglect, Resident #1. No care or dressing changes were provided to Resident #1's PEG (percutaneous endoscopic gastrostomy) tube site for ten days following an assessment of bleeding and prolapsed skin around the tube. A physician's order for topical treatment and dressing changes following the assessed bleeding was not implemented. Resident #1 had no treatment orders or evidence of routine, daily care provided to the gastrostomy site for at least three months. The findings include: Resident #1 was admitted to the facility on [DATE] with a re-admission on 12/21/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #1 with moderately impaired cognitive skills and as receiving over 51% of nutritional calories through a gastric tube. Resident #1's clinical record documented a late entry nursing note (dated 7/30/21) stating, On 7/14/21 approx. [approximately] 2200 pm [10:00 p.m.] writer called to resident room by floor nurse advising peg site with moderate amount of bright red blood, upon assessment observed bright red blood at site with surrounding skin prolapsed, area cleaned by writer with NS [normal saline] pat dry, dry gauze with applied pressure to stop bleeding successful, dressing placed, writer advised floor nurse to place on list to be seen by NP [nurse practitioner] for evaluation d/t [due to] resident with HX [history] of recurrent prolapsed skin surrounding peg site. A physician's assistant (PA, other staff #4) assessed Resident #1's PEG site on 7/14/21. A PA note dated 7/14/21 documented, .The patient is seen today per nurse request due to noticing some blood around the PEG insertion site. The patient denies any pain, very mild drainage from the site. We will continue to monitor, place gauze and steroid cream . The PA documented under the plan for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .Continue monitoring PEG site. Cover with gauze and apply steroid cream. The treatment orders for steroid cream and dressing ordered by the PA on 7/14/21 in response to the bleeding PEG site were not implemented. There was no physician's order entered and no entry on Resident #1's treatment administration record (TAR) or Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other orders or entries on the July 2021 TAR regarding cleaning and/or monitoring of the PEG site. Licensed practical nurse (LPN) #9 documented a nursing note stating the resident was found on 7/24/21 with a 10-day old dressing in place on the PEG tube site. A nursing note dated 7/24/21 at 1:57 a.m. documented, Pt [patient] observed lying in bed during med pass with PEG dressing in place dated 7/14/21. Upon removal of dressing, a thick, hard, black substance was observed with pus and serosanguinous [serosanguineous] fluid. PEG site was excoriated and tender to touch. Site was cleaned and dressing removed. Dressing reported to DON [director of nursing] .attempted to begin pt tube feeding. PEG was not patent, unable to pull residual or flush .upon viewing PEG, thick sediment observed in line .attempted to flush PEG with water and was unsuccessful .attempted to pull residual and was unsuccessful. De-clogger was used .and was successful. Tube was able to be flushed .MD [physician] .contacted and assessed pt via video and gave order to send pt to ER [emergency room ] . Another nurse (LPN #8) also documented an assessment of the 10-day old PEG site dressing. A nursing note dated 7/24/21 at 3:26 a.m. documented, .This nurse assessed patient's peg tube and upon initial observation seen the dressing around the peg tube was dated '07/14/21' [nurse initials] and had a black ring on the dressing around the tube. Upon removal of dressing, dressing had moderate amount of hard black substance and pus on the bottom of the dressing touching the skin. Skin was bright red and excoriated underneath the dressing at the peg insertion site. Cleaned and dried wound area. Peg tube was not patent . [physician] assessed patient via video consult and ordered patient be transferred to local ER for further evaluation . The emergency room report dated 7/24/21 documented the resident's gastric tube was not clogged upon arrival. The ER note dated 7/24/21 documented, .upon pt arrival PEG tube flushed well with 60 ml [milliliters] water. no blockage or resistance noted .evaluation of G-tube no abnormalities were found . The resident was diagnosed with a urinary tract infection and returned to the nursing facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of Resident #1's clinical record from 5/1/21 through 7/31/21 revealed no orders for care and/or treatment the resident's PEG site. The treatment administration records for May 2021, June 2021 and July 2021 made no mention of the resident's PEG. Prior to the assessment of the bleeding PEG site on 7/14/21, nursing notes from 5/1/21 through 7/13/21 documented notes about the patency and use of the tube for feedings and included only six notes listing an assessment and/or cleansing of the PEG site. These notes did not list what the site was cleaned with or if a dressing was in place. The PEG site was cleaned without any active physician's order for care of the site. 5/6/21 - .writer noted that Resident's PEG tube site had slight bloody drainage . 5/29/21 - .Redness noted to peg site. Cleaned area . 5/31/21 - .Redness not to peg site. Cleaned area . 6/11/21 - Resident peg site has reddish drainage around site. Area was cleaned . 6/24/21 - .Resident peg tube area is cleaned . Nursing notes after the assessed bleeding on 7/14/21, dated 7/15/21 through 7/23/21, documented the PEG was patent and in place but made no mention of the dressing placed on 7/14/21. There was no follow up assessment of the bleeding at the PEG site after 7/14/21 until the nursing note on 7/24/21. The nurse's note about the bleeding PEG site and dressing placement on 7/14/21 was not documented in the clinical record until 7/30/21. There were no care orders entered or documented for Resident #1's PEG site until 8/1/21. A physician's order with start date of 8/2/21 documented, Clean feeding tube site daily with soap and water apply drain sponge every day shift. The resident's plan of care regarding the PEG tube (revised 7/14/21) documented the resident required tube feedings due to dysphagia and a failed swallow study. Care plan goals for PEG included, .insertion site will be free of s/sx [signs/symptoms] of infection .free of aspiration .will maintain adequate nutrition . Interventions to meet care plan goals included, .Check for tube placement and gastric contents/residual volume per facility protocol or MD orders. See orders .Provide stoma site care per MD order or facility policy; see TAR . On 8/10/21 at 11:20 a.m., with the resident's permission and accompanied by LPN #3, Resident #1's PEG site was observed. A clean, dry dressing was in place around the tube. There was a small amount of dark, brown drainage on the gauze dressing next to the tube. The tube site was clean, dry and without signs of infection. The resident expressed no pain at the tube site. The dressing in place on the PEG site was not dated. An access port on the gastric tubing and the attached cap were covered with a dried brown substance. LPN #3 stated at the time of the observation that the port and cap needed to be cleaned or replaced. On 8/10/21 at 11:25 a.m., LPN #3 was interviewed about cleaning and care of Resident #1's PEG site. LPN #3 stated care orders were started on 8/2/21. LPN #3 stated this was her second day working in the facility and she did not know about previous care to the PEG site. On 8/10/21 at 2:15 p.m., the unit manager (LPN #2) was interviewed about Resident #1's PEG site care and no assessment, dressing change or cleansing for 10 days in July 2021. LPN #2 stated she was told about the nurse finding the PEG site on 7/24/21 with a 10-day old dressing. LPN #2 stated she assessed the PEG site on Monday 7/26/21 and the site had no dressing, no excoriation and a small amount of drainage. LPN #2 stated the site had been cleaned prior to her assessment on 7/26/21. When asked about what care was provided to the PEG site prior to the 7/14/21 assessment of bleeding, LPN #2 reviewed the clinical record and stated she did not see any orders for care and no entries on the July TAR regarding PEG site care. LPN #2 stated the nurse applied the dressing on 7/14/21 after finding bleeding at the PEG site. LPN #2 stated she did not know why there were no further assessments or dressing changes to the PEG site until 7/24/21. LPN #2 stated she did not know why the order for the steroid cream and gauze was not implemented. On 8/10/21 at 3:50 p.m., LPN #5 responsible for wound care in the facility was interviewed about Resident #1's PEG site. LPN #5 stated the resident was known to pick and pull at the PEG tube. LPN #5 stated the nurse on 7/14/21 assessed the PEG site with bleeding and applied a dressing. LPN #5 stated she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #5 stated the PA saw the resident on 7/14/21 and documented treatment with steroid cream and a dressing. LPN #5 stated she found no order entered or implemented for the steroid cream and dressing. LPN #5 stated she was asked to assess Resident #1's PEG site on 7/24/21 and she found the site open to air, with no swelling or drainage and with a small amount of blood noted. LPN #5 stated it was expected that PEG tube sites be cleaned daily with soap and water and care was supposed to be documented on the treatment administration record. LPN #5 stated dressings were applied to PEG sites if ordered by the physician. On 8/11/21 at 8:00 a.m., LPN #5 was interviewed again about any policy or protocols for care of PEG sites. LPN #5 stated the facility had no policy about PEG tube feedings or site care but the electronic health record had care options, when selected, that made entries on the treatment administration record for implementation by nurses. LPN #5 stated the care options included flushes, intake monitoring, cleaning of tube site daily with soap and water and checking residuals. LPN #5 stated the options for site cleansing were not selected for Resident #1 until a physician's order for the care was entered on 8/1/21. LPN #5 stated the order for the steroid cream and dressing were not entered into the record. On 8/11/21 at 8:50 a.m., the PA (other staff #4) caring for Resident #1 was interviewed about the PEG site care. The PA stated she assessed Resident #1 on 7/14/21 after nursing reported bleeding from the PEG site and she ordered steroid cream and a dressing daily as treatment. The PA stated she was not aware the steroid cream/dressing were not implemented until this morning (8/11/21). The PA did not know why the order was never entered or implemented. The PA stated PEG sites typically required daily cleansing with soap/water or normal saline but did not always need a dressing unless there was drainage. On 8/11/21 at 10:40 a.m., the director of nursing (DON) was interviewed about Resident #1's lack of PEG site care. The DON stated nurses go by the physician orders for care and the appropriate menu options for care were selected from the electronic health record options based upon orders. The DON stated there were no orders for care prior to 8/1/21. The DON stated in general, PEG sites required daily cleansing and this was part of their bath. Concerning the assessed bleeding and dressing applied on 7/14/21, the DON stated there should have been a physician's order for the dressing/care. When asked about no orders from May 2021 through 7/14/21 for routine cleansing/care of the PEG site, the DON stated, It is part of general skin care and part of the bath. The DON stated there should be a physician's order if a dressing was applied to the site. The nurse that applied the PEG dressing on 7/14/21 was not available for interview during the survey. LPN #8 and LPN #9 that found the 10-day old dressing in place on 7/24/21 were temporary agency staff and no longer worked at the facility. The facility's policy titled Abuse Prevention (revised 1/2017) documented, The facility is committed to maintaining a safe and abuse-free environment for all residents and committed to a comprehensive investigation of any allegation of activities or situations that may constitute abuse .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .A comprehensive assessment and individualized care plan will be developed for each resident to assist staff in providing effective interventions to prevent abuse and meet the resident's need . These findings were reviewed with the administrator, DON and corporate consultant during a meeting on 8/10/21 at 5:00 p.m. and on 8/11/21 at 4:20 p.m.

Based on observation, staff interview, clinical record review and complaint investigation, the facility staff failed to provide assessment, monitoring and implement a plan of care regarding a penile split for one of nine residents in the survey sample. Resident #1, assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #1 was admitted to the facility on [DATE] with a re-admission on 12/21/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #1 with moderately impaired cognitive skills and as receiving over 51% of nutritional calories through a gastric tube. Resident #1's clinical record documented the resident had a Foley urinary catheter since his admission due to [CONDITION(S)] with urine retention. Resident #1's clinical record documented a nursing note by licensed practical nurse (LPN) #9 dated 7/24/21 at 1:57 a.m. stating, .further assessment of the patient, urine in foley bag was reddish brown with sediment and pus observed. Following the catheter from foley bag to insertion point this nurse observed pt [patient's] tip of penis to be slightly blue and penis shaft split horizontally with a penny sized hole at the base of penis that foley could be observed through. Pt c/o [complained of] pain during assessment and asked to speak with a doctor. Attempted to retrieve documentation regarding this issue being chronic or new and this writer was unable to find any documentation that this was a chronic issue that had been previously addressed. MD [physician] .contacted and assessed pt via video and gave order to send pt to ER [emergency room ] .Upon receiving pt ER nurse .called to ask if pt was currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] .[ER nurse] stated .that penis being split was a chronic issue because it is in healing process and 'looks good' This nurse asked [ER nurse] if penile split and penny sized hole at base of penis was observed and she responded that it was observed and that it was a 'chronic issue' . (Sic) LPN #8 also documented assessment of the resident's penis on 7/24/21. A nursing note dated 7/24/21 at 3:26 a.m. documented, .reddish tea colored urine in the foley bag and moderate amount of sediment down the side of the foley bag. Further inspection of catheter led to observation of pus discharging out of head of penis .found the penis was horizontally split side to side and down the middle of penis shaft .catheter visible at the base of penis and testicles through a penny size hole that was red and excoriated . [physician] assessed patient via video consult and ordered patient be transferred to the local ER .Patient's groin had a foul odor and excoriated . A telemedicine assessment dated [DATE] documented, On nursing rounds pt noted to have dark urine in foley bag. on initial assessment purulent drainage seen at head of penis. On closer examination with brief removed, the catheter seems to have torn from urinary meatus down to almost base of penis .No obvious distress. Tip of penis seems slightly cyanotic as well .Large nonbleeding laceration down lateral aspect of penis with catheter seeming to be inserted at the base .Catheter associated trauma .pt needs assessment sooner as opposed to delayed .Will therefore send to ER for evaluation . The ER report dated 7/24/21 documented the reason for the visit included, Nurse also reports pt penis is split and is unsure if the issue is chronic. Pt does have long term foley in place . The ER physician assessment documented, .he has a Foley catheter in place. It looks like the penis has been split in half and easily falls back but this looks chronic there was no bleeding and there is granulation tissue present testes were nontender is no drainage around the site . (Sic) The resident was diagnosed with a urinary tract infection and returned to the facility with orders for an antibiotic. A physician's progress note dated 7/27/21 documented, .seen today at the request of the administration nursing staff for evaluation of the patient's chronic Foley catheter .There have been concerns brought up by one of agency nurses regarding the patient's Foley catheter and the changes to his penis because of this .Foley catheter in place. The penis if filleted from the urethral meatus down approximately an inch down the shaft. There is no [CONDITION(S)] or drainage from the penis .patient's penis has chronic changes associated with chronic Foley catheter placement including filleting of the penis down to approximately mid shaft. This is something that is seen with patients who have Foley catheters placed for a long period of time. There is no infectious process occurring . (Sic) Resident #1's clinical record documented the resident had a Foley catheter in place since his admission due to urinary retention. Further review of Resident #1's clinical record documented no ongoing assessments or monitoring of the penile split/erosion prior to the nursing note on 7/14/21. The resident's care plan prior to 7/30/21 made no mention the resident had a filleted/split penis. The first mention of the penile erosion in the clinical record was from a urologist consultation report dated 2/26/20 performed during a hospitalization . This report documented, .longstanding indwelling Foley catheter for years .No [CONDITION(S)] .On the ventral aspect of the penis there is a urethral resection from a contact necrosis from his indwelling Foley catheter. It extends approximately 2 cm [centimeters] proximally. There is no surrounding [CONDITION(S)] discharge stenosis or other pathology . A facility readmission assessment and body audit dated 2/26/20 documented no assessment of the penile split identified by the urologist. Body audits/skin assessments documented no ongoing assessments of the resident's penile split prior to the 7/24/21 nursing note. Body audits dated 9/24/20, 10/1/20 and 10/22/20 documented, penial erosion due to catheter use but included no description, exact location or size of the erosion/split. A skin/wound evaluation dated 7/24/21 documented a healed penis wound measuring 4.6 cm x 3.8 cm by 0.3 cm (length by width by depth in centimeters) with notification to the physician's assistant (PA). Resident #1's plan of care made no mention of the resident's penile split or erosion prior to 7/30/21. The plan of care documented the resident had a catheter due to [CONDITION(S)] and was noted to pull on the catheter tubing at times. Interventions to prevent complications from catheter use included, changing tubing/bag as ordered, urologist as needed, ensure tubing was kink-free, observe for changes in urine output, color, odor, pain and report, ensure bag was below level of bladder and catheter care as ordered. The problem, Noted with filleting of shaft due to chronic foley was added on 7/30/21 but there were no interventions regarding monitoring of the penile split for changes. On 8/10/21 at 11:20 a.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #3, Resident #1's Foley catheter and penis were observed. The resident had a healed split along the underside of the penis from the head to the base approximately 2 inches in length. The split was deep red in color with no open areas observed. LPN #3 was interviewed at this time about the penile split. LPN #3 stated this was her second day in the facility and she was not familiar with the resident's history. On 8/10/21 at 2:15 p.m., the unit manager (LPN #2) was interviewed about assessment of Resident #1's penile split prior to 7/24/21. LPN #2 stated the wound nurse advised her the split had been there awhile. LPN #2 stated she did not find a prior assessment of the penile erosion/split, did not know when the erosion started and did not understand why that condition was not noted in the clinical record. LPN #2 stated she was not aware of the penile split until the nursing assessment/note of 7/24/21 when the resident was sent to the emergency room for evaluation. LPN #2 stated the wound nurse assessed the resident's penis following the ER visit on 7/24/21. On 8/10/21 at 3:50 p.m., LPN #5 responsible for wound care in the facility was interviewed about Resident #1's penile split. LPN #5 stated she was not sure when the resident acquired the penile split but she thought the status was followed by urology. LPN #5 reviewed the record and stated the resident was last seen by urology in September 2020. LPN #5 stated she reviewed the weekly body audits since September 2020 and stated the audits were done as required but only several of the audits mentioned penile erosion. LPN #5 stated the penile split was healed and did not required current treatment but she was not sure why there were no assessments or monitoring of the split. On 8/10/21 at 4:10 p.m., the certified nurses' aide (CNA #4) that routinely cared for Resident #1 was interviewed about the split penis. CNA #4 stated the night shift staff usually bathed Resident #1 and she was not aware the penis was split. CNA #4 stated the resident pulled on his catheter tubing at times but she had not noticed a split penis when providing care. On 8/11/21 at 8:00 a.m., LPN #5 stated she reviewed the body audit history and did not find any record of measurements or description of Resident #1's penile split prior to 7/24/21. LPN #5 stated because the split was healed and did not require treatment, she did not think nurses included it on the body audits. On 8/11/21 at 8:40 a.m., the registered nurse responsible for care plans (RN #1) was interviewed about any plan of care prior to the 7/24/21 assessment of the penile split. RN #1 stated she did not recall any discussion about the penile split in care plan meetings. RN #1 reviewed the care plan history and stated she did not find anything in the plan about the penile split/erosion prior to 7/30/21. On 8/11/21 at 8:50 a.m., the PA (other staff #4) caring for Resident #1 was interviewed about the penile split/erosion. The PA stated she had cared for the resident only for a couple of months and was not sure when the split originated. The PA stated the erosion and split was due to chronic Foley catheter placement. On 8/11/21 at 9:30 a.m., LPN #5 stated she reassessed Resident #1's penile split and presented a documented assessment. The assessment dated [DATE] documented the resident had a split measuring 5.5 cm x 2.4 cm x 0.3 cm (length by width by depth) with no signs of infection. These findings were reviewed with the administrator and director of nursing during a meeting on 8/10/21 at 5:00 p.m. and on 8/11/21 at 4:20 p.m.

Based on observation, staff interview, clinical record review and complaint investigation, the facility staff failed to provide proper care to gastric tube sites for two of nine residents in the survey sample. No care or dressing changes were provided to Resident #1's PEG (percutaneous endoscopic gastrostomy) tube site for ten days following an assessment of bleeding and prolapsed skin around the tube. A physician's order for topical treatment and dressing changes following the assessed bleeding was not implemented and the resident had no treatment orders or evidence of routine, daily care provided to the gastrostomy site for at least three months. Resident #4 was observed with a dressing taped over her gastrostomy site without a physician's order for care/treatment. The findings include: 1. Resident #1 was admitted to the facility on [DATE] with a re-admission on 12/21/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #1 with moderately impaired cognitive skills and as receiving over 51% of nutritional calories through a gastric tube. Resident #1's clinical record documented a late entry nursing note (dated 7/30/21) stating, On 7/14/21 approx. [approximately] 2200 pm [10:00 p.m.] writer called to resident room by floor nurse advising peg site with moderate amount of bright red blood, upon assessment observed bright red blood at site with surrounding skin prolapsed, area cleaned by writer with NS [normal saline] pat dry, dry gauze with applied pressure to stop bleeding successful, dressing placed, writer advised floor nurse to place on list to be seen by NP [nurse practitioner] for evaluation d/t [due to] resident with HX [history] of recurrent prolapsed skin surrounding peg site. A physician's assistant (PA, other staff #4) assessed Resident #1's PEG site on 7/14/21. A PA note dated 7/14/21 documented, .The patient is seen today per nurse request due to noticing some blood around the PEG insertion site. The patient denies any pain, very mild drainage from the site. We will continue to monitor, place gauze and steroid cream . The PA documented under the plan for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .Continue monitoring PEG site. Cover with gauze and apply steroid cream. The treatment orders for steroid cream and dressing ordered by the PA on 7/14/21 in response to the bleeding PEG site were not implemented. There was no physician's order entered and no entry on Resident #1's treatment administration record (TAR) or Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other orders or entries on the July 2021 TAR regarding cleaning and/or monitoring of the PEG site. Licensed practical nurse (LPN) #9 documented a nursing note stating the resident was found on 7/24/21 with a 10-day old dressing in place on the PEG tube site. A nursing note dated 7/24/21 at 1:57 a.m. documented, Pt [patient] observed lying in bed during med pass with PEG dressing in place dated 7/14/21. Upon removal of dressing, a thick, hard, black substance was observed with pus and serosanguinous [serosanguineous] fluid. PEG site was excoriated and tender to touch. Site was cleaned and dressing removed. Dressing reported to DON [director of nursing] .attempted to begin pt tube feeding. PEG was not patent, unable to pull residual or flush .upon viewing PEG, thick sediment observed in line .attempted to flush PEG with water and was unsuccessful .attempted to pull residual and was unsuccessful. De-clogger was used .and was successful. Tube was able to be flushed .MD [physician] .contacted and assessed pt via video and gave order to send pt to ER [emergency room ] . Another nurse (LPN #8) also documented an assessment of the 10-day old PEG site dressing. A nursing note dated 7/24/21 at 3:26 a.m. documented, .This nurse assessed patient's peg tube and upon initial observation seen the dressing around the peg tube was dated '07/14/21' [nurse initials] and had a black ring on the dressing around the tube. Upon removal of dressing, dressing had moderate amount of hard black substance and pus on the bottom of the dressing touching the skin. Skin was bright red and excoriated underneath the dressing at the peg insertion site. Cleaned and dried wound area. Peg tube was not patent . [physician] assessed patient via video consult and ordered patient be transferred to local ER for further evaluation . The emergency room report dated 7/24/21 documented the resident's gastric tube was not clogged upon arrival. The ER note dated 7/24/21 documented, .upon pt arrival PEG tube flushed well with 60 ml [milliliters] water. no blockage or resistance noted .evaluation of G-tube no abnormalities were found . The resident was diagnosed with a urinary tract infection and returned to the nursing facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of Resident #1's clinical record from 5/1/21 through 7/31/21 revealed no orders for care and/or treatment the resident's PEG site. The treatment administration records for May 2021, June 2021 and July 2021 made no mention of the resident's PEG. Prior to the assessment of the bleeding PEG site on 7/14/21, nursing notes from 5/1/21 through 7/13/21 documented notes about the patency and use of the tube for feedings and included only six notes listing an assessment and/or cleansing of the PEG site. These notes did not list what the site was cleaned with or if a dressing was in place. The PEG site was cleaned without any active physician's order for care of the site. 5/6/21 - .writer noted that Resident's PEG tube site had slight bloody drainage . 5/29/21 - .Redness noted to peg site. Cleaned area . 5/31/21 - .Redness not to peg site. Cleaned area . 6/11/21 - Resident peg site has reddish drainage around site. Area was cleaned . 6/24/21 - .Resident peg tube area is cleaned . Nursing notes after the assessed bleeding on 7/14/21, dated 7/15/21 through 7/23/21, documented the PEG was patent and in place but made no mention of the dressing placed on 7/14/21. There was no follow up assessment of the bleeding at the PEG site after 7/14/21 until the nursing note on 7/24/21. The nurse's note about the bleeding PEG site and dressing placement on 7/14/21 was not documented in the clinical record until 7/30/21. There were no care orders entered or documented for Resident #1's PEG site until 8/1/21. A physician's order with start date of 8/2/21 documented, Clean feeding tube site daily with soap and water apply drain sponge every day shift. The resident's plan of care regarding the PEG tube (revised 7/14/21) documented the resident required tube feedings due to dysphagia and a failed swallow study. Care plan goals for PEG included, .insertion site will be free of s/sx [signs/symptoms] of infection .free of aspiration .will maintain adequate nutrition . Interventions to meet care plan goals included, .Check for tube placement and gastric contents/residual volume per facility protocol or MD orders. See orders .Provide stoma site care per MD order or facility policy; see TAR . On 8/10/21 at 11:20 a.m., with the resident's permission and accompanied by LPN #3, Resident #1's PEG site was observed. A clean, dry dressing was in place around the tube. There was a small amount of dark, brown drainage on the gauze dressing next to the tube. The tube site was clean, dry and without signs of infection. The resident expressed no pain at the tube site. The dressing in place on the PEG site was not dated. An access port on the gastric tubing and the attached cap were covered with a dried brown substance. LPN #3 stated at the time of the observation that the port and cap needed to be cleaned or replaced. On 8/10/21 at 11:25 a.m., LPN #3 was interviewed about cleaning and care of Resident #1's PEG site. LPN #3 stated care orders were started on 8/2/21. LPN #3 stated this was her second day working in the facility and she did not know about previous care to the PEG site. On 8/10/21 at 2:15 p.m., the unit manager (LPN #2) was interviewed about Resident #1's PEG site care and no assessment, dressing change or cleansing for 10 days in July 2021. LPN #2 stated she was told about the nurse finding the PEG site on 7/24/21 with a 10-day old dressing. LPN #2 stated she assessed the PEG site on Monday 7/26/21 and the site had no dressing, no excoriation and a small amount of drainage. LPN #2 stated the site had been cleaned prior to her assessment on 7/26/21. When asked about what care was provided to the PEG site prior to the 7/14/21 assessment of bleeding, LPN #2 reviewed the clinical record and stated she did not see any orders for care and no entries on the July TAR regarding PEG site care. LPN #2 stated the nurse applied the dressing on 7/14/21 after finding bleeding at the PEG site. LPN #2 stated she did not know why there were no further assessments or dressing changes to the PEG site until 7/24/21. LPN #2 stated she did not know why the order for the steroid cream and gauze was not implemented. On 8/10/21 at 3:50 p.m., LPN #5 responsible for wound care in the facility was interviewed about Resident #1's PEG site. LPN #5 stated the resident was known to pick and pull at the PEG tube. LPN #5 stated the nurse on 7/14/21 assessed the PEG site with bleeding and applied a dressing. LPN #5 stated she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #5 stated the PA saw the resident on 7/14/21 and documented treatment with steroid cream and a dressing. LPN #5 stated she found no order entered or implemented for the steroid cream and dressing. LPN #5 stated she was asked to assess Resident #1's PEG site on 7/24/21 and she found the site open to air, with no swelling or drainage and with a small amount of blood noted. LPN #5 stated it was expected that PEG tube sites be cleaned daily with soap and water and care was supposed to be documented on the treatment administration record. LPN #5 stated dressings were applied to PEG sites if ordered by the physician. On 8/11/21 at 8:00 a.m., LPN #5 was interviewed again about any policy or protocols for care of PEG sites. LPN #5 stated the facility had no policy about PEG tube feedings or site care but the electronic health record had care options, when selected, that made entries on the treatment administration record for implementation by nurses. LPN #5 stated the care options included flushes, intake monitoring, cleaning of tube site daily with soap and water and checking residuals. LPN #5 stated the options for site cleansing were not selected for Resident #1 until a physician's order for the care was entered on 8/1/21. LPN #5 stated the order for the steroid cream and dressing were not entered into the record. On 8/11/21 at 8:50 a.m., the PA (other staff #4) caring for Resident #1 was interviewed about the PEG site care. The PA stated she assessed Resident #1 on 7/14/21 after nursing reported bleeding from the PEG site and she ordered steroid cream and a dressing daily as treatment. The PA stated she was not aware the steroid cream/dressing were not implemented until this morning (8/11/21). The PA did not know why the order was never entered or implemented. The PA stated PEG sites typically required daily cleansing with soap/water or normal saline but did not always need a dressing unless there was drainage. On 8/11/21 at 10:40 a.m., the director of nursing (DON) was interviewed about Resident #1's lack of PEG site care. The DON stated nurses go by the physician orders for care and the appropriate menu options for care were selected from the electronic health record options based upon orders. The DON stated there were no orders for care prior to 8/1/21. The DON stated in general, PEG sites required daily cleansing and this was part of their bath. Concerning the assessed bleeding and dressing applied on 7/14/21, the DON stated there should have been a physician's order for the dressing/care. When asked about no orders from May 2021 through 7/14/21 for routine cleansing/care of the PEG site, the DON stated, It is part of general skin care and part of the bath. The DON stated there should be a physician's order if a dressing was applied to the site. The nurse that applied the PEG dressing on 7/14/21 was not available for interview during the survey. LPN #8 and LPN #9 that found the 10-day old dressing in place on 7/24/21 were temporary agency staff and no longer worked at the facility. These findings were reviewed with the administrator, DON and corporate consultant during a meeting on 8/10/21 at 5:00 p.m. and on 8/11/21 at 4:20 p.m. 2. Resident #4 was admitted to the facility on [DATE] with a readmission on 8/9/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #4 with severely impaired cognitive skills and as receiving 51% or more of nutritional calories through a gastric tube. Resident #4's clinical record documented the resident was recently hospitalized for decreased intake with vomiting and was readmitted to the facility on [DATE] and had a PEG (percutaneous endoscopic gastrostomy) placement in July 2021. On 8/10/21 at 2:45 p.m., accompanied by licensed practical nurse (LPN) #6, Resident #4's PEG tube site was observed. The resident's site was covered by two split gauze pads attached to the resident's stomach with two 1-inch wide strips of clear tape. The resident winced and moved as LPN #6 pulled the tape from the skin to view the PEG site. There was a small amount of yellow/brown drainage on the gauze and around the tube site. There was no date or initials on the dressing indicating who or when the dressing was applied. On 8/10/21 at 3:00 p.m., Resident #4's clinical record was reviewed with no physician orders found for a PEG site dressing or care. There were no entries on the resident's treatment administration record for 8/9/21 or 8/10/21 indicating care/treatment to the PEG site. Nursing notes for 8/9/21 and 8/10/21 made no mention of the application of a taped dressing. On 8/11/21 at 10:40 a.m., the director of nursing (DON) was interviewed about PEG care. The DON stated nurses were supposed to go by physician orders for PEG care. The DON stated if a dressing was in place on a PEG site, there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/11/21 at 11:35 a.m., the licensed practical nurse unit manager (LPN #2) was interviewed about the Resident #4's dressing in place without an order. LPN #2 stated the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 stated the wound nurse entered an order today (8/11/21) for PEG site care but she did not know why PEG care was not implemented when the resident was readmitted on [DATE]. LPN #2 reviewed the record and stated she did not know who or when the taped dressing was applied to the resident's PEG site. LPN #2 stated there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This finding was reviewed with the administrator and DON during a meeting on 8/11/21 at 4:20 p.m.

Based on observation, resident interview, staff interview and facility document review, the facility staff failed to ensure one of 25 residents (Resident #9) was provided food that accommodated and honored the resident's food preferences regarding likes and dislikes. Finding include: Resident #9 was admitted to the facility originally on 04/30/21. Diagnoses for Resident #9 included, but was not limited to: [CONDITION(S)], high blood pressure, peripheral vascular disease, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and dementia. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was cognitively intact for daily decision making skills. During an interview with Resident #9 on 04/27/21 at 11:15 AM, the resident was asked about the food at the facility. The resident stated that the food was pretty good, but staff were repeatedly bringing her things on her tray that she did not like and would not eat. Resident #9 stated that she doesn't like gravy, doesn't like it on her food, she doesn't like green vegetables, doesn't like eggs and doesn't like sausage. At approximately 11:45 PM, the lunch trays arrived to the unit. Resident #9 was given her lunch tray. Resident #9 stated, See, while pointing to her lunch tray. The resident had chicken tenders, mashed potatoes, and lima beans. The resident stated that this happens all the time and again stated that she did not like green vegetables. The resident's lunch tray slip was on the resident's tray and documented, .Dislikes: Fish, eggs, gravy, vegetables (green), meat (sausage) . On 04/28/21 at approximately 8:00 AM, Resident #9 was sitting in the dining area with her breakfast tray in front of her. The resident had eggs, gravy and sausage on her breakfast tray. The resident's breakfast tray slip was observed and documented, Dislikes: Eggs, gravy, meat (sausage) . Resident #9 stated that she kept telling them, but they keep bringing and that it happens all the time. Resident #9's clinical records were reviewed and included a current order for a NAS (no added salt) regular texture thin consistency diet. Resident #9's CCP (comprehensive care plan) was reviewed and documented, .at risk for altered nutrition .Discuss food preferences with resident .Honor food requests as possible . A nursing note dated 02/24/2021 and timed 5:54 PM documented, .Resident refused dinner, resident stated I do not eat gravy/sauce RP [responsible party] aware. On 04/28/21 at approximately 3:30 PM, the DM (dietary manger) was interviewed. The DM stated that she does ask residents their food preferences on admission and then quarterly and will document any changes. The DM stated that after the preferences are completed, that information is put into the computer Tray Tracker for the tray tickets to print out with the resident's preferences. The DM was made aware that Resident #9 had been observed for two meals and both meals had items on the tray that were listed on the tray ticket as dislikes for this resident. The DM stated that the facility has a caller and a [NAME] in the kitchen on the tray line, one will call out what is on the resident's ticket and then the other staff will plate what is called out to them. The DM stated that the only thing she could figure, was that the caller wasn't reading the ticket in it's entirety in order for the person who plates the food to accurately plate what the resident's requests were. The administrator and DON (director of nursing) were made aware in a meeting with the survey team on 04/28/21 at 4:30 PM. On 04/29/21 at 7:55 AM, Resident #9 was observed again at breakfast. Resident #9's breakfast tray had a waffle, bacon, hash browns, banana, tea and coffee. Resident #9 stated that the DM came and spoke with her that morning regarding the preferences. On 04/29/21 at approximately 8:25 PM, the administrator presented a policy on Tray Line Service, the policy documented, .The first employee on the tray line is responsible for reading the tray card aloud including diet, dislikes, special needs, and adaptive equipment .Each employee is responsible for checking tray accuracy. The final check is made by the employee loading the tray into the cart and/or the supervisor. To minimize distractions, talking during tray line is limited to the task at hand . The last documented dietary communication form for Resident #9 was dated 07/09/2020. This dietary communication form documented, .Resident does not like fish, sausage, eggs, no gravy, green vegetables . No further information and/or documentation was presented prior to the exit conference on 04/29/21 to evidence that the facility staff accommodated and/or honored food preferences for Resident #9.

Based on observation, staff interview and clinical record review, the facility staff failed to provide a physician ordered dressing change to a pressure ulcer for one of 25 residents in the survey sample, Resident #33. Staff failed to provide a dressing change as ordered for Resident #33's stage 4 sacral pressure ulcer. The findings include: Resident #33 was admitted to the facility on [DATE] with a re-admission on 6/12/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) assessed Resident #33 with short and long-term memory problems and severely impaired cognitive skills. Resident #33's clinical record included a wound evaluation dated 4/20/21 documenting the resident had a stage 4 sacral pressure ulcer measuring 3.2 cm x 3.0 cm x 3.0 cm (length by width by depth in centimeters) with 2.5 cm of undermining. Resident #33's clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #33's treatment record documented the ordered dressing change/treatment was not completed on Friday 4/23/21 as ordered. There was no documented explanation on 4/23/21 about why the dressing change was not completed. A nursing note dated 4/24/21 documented, Resident's wound vac [NPWT] was not changed yesterday, this writer in to change wound vac this am but did not have proper supplies to change vac. Called . [physician service] and order given to do wet to dry until Monday [4/26/21]. Dressing applied . A telephonic note from the resident's physician dated 4/24/21 at 10:25 a.m. documented, .Resident has wound being treated with a wound vac on the sacrum. Nursing reports no wound vac supplies at this time .Nurse substituting wound vac dressing with wet-to-dry dressing, due to lack of wound vac supplies . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 4/25/21 at 4:34 a.m., documented, Resident in room extremely agitated at this time, resident says her butt hurts, upon inspection her wound dressing was saturated and falling off. Irrigated with N/S [normal saline] and replaced with new wet to dry . On 4/28/21 at 10:30 a.m., accompanied by LPN #4, a dressing change to Resident #33's sacral pressure ulcer was observed. The resident had a circular, stage 4 pressure ulcer on her sacrum approximately 1 inch in diameter and 1 inch in depth. The wound was without signs of infection and had a light amount of serosanguineous drainage. The skin around the wound was pink/red in color. On 4/28/21 at 1:00 p.m., the licensed practical nurse unit manager (LPN #2) was interviewed about the missed dressing change on 4/23/21 due to lack of supplies. LPN #2 stated she was not aware of inadequate wound vac supplies but would investigate. On 4/28/21 at 3:30 p.m., the director of nursing (DON) was interviewed about the missed dressing change for Resident #33. The DON stated the facility's wound nurse was currently out on leave so the floor nurses were performing dressing changes/treatments. The DON stated on the evening of 4/23/21 the wound treatment cart with supplies was locked in the MDS office. The DON stated the floor nurses did not have access to the MDS office. The DON stated an on-call supervisor was available on the evening of 4/23/21 but the supervisor was not notified or questioned about a need for the supplies. The DON stated the nurse working the evening of 4/23/21 was new (LPN #5) and may not have known who to contact or where to look for the supplies. The DON stated that she was also available by phone after business hours but was not contacted about where to locate the wound vac supplies for Resident #33. On 4/29/21 at 8:30 a.m., the unit manager (LPN #2) was interviewed again about the missed dressing change. LPN #2 stated she did not know why the nurse did not notify the supervisor about the lack of supplies, as they were available in the wound treatment cart. This finding was reviewed with the administrator and director of nursing during a meeting on 4/28/21 at 4:00 p.m. The National Pressure Injury Advisory Panel (NPIAP) defines a stage 4 pressure injury as, Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur . (1) (1) NPIAP Pressure Injury Stages. National Pressure Injury Advisory Panel. 2016. Westford, MA. 4/29/21. https://npiap.com/page/PressureInjuryStages

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure one of 25 residents in the survey sample was free from unnecessary [CONDITION(S)] medications. Resident #87 had physician orders for as needed (PRN) [CONDITION(S)] medications that extended for more than 14 days without a stop date. The findings include: Resident #87 was admitted to the facility on [DATE] with diagnoses that included muscle wasting, [CONDITION(S)], [CONDITION(S)] disease, type 2 diabetes, hypertension, major depressive disorder, anxiety disorder, and peripheral vascular disease. The most recent minimum data set (MDS) dated [DATE] was the admission assessment assessed Resident #87 as moderately impaired for daily decision making with a score of 10 out of 15. On 04/28/2021, Resident #87's clinical record was reviewed. Observed on the physician's order summary was the following: [MEDICATION(S)] Tablet 0.5 MG (milligrams) (LORazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety. Order date: 04/08/2021 Start date: 04/08/2021 . [MEDICATION(S)] HCI Tablet 50 MG (milligrams) Give 1 tablet by mouth every 4 hours as needed for anxiety. Order Date: 04/08/2021 Start Date: 04/08/2021 There was no documented stop date for the PRN (as needed) [MEDICATION(S)] or PRN [MEDICATION(S)] HCI orders. A review of the medication administration record (MAR) for the month of April 2021 documented Resident #87 received a dose of the PRN [MEDICATION(S)] HCI on 04/15/2021. The MAR did not document Resident #87 received any doses of the PRN [MEDICATION(S)]. A review of the progress notes documented the following: 04/26/2021 Pharmacy Consultant Note. Note text: Clarify durations on prns (as needed) - rec (recommended) to provider. Medications and chart reviewed On 04/28/2021 at 2:02 p.m., the unit manager (RN #2) was interviewed regarding Resident #87's use of the medication. RN #2 stated she personally had not administered either of the medications to Resident #87. RN #2 was asked if Resident #87 displayed any anxiety or behaviors. RN #2 stated, no, not that I am aware of. Overall he has settled in and his main concern is he wants to transfer to a facility where he will be allowed to smoke. A review of the facility's My Remedi Clinical Pharmacology drug description (revised 7/14/2017) documented the following for the [MEDICATION(S)] HCI medication: [MEDICATION(S)] is a [MEDICATION(S)] class sedating antihistamine (H1-blocker) The drug is considered an effective alternate treatment for anxiety disorders (e.g. generalized anxiety) Classifications: Antihistamines Neurological Agents [CONDITION(S)] Agents For the short-term treatment of anxiety, tension, and psychomotor agitation in conditions of emotional stress On 04/28/2021 at 3:53 p.m. the administrator, DON (director of nursing), and assistant director of nursing (ADON) were informed of the above findings during a meeting.

Based on observation, facility document review and staff interview, the facility staff failed to serve food in a sanitary manner. An employee without a hair restraint walked through the main kitchen during plating of food as a shortcut to the back hallway. The findings include: On 4/27/21 at 11:15 a.m., three dietary employees were observed in the main kitchen plating food items from the steam table for lunch service. On 4/27/21 at 11:31 a.m., during the plating of food, an employee entered the kitchen from the dining room, walked past the steam table and food trays, and exited the kitchen through the door beside the walk-in freezer. This employee had no hair restraint in use. On 4/27/21 at 11:35 a.m., this employee re-entered the kitchen without a hair restraint from the back hall entrance. The dietary manager identified this employee as a dietary aide that had been called in to work. On 4/27/21 at 11:35 a.m., the dietary aide (other staff #2) was interviewed about walking through the kitchen during meal service without a hair restraint. The dietary aide stated she was going to the back hall and cut through the kitchen. The dietary aide stated she usually went through unit one to get to the back hall but today came through the kitchen as a shortcut. On 4/27/21 at 11:37 a.m., the dietary manager was interviewed. The dietary manager stated anyone in the kitchen was to have on a hair restraint. The dietary manager stated, They get in a hurry. The facility's policy Access to Kitchen (revised 9/2017) documented, Only staff members conducting food service business are permitted in the kitchen. Any staff entering the kitchen must wear hair restraints .Any staff working in the kitchen will wear hair restraints and follow safe food handling practices. This finding was reviewed with the administrator and director of nursing during a meeting on 4/28/21 at 4:00 p.m.

Based on clinical record review and staff interview, the facility staff failed to accurately complete an MDS assessment for one of 25 residents, Resident #99. Resident #99's discharge status was incorrectly coded as acute hospitalization . Findings were: Resident #99 was admitted on [DATE] and readmitted on [DATE]. Her diagnosis, included but were not limited to: Diabetes mellitus, [CONDITION(S)], COVID, and urinary tract infection. The initial MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2021, coded Resident #83 as cognitively intact with a summary score of 14. Resident #99 was added to the survey sample as a closed record and identified as hospital discharge. Review of the progress note section on 04/28/2021 at approximately 11:00 a.m., revealed the following information: 03/08/2021 11:20 [a.m.] Writer spoke with [name] POA [power of attorney] of resident. She states the plans are to still come and get her [Resident #99] on 03/08/2021 at 11 a.m 03/09/2021 09:07 [a.m.] Resident to be discharged to day 3/9/21. Family educated on resident's medication times and dosing as well as resident's transfers. Currently awaiting family arrival for discharge . 03/09/2021 11;18 [a.m.] Resident being discharged from facility at this time all personal belongings and medications taken with her at this time no distress noted upon departure all medication instructions given at discharge [sic no punctuation in this entry]. 03/09/2021 12:02 [p.m.] .Patient is scheduled to discharge home with family today . The discharge MDS with an ARD of 03/09/2021 was reviewed. In section A2100 Discharge Status, Resident #83 was coded as being discharged to an Acute Hospital. On 04/28/2021 at approximately 11:25 a.m., RN (registered nurse) #1, who worked in the MDS office, was interviewed. She stated, I see that it is coded incorrectly, she was discharged home, not to the hospital .I didn't do this one .we had travelors and remote workers at the time it was completed. One of them may have made the error .I will do a correction. The above information was discussed with the DON (director of nursing) and the administrator on 04/29/2021. No further information was received prior to the exit conference on 04/29/2021.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure a safe transfer for one of 26 residents in the survey sample resulting in a fractured humerus (upper arm); failed to ensure a call bell was accessible for one of 26 residents in the survey sample; and failed to ensure placement of wheelchair footrests and physician ordered plates/platforms for one of 16 residents in the survey sample. 1. a) Resident #95, with inability to bilaterally grip and support the majority of her body weight, slipped during a transfer from the bed to a chair with use of a sit-to-stand mechanical lift resulting in a fractured left upper arm (humerus). The lift/transfer was attempted with the assistance of one staff person, with the resident's arms improperly positioned on the lift and without the resident gripping both handles of the lift for proper support of her body weight as required by the manufacturer to ensure safety. Resident #95 had no left hand or forearm due to a previous below elbow amputation, amputations of the distal half of both feet and staff reported a decline in condition at the time of transfer. Resident #95 had swelling, pain and her shoulder/arm immobilized for over 6 weeks for treatment of [REDACTED]. b) Resident #95 was observed unattended in her room without access to her call light as required in her plan of care for safety and fall prevention. 2. Resident #40 was observed in her wheelchair without footrests in place and without physician ordered foot plates/platforms for proper leg/feet positioning during wheelchair transport. The findings include: 1. a) Resident #95 was admitted to the facility on [DATE] with a re-admission on 6/23/16. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #95 as cognitively intact. On 4/16/19 at 3:08 p.m., Resident #95 stated her left shoulder was still hurting since she had a fall and broke her shoulder. Resident #95 stated she did not remember exactly how she fell but knew she broke her shoulder several months ago. Resident #95's clinical record documented a nursing note dated 12/2/18 at 2:19 p.m. stating a mobile x-ray was ordered for Resident #95's left shoulder and humerus. A note dated 12/2/18 at 6:25 p.m. stated, MD (physician) noted resident's left shoulder and left humerus x-ray results of having a fractured humerus . A nursing note dated 12/2/18 at 7:33 p.m. documented, Writer was notified by CNA (certified nurses' aide) that resident had a fall. CNA stated that while she was attempting to transfer resident from bed to w/c (wheelchair) using sit-to-stand lift, resident's foot slipped and she had to ease resident to the floor. When writer entered the room resident was laying completely flat on the floor beside her bed. Resident was unable to state how she fell ; she just knew she had fallen. Resident was complaining of pain to left arm. Resident was holding onto left shoulder and arm .Resident was given PRN (as needed) medication for discomfort. MD (physician) and RP (responsible party) have been made notified of fall. A left shoulder x-ray report dated 12/2/18 documented, .History of pain due to fall .There is a comminuted (broken/crushed into small pieces) [MEDICAL CONDITION] head and neck with avulsion of the greater tuberosity .Impression: Acute [MEDICAL CONDITION] head . The clinical record documented a physician's orders [REDACTED].#95 to the emergency room for evaluation following the fall. The emergency room (ER) record dated 12/3/18 documented the resident presented with pain and swelling over the left clavicle and shoulder joint with bruising noted over the left upper arm and biceps. This ER report documented, This nurse spoke with (unit manager) at (nursing facility) who states that yesterday (12/2/18) patient was being transferred (transferred) using a mechanical lift. Lift was being operated with only one CNA and patient fell out of the lift and landed on her left side. She (unit manager) states the facility called for a mobile Xray unit .found a left hurmeral (humeral) head fracture . The ER report listed the x-ray of the resident's left shoulder revealed trauma/injury and documented, Films of the shoulder/clavicle show: mild osteopenia and [MEDICAL CONDITION]. Associated soft tissue [MEDICAL CONDITION] present. Comminuted [MEDICAL CONDITION] humeral head. Mild displacement of the fracture fragments . The resident was discharged from the emergency with pain documented as 8 out of 10 (on scale with 0 = no pain, 10 = worst pain) with orders for referral to orthopedics for treatment of [REDACTED]. The resident was seen by orthopedics on 12/4/18. The orthopedic consultation report dated 12/4/18 documented, .in for evaluation of a right shoulder injury. She (Resident #95) fell while being transferred using a lift device in the nursing home. X-rays confirm the presence of a displaced [MEDICAL CONDITION] neck of the left humerus. Unfortunately the patient also has an amputation just below the elbow .recommendation is that a shoulder immobilizer be used to immobilize the humerus to the trunk to help decrease pain . The clinical record documented the resident was treated with immobilization of the left shoulder along with pain medication as needed. The resident was evaluated by orthopedics again on 12/20/18 and on 1/17/19. The orthopedic report dated 1/17/19 documented healing of the humeral fracture with orders for gentle range of motion and no further need for immobilization. Resident #95's clinical record documented the MDS assessment prior to the 12/2/18 fall was completed on 11/14/18. This MDS documented the resident weighed 191 pounds and required extensive physical assistance of two + persons for transfers (to and/or from bed, chair, wheelchair or to standing). This MDS also listed the resident had impaired balance and was Not steady, only able to stabilize with human assistance when moving from seated position to standing and when transferring between bed and chair. Resident #95's plan of care prior to the fall (revised 11/29/18) listed the resident was at risk for falls due to unsteady gait due to upper and lower extremity amputations (left arm, distal portions of both feet), poor balance, history of falls and history of sliding out of wheelchair. Interventions to prevent serious injury included, Resident Transfers: Requires limited to total dependence 1 or 2 person assist. This care plan documented the resident required assistance with activities of daily living (ADL's) due to upper and lower extremity amputations. Interventions to prevent a decline in ADL's included, Requires mechanical lift to aid with transfers. The resident's plan of care (revised 11/29/18) did not specify the type of mechanical lift to use for transfers (sit-to-stand versus total lift). The care plan interventions did not specify the type or number of persons required to ensure safe transfers for Resident #95. The transfer assistance listed in the care plan ranged from limited assistance to total dependence with 1 or 2 persons. The care plan interventions (limited to total assistance of 1 to 2 persons) did not match the MDS assessment indicating the provision of extensive assistance of 2 + persons for transfers. The facility's investigation of Resident #95's fall/fracture documented a written statement from CNA #3 who was with the resident at the time of the fall. CNA #3's written statement (undated) documented, I put (Resident #95's) pants on and pulled them above her ankles while she was in bed then I put her shoes on then I got her up in the bed and strapped her onto the sit to stand and eased her feet to the edge of the bed once her feet were on the sit to stand I strapped her shoes down once again because they were big on her but those were all the shoes she had. As I raised her up I was pulling up her pants and then her feet started to slip. Her shoe had came off and part of her sock had too. As I was trying to put her shoe and sock back on her other shoe came off and that foot started to slip off as well. I put both shoes back on as both of her feet touched the floor then I moved everything that was in the way out of the way while her arms were still up and attached to the sit to stand after I did that I lowered her arms and when her arms were up she told me her arm was hurting but I couldn't let her down until everything was out of the way. once I lowered and unstrapped her I held onto her as I eased her onto the floor. After she was eased onto the floor I was still holding on to her and layed her gentally (gently) on her back because she isn't strong enough to hold her back up and the I went to get help. (Sic) The facility's investigation documented a note written by the director of nursing (DON) dated 12/3/18 stating, On 12/2/18 (CNA #3) was attempting to get (Resident #95) up using a sit to stand lift .On 12/3/18, I had (CNA #3) demonstrate for me and the ADON (assistant director of nursing) the way in which the patient was positioned on the lift and what transpired. (CNA #3) states the patient did not fall and she was lowered to the floor. After investigating it is determined that using the sit to stand and the decline in the patient's condition, history of [MEDICAL CONDITION] and Vit (vitamin) D and Calcium levels were in combination the main factors resulting in a [MEDICAL CONDITION] humerus. The patient's arms were bearing the weight of the body against the metal bars of the lift and the patient was not bearing any of her weight on her legs. Staff are being re-educated on the use of all lifts and patient appropriateness . CNA #3 was not available for interview during the current survey. On 4/17/19 at 2:09 p.m., the licensed practical nurse (LPN #1) caring for Resident #95 was interviewed about the fractured arm on 12/2/18. LPN #1 stated she was not working on Resident #95's unit when the incident occurred. LPN #1 stated that two people were always required when transferring residents with a mechanical lift. LPN #1 stated CNA #3 was a prn (as needed) employee and not currently at work. On 4/17/19 at 2:28 p.m., the unit manager (LPN #3) was interviewed about Resident #95's fractured left arm. LPN #3 stated two people were always required when using a mechanical lift. The DON entered the unit manager's office on 4/17/19 at 2:29 p.m. and was interviewed at this time about Resident #95's transfer with the resulting fracture. The DON stated the CNA was using the sit-to-stand lift when Resident #95's feet slipped and the CNA lowered the resident to the floor. The DON stated the CNA was by herself with Resident #95 when the incident occurred. The DON stated, There is never to be one person using a mechanical lift. The DON stated they had the CNA demonstrate the events of the incident. The DON stated the CNA did two things wrong during the transfer and was not using the lift correctly. The DON stated there should have been two people assisting with the transfer and the CNA had the resident positioned improperly on the lift. The DON stated the resident's arms were resting across the metal support bars instead of the resident holding her weight with her right hand and left stump. The DON stated the resident used the sit-to-stand lift in the past and partially supported her body weight even with only one hand. The DON stated the resident had experienced a decline in condition and was unable to participate as much during the transfer. The DON stated when the resident's feet slipped her body weight was applied to her arms. The DON stated the left upper arm was fractured near where the arm hit against the support bar. The DON presented a copy of the facility's mechanical lift policy/procedure. The policy titled (Hydraulic) Lift (undated) documented, Purpose: to enable two people to lift and move a resident safely and with as little physical effort as possible .Any resident who weights greater than 150 lbs. (pounds) and is unable to bear weight to assist with the transfer must be transferred with the Hydraulic Lift to ensure the safety of the resident and the employee. The DON presented a copy of the skills checklist for the sit-to-stand lift that was used for re-education of CNA #3 and other CNA's in the facility following the incident with Resident #95. CNA #3's skill checklist dated 12/4/18 documented to always use two people with the sit-to-stand lift and included the following requirements for use of the sit-to-stand lift: .Must be able to bear 20% of body weight on at least one leg .Must have some upper body strength and ability to grip handles AND is able to sustain pressure to mid and lower back .Must be able to participate in the transfer or lift & be able to follow simple instructions . The Points to remember included, Never leave anyone unattended during lift and/or transfer procedures .Follow all policies and procedures .Use correct number of staff required for lift and/or transfer . Steps for use of sit-to-stand lift included, .Begin with individual seated. If in bed, raise head of bed and then assist individual to sit in the dangling position. Support as needed, using two caregivers, if necessary . The lift manufacturer's manual titled Stand Up Patient Lift (revised 11/13) listed a requirement that healthcare staff determine the appropriate assistance needed to ensure a safe transfer and a requirement that the patient grip both of the lift handles and support the majority of their own weight in order to prevent injury. The manufacturer's instructions documented on page 8, The stand up lift may be operated by one healthcare professional for all lifting preparation, transferring from and transferring to procedures with a cooperative, partial weight-bearing patient. However, since medical conditions vary, (manufacturer) recommends that the healthcare professional evaluate the need for assistance and determine whether more than one assistant is appropriate in each case to safely perform the transfer. Page 14 of this manual documented, Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur. Page 15 of this manual documented, .Adjustments for safety and comfort should be made before moving the patient .Instruct the patient to hold onto the hand grips on both sides of the stand up lift . These findings were reviewed with the administrator, director of nursing and corporate nursing consultants during a meeting on 4/17/19 at 4:45 p.m. On 4/18/19 at 9:55 a.m., the DON requested to share further information about Resident #95's lift incident and resulting fractured arm. The DON stated the resident had last been evaluated by therapy on 8/3/18 indicating the resident's use of the mechanical standing lift. The DON stated after completion of a root cause analysis the resident had [MEDICAL CONDITION], staff were re-educated on the lift procedures and the resident was switched to a total mechanical lift after the fall. The DON stated, We can have one person with the sit-to-stand. The DON stated the resident's foot slipped and the requirement for two person assistance with the use of the sit-to stand was not started until after Resident #95's slip/fracture on 12/2/18. This was opposite to what the DON stated during an interview on 4/17/18 at 2:29 p.m. indicating mechanical lifts always required assistance of two persons. The occupational therapy (OT) note presented by the DON (dated 8/3/18) was an evaluation regarding poor wheelchair positioning and use of a new wheelchair and cushion. The OT evaluation was not an assessment regarding safe use of any type of mechanical lift. This evaluation listed the resident used a mechanical lift during transfers under the section regarding the resident's medical history. On 4/18/19 at 10:36 a.m., the corporate nursing consultant stated before Resident #95's fall on 12/2/18 the care plan listed one to two person assistance for transfers and did not indicate a requirement for two people. On 4/18/19 at 11:04 a.m., the corporate nursing consultant stated the Hydraulic lift procedure presented on 4/17/19 did not apply to the sit-to-stand lift but only to total lifts. The corporate nursing consultant stated the facility did not have a policy about use of the sit-to-stand lift. The corporate nursing consultant stated that since they had no policy about use of the sit-to-stand, they referenced the manufacturer's manual as a guide for proper use of the lift. When asked who decided when to use limited or total assistance or one or two people for transferring Resident #95 as listed in the care plan, the corporate nursing consultant stated, the decision was multi-faceted because the resident had a variety of health issues. When asked how the resident could grip both lift handles when she only had one hand, the corporate nursing consultant stated the resident had used the lift in the past pulling her weight with one hand. Additional interviews were conducted with CNA's caring for other residents in the facility identified as using the sit-to-stand lift. On 4/18/19 at 2:35 p.m., CNA #1 was interviewed about assistance required with sit-to-stand lifts. CNA #1 stated two staff members were always required when she used the sit to stand lift. CNA #4 was interviewed on 04/18/19 at 2:50 p.m. regarding use of a sit to stand lift. CNA #4 stated, We always use two people. I have worked here for almost three years and have used two people when using any kind of lift. On 4/18/19 at 3:00 p.m., two CNA's were interviewed independently regarding transfer procedures for residents who use the sit-to-stand lift. Both CNA #5 and CNA #6 said they had been employed at the facility for a little over two years. When asked if they ever transferred residents by themselves, both stated that two people were always used during a sit-to-stand lift transfer. CNA # 5 said, We've been using two people for at least two years. CNA # 6 stated, As long as I've been here we've been using two people to transfer. There was no explanation from the DON about her conflicting statements regarding assistance required with use of the sit-to-stand lift on 4/17/19 and on 4/18/19. The DON stated on 4/17/19 that two people were always required when using mechanical lifts and that CNA's had been re-educated regarding that requirement after Resident #95's injury. On 4/18/19, the DON stated the requirement of two people with the sit-to-stand lift was not started until after Resident 95's fracture on 12/2/18. This statement conflicted with the unit manager report to the emergency roiagnom on [DATE] and other direct care staff interviews that indicated mechanical lifts had always required the assistance of two persons. There was also no explanation provided for why the resident's plan of care in place at the time of the fall did not specify the number of staff persons required to ensure safe transfers for Resident #95. These findings were reviewed with the administrator, director of nursing and corporate nursing consultants again during a meeting on 4/18/19 at 3:00 p.m. 1. b) 04/16/19 at 3:24 p.m., Resident #95 was observed seated in a specialized wheelchair in her room. The resident was unattended by staff. When asked if she had a call light, Resident #95 stated she did not have the call light with her and did not know where it was located. The call light was observed in the middle of her bed and out of the resident's reach. On 4/17/19 at 10:15 a.m., Resident #95 was observed in bed. When asked about her call light, Resident #95 looked about her bed and stated she did not know where her call light was located. The call light was observed on top of the bed table to the left of the resident. The resident's left lower arm was amputated just below the elbow. The resident stated she was unable to reach the call light. The resident stated the call light needed to be on her right side as that was her only hand. Resident #95's plan of care (revised 4/4/19) listed the resident was at risk of falls due to a history of falls, upper and lower extremity amputations, poor balance and sliding out of her wheelchair. Interventions for fall and injury prevention included, Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance .Provide a safe environment with .a working and reachable call light .staff to remind to call for assistance if an item is not in close reach, she needs to avoid over reaching and losing balance . On 4/17/19 02:40 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about call light access for Resident #95. LPN #3 stated call lights were supposed to be available to residents when in the bed and/or in the chair. LPN #3 stated the resident could have been brought back from an activity and the call light not placed within reach. This finding was reviewed with the administrator and director of nursing during a meeting on 4/17/19 at 4:45 p.m. 2. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #40 as cognitively intact and as totally dependent upon one person for mobility on and/or off her unit with use of a wheelchair. On 4/16/19 at 2:38 p.m., Resident #40 was observed in her room in her wheelchair. The wheelchair had no footrests or foot pedals in place. The resident was interviewed at this time about any type of footrests for the chair. The resident stated she did not self-propel in the wheelchair but required staff to push her for transport in and out of her room. The resident stated she did not know where the footrests were for her wheelchair. Resident #40's clinical record documented a physician's orders [REDACTED]. Resident #40's plan of care (revised 3/25/19) listed the resident had limited mobility due to obesity and bilateral upper extremity tremors. Included in interventions to prevent decline in function was, Foot plate/platform when in wheelchair to prevent feet from sliding off legrest. On 4/17/19 at 2:17 p.m., the certified nurses' aide (CNA #2) caring for Resident #40 was interviewed. CNA #2 stated she did know anything about footrests for the resident's wheelchair. CNA #2 stated, As far as I know, she has no footrests. CNA #2 stated the resident was unable to self-propel in the wheelchair and described the resident as total assist. CNA #2 stated she did not know anything about a plate or platform on the wheelchair. On 4/17/19 at 3:00 p.m., the unit manager (LPN #3) was interviewed about footrests and the physician ordered foot plate/platform for Resident #40. LPN #3 stated she did not recall anything about use of a plate or platform. LPN #3 stated the resident should have footrests somewhere and stated she would look for them in her room. LPN #3 stated the resident should have footrests in place when in the wheelchair. On 4/17/19 at 4:05 p.m., the occupation therapist (OT) was interviewed about Resident #40 footrests and the physician ordered plates/platforms. The OT stated the resident should have footrests in place when in the wheelchair to keep her feet and/legs from going under the chair during transport. The OT stated therapy recommended the order for the platform to help keep the resident's feet on the footrest pedal and prevent her feet/legs from going under the chair during movement. The OT stated nursing was responsible for putting the footrests and ordered platforms on the chair. This finding was reviewed with the administrator and director of nursing during a meeting on 4/17/19 at 4:45 p.m. On 4/18/19 at 8:30 a.m., the OT stated the resident's footrests were found in the dresser drawer. The OT stated they did not find the physician ordered platforms/plates. The OT stated she did not know why the footrests and plates were not installed as ordered. The OT stated the footrests were needed to ensure resident safety during transportation in the wheelchair as the resident did not self-propel.

Based on observation, facility document review, staff interview and clinical record review, the facility staff failed to follow professional standards of practice during medication administration. The medication Breo Ellipta was administered to a resident without any instruction or prompt from the nurse for the resident to rinse her mouth with water following inhalation of the medicine as recommended by the manufacturer. The findings include: A medication pass observation was conducted on 4/17/19 at 7:55 a.m. with licensed practical nurse (LPN) #1 administering medications to Resident #89. Among the medication administered was Breo Ellipta 100/25 mcg/inhale with use of an inhaler device. The resident did not rinse her mouth with water after the inhalation of Breo Ellipta. LPN #1 did not instruct or prompt the resident to rinse her mouth after the administration of Breo Ellipta. Resident #89's clinical record documented a physician's orders [REDACTED]. The manufacturer's package insert for Breo Ellipta documented the possible side effects of the medication included fungal infection of the mouth or throat (thrush). The package insert stated, Rinse your mouth with water without swallowing after using Breo Ellipta to help reduce your chance of getting thrush. On 4/17/19 at 8:50 a.m., LPN #1 was interviewed about no instruction to Resident #89 about rinsing her mouth following the inhalation of the Breo Ellipta. LPN #1 stated she was aware that Breo Ellipta required a rinse and spit after administration. LPN #1 stated she got nervous during the medication pass and failed to instruct the resident to rinse. The Nursing (YEAR) Drug Handbook on page 656 describes Breo Ellipta as a corticosteroid [MEDICATION NAME][MEDICATION NAME] used for the treatment of [REDACTED]. (1) This finding was reviewed with the administrator and director of nursing during a meeting on 4/17/19 at 4:45 p.m. (1) Rader,(NAME) Dorothy(NAME)and(NAME)Ann Trujillo. Nursing (YEAR) Drug Handbook. Philadelphia: Wolters Kluwer, (YEAR).

Based on staff interview, facility document review and clinical record review, the facility staff failed to report to the state agency and adult protective services verbal abuse by one of 26 residents in the survey sample. Episodes of abusive verbal threats and racial slurs made by Resident #92 toward and in presence of other residents were not reported to the state agency or adult protective services. The findings include: Resident #92 was admitted to the facility on [DATE] with a re-admission on 3/13/19. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #92 with moderately impaired cognitive skills. Resident #92's clinical record documented on 3/7/19 at 8:43 a.m., Cursing and yelling at (another resident) after breakfast. Residents were separated and redirected . A nursing note dated 3/7/19 at 2:55 p.m. documented, Resident observed yelling at (another resident). When writer tried to redirect resident from situation, he began swinging back towards me and cursing. Resident then made multiple threats to harm other staff and residents. Resident had a plan to use silverware from dining room to harm (another resident). Resident stated he could get a gun from his house to kill (another resident). A nursing note by the director of nursing (DON) dated 3/7/19 documented, Resident in dining room and upon leaving started making threats to another resident. This resident was unprovoked according to staff statements. The other resident looked in this residents direction and this resident started making threats such as 'I will kill you' and racial slurs and comments. The other resident proceeded to escalate with name calling also, but only after this resident provoked the verbal confrontation . The resident was referred to psychiatry due to aggressive, threatening verbal behaviors. A psychiatry progress note dated 3/7/19 documented, .exhibits multiple behaviors that are very concerning. he becomes agitated and aggressive without any triggers. He was witnessed by multiple staff members this morning (3/7/19) when he made homicidal comments towards a paralyzed resident. The other resident didn't provoke him in any way, he just looked at (Resident #92). (Resident #92) quickly started yelling at the other resident 'I'm going to kill you, you dumb honkey.' During my interview with (Resident #92) he became agitated within the first 30 seconds .became more verbally confrontational .Yells frequently in an aggressive tone .Mood and affect is agitated. He becomes agitated without any trigger .He is able to walk using assisted devices . The psychiatric progress note listed the resident's [DIAGNOSES REDACTED]. The psychiatry consult recommended transfer of Resident #92 due to safety concerns to other residents. The recommendations documented, .This patient is unstable and has unprovoked aggressive tendencies. He has made homicidal comments to a paralyzed resident this morning .currently a potential threat to self and others . (sic) The clinical record documented the resident was transferred to the emergency roiagnom on [DATE] due to increasing agitation and threatening another resident. The resident was re-admitted to the facility on [DATE]. A nursing note dated 4/11/19 documented, Yelling heard coming from TV room .this resident yelling at (two identified residents) yelling back. Both residents yelling racial slurs and name calling to one another. Another resident that was in the TV room witnessed the verbal altercation and stated (Resident#92) started yelling at (another resident) first and (that resident) was doing nothing at the time but watching television .(Resident #92) continued to state 'that white boy don't mean nothing to me, I can't stand no white boy talking to me, trying to tell me what to do and calling me nigger, I will kill him, I was in a gang and I don't mind and anybody getting in my way will get some too'. A note dated 4/15/19 documented, .overheard loud voices coming from the TV room and when she entered the area this resident and another resident .were arguing with each other loudly, exchanging insults and talking about 'I ain't scared of you' .This resident continued to talk negatively about the other resident . There was no report to the state agency or adult protective services regarding Resident #92's verbal threats on 3/7/19 directed to toward another resident, transfer of the resident on 3/7/19 due to potential threat to self and others or the incidents of verbal threats and negative remarks documented on 4/11/19 and 4/15/19. There was no comprehensive investigation of the 3/7/19 behaviors and the threats toward other residents. The administrator identified most of Resident #92's verbal threats were directed at Resident #2 and #21. The administrator presented six written and/or typed witness statements from staff regarding the 3/7/19 behaviors demonstrated by Resident #92. Two of the statements were not dated and had no identification of the writers. There were no interviews or statements documented from the residents targeted by Resident #92. There was no other documented investigation or summary of the events and actions taken. The written staff statements regarding the events of 3/7/19 documented behaviors by Resident #92 that included plans to attack a named resident by using a nail or silverware from the dining room to slit the resident's throat and a statement he had a gun at his house and would use it to kill a named resident (Resident #2). On 4/17/19 at 2:50 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about Resident #92. LPN #3 stated most of the time Resident #92's verbal threats and comments were targeted toward Resident #2 and occasionally toward Resident #19 when in the television room. LPN #3 stated Resident #92 made verbal threats to kill other residents and staff. On 4/18/19 at 7:50 a.m., the administrator was interviewed about Resident #92's verbal threats and unsafe behaviors toward other residents. The administrator stated they were unable to redirect Resident #92 on 3/7/19 so he was evaluated by psychiatry services and was determined to be a threat to other residents and staff. The administrator stated the resident would not go willingly to the emergency room and the local law officers assisted with transfer of the resident out of the facility for the safety of staff and residents. The administrator produced no report of this or the other incidents of threatening behavior to the state agency or adult protective services. The administrator stated, Our line of thinking, it was a behavior. He had them before and he was redirected. The administrator stated other residents kind of ignore him. The administrator stated she was focused on getting the resident out of the facility on 3/7/19 and had not filed a report to adult protective services or the state agency. The facility's policy titled Abuse Prevention (revised 1/2017) documented, The facility is committed to maintaining a safe and abuse-free environment for all residents and committed to a comprehensive investigation of any allegation of activities or situations that may constitute abuse. Corrective and prevention action to minimize recurrence will be developed and implemented on an individual resident and or a facility basis. Outside agencies, including regulatory agencies, ombudsman, protective services, police, etc. will be notified and involved as appropriate to the situation. Section V of this policy documented, The facility will investigate and report incidents or occurrences in accordance with federal and state guidelines. This policy documented in section VII, The Facility Administrator, DON or designee must, report all alleged incidents of abuse, neglect, exploitation or mistreatment including injuries of unknown origin, misappropriation of property and unusual occurrences .to the .state agency and to all other required agencies .A final report with results of the investigation is filed with the (state agency) in 5 working days of the alleged incident. These findings were reviewed with the administrator and director of nursing during a review on 4/18/19 at 3:10 p.m.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure thorough investigation of verbal abuse by one of 26 residents in the survey sample. Episodes of abusive verbal threats and racial slurs made by Resident #92 toward and in presence of other residents were not thoroughly investigated or reported to the state agency. The findings include: Resident #92 was admitted to the facility on [DATE] with a re-admission on 3/13/19. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #92 with moderately impaired cognitive skills. Resident #92's clinical record documented on 3/7/19 at 8:43 a.m., Cursing and yelling at (another resident) after breakfast. Residents were separated and redirected . A nursing note dated 3/7/19 at 2:55 p.m. documented, Resident observed yelling at (another resident). When writer tried to redirect resident from situation, he began swinging back towards me and cursing. Resident then made multiple threats to harm other staff and residents. Resident had a plan to use silverware from dining room to harm (another resident). Resident stated he could get a gun from his house to kill (another resident). A nursing note by the director of nursing (DON) dated 3/7/19 documented, Resident in dining room and upon leaving started making threats to another resident. This resident was unprovoked according to staff statements. The other resident looked in this residents direction and this resident started making threats such as 'I will kill you' and racial slurs and comments. The other resident proceeded to escalate with name calling also, but only after this resident provoked the verbal confrontation . The resident was referred to psychiatry due to aggressive, threatening verbal behaviors. A psychiatry progress note dated 3/7/19 documented, .exhibits multiple behaviors that are very concerning. he becomes agitated and aggressive without any triggers. He was witnessed by multiple staff members this morning (3/7/19) when he made homicidal comments towards a paralyzed resident. The other resident didn't provoke him in any way, he just looked at (Resident #92). (Resident #92) quickly started yelling at the other resident 'I'm going to kill you, you dumb honkey.' During my interview with (Resident #92) he became agitated within the first 30 seconds .became more verbally confrontational .Yells frequently in an aggressive tone .Mood and affect is agitated. He becomes agitated without any trigger .He is able to walk using assisted devices . The psychiatric progress note listed the resident's [DIAGNOSES REDACTED]. The psychiatry consult recommended transfer of Resident #92 due to safety concerns to other residents. The recommendations documented, .This patient is unstable and has unprovoked aggressive tendencies. He has made homicidal comments to a paralyzed resident this morning .currently a potential threat to self and others . (sic) The clinical record documented the resident was transferred to the emergency roiagnom on [DATE] due to increasing agitation and threatening another resident. The resident was re-admitted to the facility on [DATE]. A nursing note dated 4/11/19 documented, Yelling heard coming from TV room .this resident yelling at (two identified residents) yelling back. Both residents yelling racial slurs and name calling to one another. Another resident that was in the TV room witnessed the verbal altercation and stated (Resident#92) started yelling at (another resident) first and (that resident) was doing nothing at the time but watching television .(Resident #92) continued to state 'that white boy don't mean nothing to me, I can't stand no white boy talking to me, trying to tell me what to do and calling me nigger, I will kill him, I was in a gang and I don't mind and anybody getting in my way will get some too'. A note dated 4/15/19 documented, .overheard loud voices coming from the TV room and when she entered the area this resident and another resident .were arguing with each other loudly, exchanging insults and talking about 'I ain't scared of you' .This resident continued to talk negatively about the other resident . There was no report to the state agency or adult protective services regarding Resident #92's verbal threats on 3/7/19 directed to toward another resident, transfer of the resident on 3/7/19 due to potential threat to self and others or the incidents of verbal threats and negative remarks documented on 4/11/19 and 4/15/19. There was no comprehensive investigation of the 3/7/19 behaviors and the threats toward other residents. The administrator identified most of Resident #92's verbal threats were directed at Resident #2 and #21. The administrator presented six written and/or typed witness statements from staff regarding the 3/7/19 behaviors demonstrated by Resident #92. Two of the statements were not dated and had no identification of the writers. There were no interviews or statements documented from the residents targeted by Resident #92. There was no other documented investigation or summary of the events and actions taken. The written staff statements regarding the events of 3/7/19 documented behaviors by Resident #92 that included plans to attack a named resident by using a nail or silverware from the dining room to slit the resident's throat and a statement he had a gun at his house and would use it to kill a named resident (Resident #2). On 4/17/19 at 2:50 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about Resident #92. LPN #3 stated most of the time Resident #92's verbal threats and comments were targeted toward Resident #2 and occasionally toward Resident #19 when in the television room. LPN #3 stated Resident #92 made verbal threats to kill other residents and staff. On 4/18/19 at 7:50 a.m., the administrator was interviewed about Resident #92's verbal threats and unsafe behaviors toward other residents. The administrator stated they were unable to redirect Resident #92 on 3/7/19 so he was evaluated by psychiatry services and was determined to be a threat to other residents and staff. The administrator stated the resident would not go willingly to the emergency room and the local law officers assisted with transfer of the resident out of the facility for the safety of staff and residents. The administrator produced no report of this or the other incidents of threatening behavior to the state agency or adult protective services. The administrator stated, Our line of thinking, it was a behavior. He had them before and he was redirected. The administrator stated other residents kind of ignore him. The administrator stated she was focused on getting the resident out of the facility on 3/7/19 and had not filed a report to adult protective services or the state agency. The facility's policy titled Abuse Prevention (revised 1/2017) documented, The facility is committed to maintaining a safe and abuse-free environment for all residents and committed to a comprehensive investigation of any allegation of activities or situations that may constitute abuse. Corrective and prevention action to minimize recurrence will be developed and implemented on an individual resident and or a facility basis. Outside agencies, including regulatory agencies, ombudsman, protective services, police, etc. will be notified and involved as appropriate to the situation. Section V of this policy documented, The facility will investigate and report incidents or occurrences in accordance with federal and state guidelines. This policy documented in section VII, The Facility Administrator, DON or designee must, report all alleged incidents of abuse, neglect, exploitation or mistreatment including injuries of unknown origin, misappropriation of property and unusual occurrences .to the .state agency and to all other required agencies .A final report with results of the investigation is filed with the (state agency) in 5 working days of the alleged incident. These findings were reviewed with the administrator and director of nursing during a review on 4/18/19 at 3:10 p.m.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow their abuse prevention policies for investigation and reporting to the state agency and adult protective services episodes of verbal abuse by one of 26 residents in the survey sample. Episodes of abusive verbal threats and racial slurs made by Resident #92 toward and in presence of other residents were not thoroughly investigated or reported to the state agency and adult protective services as required in the facility's abuse prevention policies. The findings include: Resident #92 was admitted to the facility on [DATE] with a re-admission on 3/13/19. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #92 with moderately impaired cognitive skills. Resident #92's clinical record documented on 3/7/19 at 8:43 a.m., Cursing and yelling at (another resident) after breakfast. Residents were separated and redirected . A nursing note dated 3/7/19 at 2:55 p.m. documented, Resident observed yelling at (another resident). When writer tried to redirect resident from situation, he began swinging back towards me and cursing. Resident then made multiple threats to harm other staff and residents. Resident had a plan to use silverware from dining room to harm (another resident). Resident stated he could get a gun from his house to kill (another resident). A nursing note by the director of nursing (DON) dated 3/7/19 documented, Resident in dining room and upon leaving started making threats to another resident. This resident was unprovoked according to staff statements. The other resident looked in this residents direction and this resident started making threats such as 'I will kill you' and racial slurs and comments. The other resident proceeded to escalate with name calling also, but only after this resident provoked the verbal confrontation . The resident was referred to psychiatry due to aggressive, threatening verbal behaviors. A psychiatry progress note dated 3/7/19 documented, .exhibits multiple behaviors that are very concerning. He becomes agitated and aggressive without any triggers. He was witnessed by multiple staff members this morning (3/7/19) when he made homicidal comments towards a paralyzed resident. The other resident didn't provoke him in any way, he just looked at (Resident #92). (Resident #92) quickly started yelling at the other resident 'I'm going to kill you, you dumb honkey.' During my interview with (Resident #92) he became agitated within the first 30 seconds .became more verbally confrontational .Yells frequently in an aggressive tone .Mood and affect is agitated. He becomes agitated without any trigger .He is able to walk using assisted devices . The psychiatric progress note listed the resident's [DIAGNOSES REDACTED]. The psychiatry consult recommended transfer of Resident #92 due to safety concerns to other residents. The recommendations documented, .This patient is unstable and has unprovoked aggressive tendencies. He has made homicidal comments to a paralyzed resident this morning .currently a potential threat to self and others . (sic) The clinical record documented the resident was transferred to the emergency roiagnom on [DATE] due to increasing agitation and threatening another resident. The resident was re-admitted to the facility on [DATE]. A nursing note dated 4/11/19 documented, Yelling heard coming from TV room .this resident yelling at (two identified residents) yelling back. Both residents yelling racial slurs and name calling to one another. Another resident that was in the TV room witnessed the verbal altercation and stated (Resident#92) started yelling at (another resident) first and (that resident) was doing nothing at the time but watching television .(Resident #92) continued to state 'that white boy don't mean nothing to me, I can't stand no white boy talking to me, trying to tell me what to do and calling me nigger, I will kill him, I was in a gang and I don't mind and anybody getting in my way will get some too'. A note dated 4/15/19 documented, .overheard loud voices coming from the TV room and when she entered the area this resident and another resident .were arguing with each other loudly, exchanging insults and talking about 'I ain't scared of you' .This resident continued to talk negatively about the other resident . There was no report to the state agency or adult protective services regarding Resident #92's verbal threats on 3/7/19 directed to toward another resident, transfer of the resident on 3/7/19 due to potential threat to self and others or the incidents of verbal threats and negative remarks documented on 4/11/19 and 4/15/19. There was no comprehensive investigation of the 3/7/19 behaviors and the threats toward other residents. The administrator identified most of Resident #92's verbal threats were directed at Resident #2 and #21. The administrator presented six written and/or typed witness statements from staff regarding the 3/7/19 behaviors demonstrated by Resident #92. Two of the statements were not dated and had no identification of the writers. There were no interviews or statements documented from the residents targeted by Resident #92. There was no other documented investigation or summary of the events and actions taken. The written staff statements regarding the events of 3/7/19 documented behaviors by Resident #92 that included plans to attack a named resident by using a nail or silverware from the dining room to slit the resident's throat and a statement he had a gun at his house and would use it to kill a named resident (Resident #2). On 4/17/19 at 2:50 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about Resident #92. LPN #3 stated most of the time Resident #92's verbal threats and comments were targeted toward Resident #2 and occasionally toward Resident #19 when in the television room. LPN #3 stated Resident #92 made verbal threats to kill other residents and staff. On 4/18/19 at 7:50 a.m., the administrator was interviewed about Resident #92's verbal threats and unsafe behaviors toward other residents. The administrator stated they were unable to redirect Resident #92 on 3/7/19 so he was evaluated by psychiatry services and was determined to be a threat to other residents and staff. The administrator stated the resident would not go willingly to the emergency room and the local law officers assisted with transfer of the resident out of the facility for the safety of staff and residents. The administrator produced no report of this or the other incidents of threatening behavior to the state agency or adult protective services. The administrator stated, Our line of thinking, it was a behavior. He had them before and he was redirected. The administrator stated other residents kind of ignore him. The administrator stated she was focused on getting the resident out of the facility on 3/7/19 and had not filed a report to adult protective services or the state agency. The facility's policy titled Abuse Prevention (revised 1/2017) documented, The facility is committed to maintaining a safe and abuse-free environment for all residents and committed to a comprehensive investigation of any allegation of activities or situations that may constitute abuse. Corrective and prevention action to minimize recurrence will be developed and implemented on an individual resident and or a facility basis. Outside agencies, including regulatory agencies, ombudsman, protective services, police, etc. will be notified and involved as appropriate to the situation. Section V of this policy documented, The facility will investigate and report incidents or occurrences in accordance with federal and state guidelines. This policy documented in section VII, The Facility Administrator, DON or designee must, report all alleged incidents of abuse, neglect, exploitation or mistreatment including injuries of unknown origin, misappropriation of property and unusual occurrences .to the .state agency and to all other required agencies .A final report with results of the investigation is filed with the (state agency) in 5 working days of the alleged incident. These findings were reviewed with the administrator and director of nursing during a review on 4/18/19 at 3:10 p.m.

Based on staff interview, clinical record review and complaint investigation, the facility staff failed to assess and implement interventions for the prevention and treatment of [REDACTED]. 1. Resident #1, listed as a high risk for pressure ulcers, was assessed with [REDACTED]. The pressure sore was found measuring 6.0 cm x 5.0 cm x .1 cm (length by width by depth in centimeters) twelve days after her admission. Daily skin assessments documented prior to the pressure ulcer were inaccurate and failed to provide ongoing monitoring of open areas including identified skin excoriation on the buttock area. When the pressure ulcer failed to improve with treatments and deteriorated to an unstageable status, facility staff failed to provide surgical debridement to remove the necrotic tissue as recommended by the wound physician. Ten days after the recommendation for surgical debridement, the resident developed fever, lethargy and poor intake and was sent to the emergency room for treatment where she was diagnosed with [REDACTED]. The resident was placed on hospice care and died four days later. 2. Resident #3, with ongoing treatment of [REDACTED]. The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure injury as, localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in the combination with shear. This reference defines a stage 2 pressure injury (ulcer) as, Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present .Stage 3 pressure injury .Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location .Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury .Stage 4 Pressure Injury .Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss .Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . (1) The facility's Quick Reference Guideline for Topical Wound Care (revised [DATE]) defines eschar as Dead or devitalized tissue that is hard or soft in texture; usually black brown, or tan in color, and may appear scab-like. Necrotic tissue & eschar are usually firmly adherent to the base of the wound and often the side/edges of the wound. The findings include: 1. Resident #1, listed as a high risk for pressure ulcers, was assessed with [REDACTED]. The pressure sore was found measuring 6.0 cm x 5.0 cm x .1 cm twelve days after her admission. Daily skin assessments documented prior to the pressure ulcer were inaccurate and failed to provide ongoing monitoring of open areas including identified skin excoriation on the buttock area. When the pressure ulcer failed to improve with treatments and deteriorated to an unstageable status, facility staff failed to provide surgical debridement to remove the necrotic tissue as recommended by the wound physician. Ten days after the recommendation for surgical debridement, the resident developed fever, lethargy and poor intake and was sent to the emergency room for treatment where she was diagnosed with [REDACTED]. The resident was placed on hospice care and died four days later. Resident #1 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 with short and long-term memory problems and severely impaired cognitive skills. The MDS documented Resident #1 was totally dependent on two people for bed mobility and transfers. The resident was assessed as totally incontinent of bowel and had a urinary catheter in place due to bedfast status and pain with turning due to bilateral [MEDICAL CONDITION]. Resident #1's clinical record documented the resident was admitted to the facility for therapy and care following hospitalization for treatment of [REDACTED]. A Braden scale for predicting pressure sore risk dated [DATE] assessed Resident #1 as high risk for pressure ulcers due to her bedfast status, very limited sensory perception, potential for friction/shear when moved with assistance and her completely immobile status. An admission nursing assessment dated [DATE] listed the resident had excoriation at the top fold of buttock. A nursing note dated [DATE] documented the resident was on total bed rest. This note stated, Nurse reported that resident does have 2 small areas to sacrum . There was no further assessment of the 2 small areas providing a description, color, appearance and/or size of the areas. There was no order for treatment of [REDACTED]. A nursing note on [DATE] at 3:21 p.m. documented, Skin is not intact. Skin discoloration noted. No signs or symptoms of wound infection or inflammation. Daily nursing notes starting on [DATE] at 11:18 p.m. through [DATE] documented, Skin is intact. A weekly body audit of Resident #1's skin was documented on [DATE] and listed the resident's skin as intact with no mention of excoriation. A nursing note dated [DATE] at 12:03 p.m. documented the resident had excoriation on her sacrum. This note stated, In to assess sacral: excoriation noted. New order to apply Dermaseptin Qbrief (at each brief) change and PRN (as needed). MD/RP (physician/responsible party) aware. (sic) A physician's order was listed for the Dermaseptin ointment to be applied at each brief change. Treatment records documented the Dermaseptin was applied as ordered. There were no documented ongoing assessments monitoring the appearance, size or extent of the resident's excoriation identified on [DATE]. Subsequent nursing notes from [DATE] through [DATE] documented conflicting assessments (skin intact vs. not intact) of the resident's skin with no further description of the status of the excoriation other than open area. The notes did not specify the location, color, appearance, size or any description of the open areas. There were no tracking records documenting the status of the resident's excoriation. Nursing notes documented the following. [DATE] at 1:02 p.m. - Skin is intact. [DATE] at 10:30 a.m. - Skin is intact. [DATE] at 11:37 p.m. - Skin is not intact. Skin discoloration noted. Scarring noted. No signs or symptoms of wound infection or inflammation. [DATE] at 12:20 a.m. - Skin is intact. [DATE] at 4:24 a.m. - Skin is intact. [DATE] at 2:18 p.m. - Skin is not intact. Open areas noted. There is one open area that is being monitored and treated. No signs or symptoms of wound infection or inflammation. [DATE] at 1:22 a.m. - Skin is not intact. Open areas noted. There is one open area that is being monitored and treated. No signs or symptoms of wound infection or inflammation. [DATE] at 10:57 a.m. - Skin is not intact. Open areas noted. There is one open area that is being monitored and treated. No signs or symptoms of wound infection or inflammation. [DATE] at 2:00 a.m. - Skin is not intact. Open areas noted. There is one open area that is being monitored and treated. No signs or symptoms of wound infection or inflammation. [DATE] at 11:08 a.m. - Skin is intact. [DATE] at 11:35 a.m. - Skin is not intact. Open areas noted. There is one open area that is being monitored and treated. No signs or symptoms of wound infection or inflammation. The next full body audit conducted for Resident #1 was 10 days later on [DATE] when the resident was found with a stage 2 pressure ulcer on her sacrum measuring 6.0 cm x 5.0 cm by .1 cm. A nursing note dated [DATE] stated, In to assess sacrum: stage 2 PU (pressure ulcer) 6.0 x 5.0 x 0.1 cm, 100% pink tissue noted. New order: cleanse with NS (normal saline), apply foam dressing Q Mon/Thurs/PRN (each Monday, Thursday and as needed) . Treatment records documented treatment/dressing changes as ordered. Weekly Pressure ulcer reports documented the following ongoing assessments of Resident #1's sacral pressure ulcer. [DATE] - Stage 2 measuring 6.0 x 5.0 x 0.1 cm [DATE] - Stage 2, 6.0 x 5.0 x 1.0 cm, 100% pink tissue [DATE] - Area to sacrum noted with 100% pink wound bed, 4 cm x 2.8 cm with dark discoloration noted to periwound, no odor, no s/s (signs/symptoms) of infection present at this time. Improved. [DATE] - Deteriorated - Unstageable, 10% pink tissue 90% thick gray/black eschar .6 cm x 6 cm .no drainage or odor. Treatment was changed on [DATE] to normal saline and [MEDICATION NAME] dressing to be changed every Tuesday, Friday and as needed. [DATE] - Unstageable 6 cm x 7 cm, 20% pink tissue to outer wound bed, 80% thick yellow leathery slough, treatment with [MEDICATION NAME] dressing continued. [DATE] - Deteriorated - 10% pink edges 90% thick yellow/gray slough Unstageable wound noted 8 cm x 7 cm x 1.3 cm .Will continue poc (plan of care) and f/u (follow up) with (wound physician) on possible eval (evaluation) of site for any new recommendations on [DATE]. The wound physician assessed Resident #1 in the facility on [DATE]. The wound physician's note dated [DATE] documented, .presents today with a chief complaint of sacral decubiti (pressure ulcer) .The symptoms are located sacrum and are severe in nature. The nature of the symptoms are stage 3 - 4 and have lasted past month. Factors affecting the symptoms are sedentary patient . The wound physician documented the resident had approx. (approximately) 5 x 5 cm necrotic sacral decubiti. The wound physician's plan stated, The patient has a large necrotic decubiti on his (her) sacrum. I recommend operative debridement. We will proceed if consent can be obtained. (sic) A nursing note dated [DATE] documented, (Wound physician) in facility, rounds done with patient MD (physician) to get in contact with family member for possible surgical debridement, no new orders at this time, continue [MEDICATION NAME] for autolytic debridement until procedure set up. Writer called RP (responsible party) and left message to call facility, spoke with 2nd rp (spouse) and made aware of MD visit today. There were no arrangements made for Resident #1's surgical debridement. A physician's progress note dated [DATE] documented the resident was assessed for cough and congestion and was diagnosed with [REDACTED]. This note documented, Nursing reports no (change) in sacral area. The note made no mention of the surgical debridement. A pressure ulcer report dated [DATE] documented Resident #1's sacral wound had deteriorated further with drainage and odor noted in addition to a fever. This report listed the sacrum pressure sore as, Unstageable noted 8 cm x 7 cm x 1.3 cm in depth .Area noted with purulent drainage, 100% slough to wound bed, slight odor r/t (due to) autolytic debridement of dressing in place, no gricmaces (grimaces) of pain .Awaits (wound physician's) office to set patient up for debridement out of facility. Resident with fever noted 101.5 during treatment . (sic) A physician's progress note dated [DATE] documented the resident had a temperature of 102, was more lethargic and stated lab work was ordered in addition to a urinalysis. This note documented, Surgical consult (with wound physician) pending on decubitus. Treatment to the resident's sacrum pressure ulcer was changed on [DATE]. A physician's order was documented on [DATE] for cleansing with wound cleanser, Santyl ointment with an ABD pad to cover to be done each day. The physician ordered a urinalysis on [DATE] and blood work due to the resident's change in condition. A nursing noted dated [DATE] documented the resident's urinalysis indicated infection. This note documented, .Urine positive for +1 leukocytes, + [MEDICATION NAME], + protein, + blood MD aware of U/A (urinalysis) results and sent urine for C/S (culture and sensitivity). This note indicated blood was drawn and sent to lab for analysis. A nursing note date [DATE] documented the resident was unable to take food or medications due to not swallowing, pocketing food in her mouth and refusing intake. An order was entered for a speech evaluation due to swallowing difficulties. A nursing note dated [DATE] at 11:10 p.m. documented a discussion with the family including the responsible party about the resident's condition. This note documented, .MD noted residents poor intake and refusal of meals/supplements/medications and new order received for speech eval (evaluation). Phone call placed to RP to make her aware of residents overall condition .Writer also discussed wound and slight increase in measurement per wound nurse . Writer discussed full code status vs DNR (do not resuscitate) vs comfort care status with RP and she stated she would like for resident to be DNR . (sic) There were no documented orders for comfort care for Resident #1 or any mention the debridement procedure was discussed with the family and RP. A nursing note on [DATE] documented, .Resident very warm to touch and sweating. VS (vital signs) taken 102.5 axillary (temperature), P (pulse) 129 R (respirations) 40 shallow and rapid .Wheezing noted to right lobe .Left lobe diminished. No cough reported. Resident aroused to tactile stimuli. Jerking motions noted. MD notified and new order to send to ER (emergency room ) for evaluation and treatment . There were no arrangements made for the resident to get the recommended surgical debridement of the sacral pressure ulcer as recommended on [DATE]. An addendum to the wound physician's note was documented on [DATE] stating, I tried to call to call the patients family for consent twice and the daughter states she got a message on the 15th ([DATE]) but did not respond back to me as per conversation with social services today .when I called back to (nursing facility) they said they admitted her (Resident #1) to the hospital .and were making her comfort care. (sic) The hospital emergency room (ER) report dated [DATE] documented the resident was diagnosed with [REDACTED]. The ER nursing assessment dated [DATE] documented, Wound measurement completed and wound measures 8 x 4 cm with a depth measured of 3 cm, wound tunneling present. Surrounding redness is present and is non-blanchable. Foul smelling odor coming from wound with green/yellow purulent exudate present . The ER physician's physical examination documented, Pt has an 8 cm x 4 cm large very deep open pressure wound with very foul smell in the lower bk (back). The wound extends down to the sacrum, which is visible. There is gangranous (gangrenous) dark tissue noted to the left side of the wound pocket. Wound has smell .concern for Gangrene. (sic) The ER report listed the resident's primary [DIAGNOSES REDACTED].* A blood culture dated [DATE] listed the resident was infected with gram positive cocci. A wound culture of Resident #1's sacral pressure ulcer dated [DATE] documented the wound was infected with gram positive cocci, gram negative and gram positive bacilli. The ER summary report dated [DATE] documented, .Pt (patient) has a very foul smell that upon exam appears to be coming from a VERY LARGE open pressure wound on her lower back . Pt's prior note stated that there was no prior wound in the area .Pt's labs recently show that she had a UA that showed UTI (urinary tract infection) but pt is not currently on Rx (prescription) for this and C/S (culture and sensitivity) just came back today .I spoke to the pt's daughter and at this time she would like to d/c (discontinue) all of the pt's care and just place her into Hospice d/t (due to) the severity of the pt's illness and the obvious distress the pt is currently having .pt's daughter decided to even stop ABX tx (antibiotic treatment) at this time and just make comfort measures only . The resident was entered into hospice care and died at the hospital on [DATE]. *Sepsis is a disease caused by the spread of bacteria or toxins in the bloodstream .Sepsis is a serious medical condition caused by an overwhelming immune response to infection .Sepsis does not arise on its own. It stems from another medical condition such as an infection in the lungs, urinary tract, skin, abdomen .or other part of the body. (2) Resident #1's plan of care upon admission to the facility (dated [DATE]) listed the resident required assistance with mobility due to bilateral hip/femur fractures in addition to impaired skin integrity. Interventions for assistance with mobility included a requirement for the resident to be log rolled with the assistance of two people. Interventions to promote healing and prevention of pressure injury included, Assess skin thoroughly and implement precautions and/or treatment as indicated .Encourage frequent position changes for pressure relief .Encourage patient to allow heels to be floated while in bed .Observe for moisture and incontinence issues that affect skin .Report for further assessment if noted .Provide pressure reduction surfaces as ordered .Report changes in skin integrity or condition for further assessment and treatment. After the resident was assessed with [REDACTED]. The care plan was updated on [DATE] for the resident to be up in a recliner or chair as desired following instructions from the orthopedist caring for her fractures. On [DATE] at 2:05 p.m. the director of nursing (DON) was interviewed about Resident #1's lack of skin assessments and the development of the sacral pressure sore. The DON stated certified nurses' aides were responsible for reporting any skin issues seen during personal care each day. The DON stated full body audits were supposed to be conducted weekly by the assigned nurses according to a schedule. The DON stated any wounds or skin impairments found by nurses were reported to the wound nurse. The DON stated the wound nurse tracked and monitored wounds at least weekly and documented the wound assessments on the pressure ulcer report forms. On [DATE] at 2:20 p.m. the licensed practical nurse unit manager (LPN #1) and the DON were interviewed about Resident #1's skin assessments. LPN #1 stated the body audit forms were performed by the floor nurses and were supposed to be done weekly for each resident. The DON stated Resident #1 was admitted with excoriation to her buttock area. The DON stated the treatment in place upon admission was use of a standard barrier cream at each brief change in addition to turning and repositioning, a pressure relief mattress and interventions listed on the care plan. The DON stated the treatment was changed on [DATE] to use of the Dermaseptin cream when the excoriation was reported to the wound nurse. When asked about why the surgical debridement recommended by the wound physician was not performed or arranged, the DON stated the wound doctor was supposed to call the family and make arrangements and he never got back with the facility. The DON stated the wound nurse also tried to contact the RP about consent for the debridement. On [DATE] at 3:20 p.m. LPN #2, responsible for the initial wound care with Resident #1 was interviewed. LPN #2 stated she was notified on [DATE] that the resident had excoriation on her sacral area. LPN #2 stated she assessed the area as excoriation and obtained a physician's order to start the Dermaseptin cream. LPN #2 stated the floor nurses were responsible for treating and assessing the excoriation. LPN #2 stated the excoriation was an abrasion type injury. LPN #2 stated she was not advised of excoriation prior to [DATE]. LPN #2 stated she was not informed of any other skin issues with Resident #1 until [DATE] when she assessed the resident with the stage 2 pressure ulcer. On [DATE] at 3:30 p.m. LPN #4 that took over wound care duties on [DATE] was interviewed about Resident #1. LPN #4 stated they had a wound physician available each Wednesday for consultation as needed for wounds. LPN #4 stated Resident #1's pressure ulcer deteriorated and after it did not show improvement with the [MEDICATION NAME] dressing treatment the wound physician was asked to evaluate the wound. LPN #4 stated the wound physician assessed the resident as needing surgical debridement to remove the necrotic tissue. LPN #4 stated the wound physician was going to call the RP about consent for the debridement. LPN #4 stated she talked with the resident's spouse and explained to him the wound physician was going to call him. LPN #4 stated the resident's spouse was ok with the debridement procedure. When asked why the debridement was not scheduled or done, LPN #4 stated they were waiting on the wound physician to make arrangements. LPN #4 stated she called the wound physician's office and they reported they had tried to call the family twice and had not reached them. When asked if the family indicated they did not want the debridement done, LPN #4 stated, Oh no. They (family) were ok with it (debridement). On [DATE] at 4:00 p.m. the resident's physician was interviewed about the condition of the sacral wound at the emergency room and not performing the recommended surgical debridement. The physician stated the resident initially was doing well and the wound showed improvement but then began to decline. The physician stated the family was in the resident's room quite often and was aware of the resident's condition including the wound. When asked about any initiative to get the debridement done, the physician stated he was under the assumption the wound physician was taking care of the arrangements for the debridement. When asked if he discussed the need for debridement with the family at any point, the physician stated he did not recall a conversation about the debridement. The physician stated he had conversations with the family about comfort care and the family was leaning toward that (comfort care). When asked why he did not reach out to the family about getting the debridement done when recommended, the physician stated, I assumed they (family) were waiting to decide (about comfort care). When asked to explain the condition of Resident #1's sacral pressure sore (necrotic, foul odor, purulent exudate, sacrum visible) at the emergency roiagnom on [DATE], the physician stated the wound was not that bad two days earlier. The physician stated the wound had slough when he last assessed it but the wound had not gone to the sacrum. The physician stated again he assumed the family was waiting to decide how aggressive they wanted to be with treatment. When asked about his progress note dated [DATE] making no mention of a conversation with the family about comfort care and no assessment of the resident's sacral wound, the physician stated he monitored the wound frequently and that he was more involved than the notes indicated. The clinical record had no physician's order for comfort care and there was no documented discussion by the physician with the family about the needed debridement or comfort care wishes. On [DATE] at 5:15 p.m. the wound physician was interviewed by telephone concerning Resident #1 and the surgical debridement that never happened. The wound physician stated he was asked to look at the resident and assessed Resident #1 on [DATE]. The wound physician stated the resident had an old wound that was about as big as your hand with necrotic tissue. The wound physician stated the resident was not toxic and the wound had no drainage when he assessed her on [DATE]. The wound physician stated the resident needed surgical debridement of the pressure ulcer to clean off the necrotic tissue due to its size. When asked about the urgency for the debridement the physician stated the resident didn't need it the next day but it needed to be done promptly in order for the wound to start healing. The wound physician stated he tried to call the family twice and left a message once but never got a response. The wound physician stated he called back to the nursing facility to check on the status of the resident and he was told the resident had been sent to the hospital and placed on comfort care. When told about the deteriorated condition of the wound assessed at theER on [DATE], the wound physician stated he was not notified of any changes in the resident's condition after his initial assessment on [DATE]. On [DATE] at 8:25 a.m. the wound nurse (LPN #4) was interviewed again about any actions taken by the facility to arrange for the recommended surgical debridement for Resident #1. LPN #4 stated she spoke to the resident's husband on [DATE] about the wound physician's assessment and need for the debridement. LPN #4 stated she did not remember the date, but she also spoke with the resident's daughter-in-law (listed as power of attorney) during a family visit about the debridement. LPN #4 stated the daughter in law said she had been busy with a funeral and had not returned the call to the wound doctor's office. LPN #4 stated the daughter-in-law was in agreement with the debridement. When asked why actions were not taken to arrange for the procedure based upon the conversation with the spouse and/or daughter-in-law, LPN #4 stated they were waiting on the wound physician's office for the arrangements. On [DATE] at 8:45 a.m. the previous wound nurse (LPN #2) was interviewed about tracking/monitoring of the excoriation initially assessed upon Resident #1's admission. LPN #2 stated wound tracking records were not typically initiated for excoriation. LPN #2 stated the floor nurses were responsible for assessing and monitoring the resident's skin including the excoriation and their assessments were in nursing notes. On [DATE] at 8:50 a.m. the DON was interviewed again about the conflicting skin assessments and lack of a weekly body audit for Resident #1 prior to the development of the stage 2 sacral pressure ulcer on [DATE]. The DON stated the resident was admitted with excoriation on her buttocks area as documented on the admission assessment. The DON stated she spoke with LPN #3 that assessed the resident's skin as intact from [DATE] through [DATE]. The DON stated LPN #3 documented in error as LPN #3 recalled the resident continued with excoriation on the buttock area even though she documented the skin as intact. The DON stated we have identified the assessment errors as an opportunity for education and improvement. The DON stated the standard documentation in notes referring to the excoriation as an open area came from a menu selection on the skilled nursing form. The DON stated the open area category was the option picked reflecting the excoriation. When asked why the resident did not have an air mattress until after the development of the stage 2 pressure ulcer, the DON stated the interdisciplinary team assessed residents for mattress needs. The DON stated the resident had a standard pressure relief mattress upon admission and did not get the air mattress until she was found with the stage 2 pressure ulcer. When asked about the physician's involvement with the wound assessment and taking initiative to get the needed debridement done, the DON stated the physician admitted to not always writing a note. The DON stated the physician saw the resident more often than the notes indicated and the facility noted that as an opportunity for improvement. When asked why Resident #1 went 10 days without a body audit ([DATE] until [DATE]) prior to the finding of the stage 2 sacral pressure sore, the DON stated, We missed a body audit. The DON stated the nurses were supposed to be reviewing the skilled resident's skin daily and body audits weekly. On [DATE] at 9:30 a.m. LPN #5 that routinely cared for Resident #1 during her stay was interviewed. When asked why there were no descriptive assessments of the resident's excoriation referred to the notes as open areas, LPN #5 stated the open area documentation was selected from a drop down menu on the daily skilled nursing note form in the computer. LPN #5 stated there was space at the end of the form to enter custom notes as needed. When asked why she did not make a note describing the excoriation's appearance, size and exact location, LPN #5 stated she did not know. When asked if she remembered anything about the appearance of Resident #1's open areas prior to the development of the stage 2 pressure ulcer, LPN #5 stated it had been too long ago and she did not remember the extent of the skin excoriation. The facility's policy title Skin Assessment (undated) documented, The purpose of the Skin Assessment is to evaluate the condition of each resident's skin on a regular basis .A licensed nurse will complete a full body assessment for each resident upon admission, readmission, weekly, and when a new skin integrity issue is observed. Findings will be documented in the resident's EMR (electronic medical record) on a Body Audit assessment. The NPUAP Prevention and treatment of [REDACTED].With each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g. wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications) .Address signs of deterioration immediately .Signs of deterioration (e.g., increase in wound dimensions, change in tissue quality, increase in wound exudate or other signs of clinical infection) should be addressed immediately . This reference states on page 40 concerning debridement, Use mechanical, autolytic, enzymatic and/or biological methods of debridement when there is no urgent clinical need for drainage or removal of devitalized tissue .Surgical/sharp debridement is recommended in the presence of extensive necrosis, advancing [MEDICAL CONDITION], crepitus, fluctuance, and/[MEDICAL CONDITION] secondary to ulcer-related infection .Clinical indication that the dry, stable eschar requires assessment and interventions include signs of [DIAGNOSES REDACTED], tenderness, [MEDICAL CONDITION], purulence, fluctuance, crepitus, and/or malodor (i.e. signs of infection) in the area around the dressing .Debride the pressure ulcer urgently in the presence of the above symptoms (i.e., [DIAGNOSES REDACTED], tenderness, e (TRUNCATED)

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide supervision to prevent accidents with major injury for two of 24 residents, Resident #4 and Resident #22. 1. Resident #4 sustained a fractured hip after being pushed to the floor by Resident #21. Resident #21 was known to the facility as having threatening behaviors to staff, other resident and visitors. 2. Facility staff failed to provide supervision for the prevention of an accident with injury for one of 24 residents. Resident #22 sustained a laceration to his head requiring sutures during a resident to resident altercation on the Garden unit. Findings were: 1. Resident #4 sustained a fractured hip after being pushed to the floor by Resident #21. Resident #21 was known to the facility as having threatening behaviors to staff, other resident and visitors. Resident #4 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Dementia, atrial fibrillation, hypertension, and depressive disorder. The most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 11/24/2014. Resident #4 was assessed as having a cognitive summary score of "0", indicating severe impairment with her cognitive status. On 12/11/2014 at approximately 8:25 a.m., Resident #4 was observed lying in her bed, moving legs, lifting arms up, making jabberish non word sounds, clip alarm in place, left side of bed against the wall, right side of bed with fall mat. Unable to speak to or focus on surveyor. The clinical record was reviewed on 12/11/2014 at approximately 11:00 a.m. Progress notes described Resident #4 as: "wandering aimlessly throughout the unit", "oldest of 12 siblings and was required to take car and tend to them, often sits self in floor to take care of them", "always wiping and cleaning", "wandering in and out of patient rooms", hallucinating picking up items not in floor." An entry dated 11/10/2014 at 16:55 (4:55 p.m.) was observed to read: "...Resident was witnessed to be pushed to floor by another resident (Resident #21). Resident was walking around the unit when she got close to another resident. He yelled 'leave me alone,' he then took both hands and pushed her in the floor. Resident fell backwards onto her buttock and did not hit her head. Assessed resident and found to be in a lot of pain, refusing to move right arm, leg, foot, and left foot/leg. Laying in fetal position screaming with minimal touch...send to ER...Resident alert, responsive, complaining of pain also pain in left knee." Resident #4 was admitted to the hospital and diagnosed with [REDACTED]. She was readmitted to the facility on [DATE]. Prior to the fall Resident #4's functional status (Section G) on her quarterly MDS with an ARD of 11/10/2014 (same day as the fall) was assessed as follows: Walk (room/corridor) 2/2 (limited assistance of one person); Eating 3/2 (extensive assistance/one person physical assist); Toilet Use: 3/2 (extensive assistance/one person physical assist); ROM (range of Motion Limits: No impairments in upper or lower extremities. Under Section H, Bowel and Bladder, Resident #4 was assessed as "0/1 Always continent of Bowel and Occasionally Incontinent of Bladder." The Significant change assessment completed after her return to the facility assessed as decline in the above mentioned areas. The declines were assessed as: Walk (room/corridor) 8/8 (activity did not occur); Eating 4/3 (total dependence/two person physical assist); Toilet Use: 4/3 (total dependence/two person physical assist); ROM (range of Motion Limits: No impairment in upper extremities, impairment on one side of lower extremities. Under Section H, Bowel and Bladder, Resident #4 was assessed as "3/2 Always incontinent of Bowel and Frequently Incontinent of Bladder." Throughout the day on 12/11/2014, Resident #4 was observed in her bed. Very restless, nonverbal, unable to lie still. RN (registered nurse) #2 went into the room and attempted to calm Resident#4 without success. RN #2 was asked if Resident #4 had declined since the fall and fracture of her hip. She stated, "Oh yes." Resident #21's closed record was reviewed due to the incident on 11/10/2014. Resident #21 was admitted to the facility on [DATE] after being treated (hospital named) for short term dementia care. He was admitted with the following diagnoses, but not limited to: dementia with behaviors, other and unspecified alcohol dependence, unspecified drunkenness, vascular dementia, other persistent mental disorder conditions classified elsewhere and constipation. The admission MDS with an ARD of 10/09/2014 assessed Resident #21 as having a cognitive summary score of "06", indicating severe cognitive impairment. The progress note section for Resident #21 was reviewed from the time of his admission until the time of the incident involving Resident #4. The following entries were observed but not limited to: "10/01/14 MD in to admit resident resident cursing at (name of doctor) stated don't come in her asking me no stupid (expletive) question...refused to take meds X 3 attempts threw them on floor wandering in others rooms...10/02/14...Resident has an ink pen stating 'I might need this to stab someone'. Attempted to get pen with no luck...10/03/14 Resident sitting at nurse's station rapid periods of mood changes. Joking and laughing with staff then angry and aggressive. Stated to other residents when walking by "Go away, get on"...I don't need that medicines, I need some crack or cocaine...to be honest I need some alcohol...noted to be wearing roommates hat and other belongings. Writer attempted to explain hat belonged to another resident but resident got aggressive...I know what's mine...10/12/2014 Resident sitting in chair near nurses station, another resident walked near chair and resident began cursing and threatening resident stating, "If you don't get the hell away from me, I'm going to kill you...10/13/14...going through roommates drawers and closet saying everyone was stealing his clothes...'yall are all damn thieves and I'm gonna kill yo all...cursing in front of roommates family...10/17/2014 Resident extremely combative when trying to give him his 0800 meds. Cursing and threatening to throw meds across room and in the trash can...finally took them on third attempt while cursing and fussing the whole time and claiming we are trying to poison him 10/20/14 MSW briefly interviewed resident...stated he was tired of this place and SW could 'go to hell'. Resident is extremely frustrated with himself and anyone who tries to interview or assist with anything or anyone. 11/07/14 Resident becoming increasingly agitated and screaming at other residents that enter his room. Attempted to redirect with one on one and ball toss but unsuccessful at this time...11/09/14 Resident's roommate up OOB (out of bed) talking real loud and this residents side of the room, he became real upset and told this writer 'Get him out of here or I will" Redirected and took roommate out of room. 11/10/2014 Resident was witnessed by staff pushing resident (Resident #4) in floor. Resident was walking around the unit when she to too close to him, he yelled 'Leave me alone," he then took both hands and pushed her in the floor. Resident fell backwards onto her buttock and did not hit her head...no verbal or physical aggression noted prior to the incident..." Observed during the time frame of 09/30/14 until 11/10/2014 were documented calls to the (hospital named) requesting Resident #21's case worker to call the facility regarding his behaviors. The calls were not returned until after the incident between Resident #4 and Resident #21. Resident #21 was sent out of the facility and to (hospital named) for an evaluation on 11/26/2014. He did not return to the facility. An end of the day meeting was held on 12/201/2014 at approximately 3:30 p.m., with the DON (director of nursing) and the administrator. Concerns were voiced by this surveyor regarding the above information. A timeline outlining Resident #21's behaviors and interventions implemented by the facility was requested. The DON stated that (hospital named) had attempted to return Resident #21 to the facility and they had refused his readmission based on his previous behaviors. On the morning of 12/11/2014 an "Action Plan" was presented by the DON regarding the incident that occurred between Resident #4 and Resident #21. The DON stated that the action plan had been created at the time the incident occurred. The DON was asked why the action plan had not been mentioned the previous day. She stated, "I don't like to mention anything until I have had a chance to review it." The action plan was specific to the behaviors displayed by Resident #21. The plan was reviewed and accepted by the survey team. The deficient practice will be considered as past non-compliance with an AOC date of 11/17/2014. No further information was presented prior to the exit conference on 12/11/2014. 2. The facility failed to ensure Resident #22 was free from and incident causing harm, which required medical treatment from an outside facility. Due to the facility's inability to provide adequate supervision for a resident with agitation and violent behaviors, Resident #22 was struck in the head by another resident with a cane, which caused a 2 cm (centimeter) laceration to the top of his head requiring the resident being sent out to the hospital for sutures and a CT (computerized tomography) scan. Resident #22 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/28/14 was an admission assessment. The resident was assessed as having short and long-term memory impairment and severely impaired in decision-making skills. On 12/11/14 at approximately 8:30 a.m. Resident #22's closed clinical record was reviewed to include the following notes: A "Discharge Instruction Form" from Psych Acute Care signed by the physician at the nursing home, where the resident resided, accepting the resident on 5/19/14 to include: "admitted [DATE]...discharge date : May 19, 2014...You were hospitalized for [REDACTED]. Psych Progress Note: "5/14/14 Assessment and Plan: ...Due to (patient) unable to have cane or walker on unit, (patient) requires nursing one to one for safety per PCP (primary care physician). (patient) has a history of agitation, combativeness and violent behaviors..." Discharge Progress Notes with recommended medications: "Active... Medications: 1. Amantadine 50 mg/5ml Syrup 10 ml (100 mg) by mouth twice a day. 2. Docusate NA 50 mg/5ml Liquid 10 ml (100 mg) mouth once daily. 3. Quetiapine Tab 12.5 mg mouth at bedtime. 4. Trazodone HCL 50 mg tab 25 mg at bedtime as needed. 5. Valproic Acid 250 mg /5ml Soln, Oral 750 mg/15 ml mouth twice a day." History and Physical from attending physician from facility where resident resided prior to discharge on 7/15/14: "5/20/14 Assessment: 1. ...Presently on Alzheimer's unit...Plan: 1. Will continue with his admission medications..." "5/26/14 Recertification...The patient is seen for recertification purposes. He is off his Seroquel. No longer drooling...Seems to be much quieter. No behavior problems. He is not sleeping at night...Plan: 1. We will decrease his Amantadine to 10 ml daily. Will eventually discontinue it... 2. Continue off Seroquel...3. Continue on Depakote..." "6/3/14 Recertification...The patient is seen for recertification purposes. He is still roaming around quite a bit. He is not sleeping at night...Assessment: 1. Psychosis...2. Insomnia...Plan: 1. Due to his insomnia, we will completely discontinue his Amantadine..." "6/24/14 Follow up visit per wife request...he has had some increases agitated here recently. We have taken away a lot of his medicines that were causing rather erratic and bizarre behavior. He is off Emetamine. He is off Seroquel. He is taking Depakote. He does seem to be a little bit more aggressive now...Assessment: 1. Psychosis...Plan: 1. Will add Aricept 5 mg daily x 5 days then 10 mg daily...2. We will check a Depakote level, make sure he is getting enough of that. He may need an anxiolytic in the future." "7/11/14 Psych Consult...Recommendation: 1. Continue Aricept and Trazadone...2 . Start Zoloft 25 mg po daily, Zyprexa 25 mg daily prn (as needed) agitation, please consult PCP to start Multivitamin daily..." "5/19/14 15:29 (3:29 p.m.) Resident arrived onto unit ambulatory with daughter and son in law from unit one...History of agitation, combativeness, and violent behaviors. Resident appears to be confused , forgetful, disoriented, and mumbles incoherent information at times..." "5/19/14 17:04 (5:04 p.m.) ...Resident is to be moved to Garden, Alzheimer's unit, when bed cleaned." "5/20/14 07:05 a.m. Resident has been up all night ambulating around unit, easily redirected. He talks to himself, he sometimes does not understand what is being said to him at times..." "5/20/14 17:51 (5:51 p.m.) Resident has seemed to adjust fine to transition of admission to the facility. He is continuing to walk around the unit and has started to interact with other residents...Resident has been speaking understandable words..." "5/21/14 07:19...resident ambulating round unit constantly until approx 2330 (11:30 p.m.) this writer assisted him to bed...he got up at 0400 constantly ambulating around unit, trespassing into others room urinating on floor. He took CNA's lab jacket and urinated on it. He is not easily redirected. He either doesn't understand or maybe cannot hear." "5/21/14 15:14 (3:14 p.m.) Resident ambulating unit most of shift, drooling. Mumbling "kill and stop..." "5/21/14 18:05 (6:05 p.m.) New order to change dx (diagnosis) of Seroquel to Psychosis." "5/21/14 01:51...persistent drooling, resident wandering unit in and out of other residents rooms. attempts at redirection unsuccessful, resident unable to follow directions. 1/1 given..." "5/21/14 09:06 Resident wandering in and out of others room most of morning. Unable to sit for any period of time. Unable to redirect as resident looks other way..." "5/22/14 14:32 (2:32) Resident telling staff and other residents "oh yeah you think your gonna take my money, but you won't. I'll kill you first" Unable to redirect, resident continuously drooling and wandering unit. Mumbling "kill" several times, unable to understand phrases..." "5/22/14 15:59 (Resident continues to wander into others rooms. Continue to refuse care..." "5/22/14 16:03 New order: D/C (discontinue) seroquel and check Depakote level 5-23-14." "5/22/14 16:19 Resident took shirt off in dining area, attempted to take another residents shirt. Refused for staff to help assist in placing shirt back on..." "5/22/14 23:35 p.m. Resident up wandering in other resident room not easily redirected gave prn trazadone." "5/23/14 10:09 Resident up wandering into other residents and to the door resident not easily redirected..." "5/23/14 12:06 Resident in his room standing over his room mate trying to take his clothes off and pulling his covers back redirection unsuccessful by staff x5 attempts, 1/1 succssful by staff..." "5/25/14 03:35 Resident has been up all night ambulating around unit mumbling to himself, wandering in and out of others rooms...He was Trying to eat gloves, he stuffed them in his mouth and was chewing on them when this writer saw him, redirected he would not spit the glove out he kept chewing it finally I gave him something to drink and he spit it out in his hand..." "5/25/14 09:10 Wandering unit, attempting to urinate into heaters. In and out of others rooms...attempting to eat inedible objects..." "5/26/14 11:38 New order to decrease amantadine to 10 ml po qd... (see recertification note above)." "5/27/14 02:27 resident wandering unit, in and out of other residents rooms, crawled in bed with another sleeping resident. escorted to his own bed..." "5/28/14 14:06 Resident wandering unit most of shift, in and out of others room. Resident urinated in another room in floor..." "5/29/14 11:49 Resident has been wandering in and out of other resident's rooms. He broke a snowman on the bedside table of the resident of 300D..." "5/30/14 22:26 Resident was wandering around unit CNA hear door alarm go off he was holding door knob down and door opened he did not attempt to get out." "5/31/14 02:28 Resident up ambulating from room to room not easily redirected, he urinated behind door in room (#) this writer tried to direct him to commode and he tried to urine on this writer. He stood in bathroom floor and urinated would not use commode." "5/31/14 06:37 He finally settled down at 0500 went to bed...He has wandered in and out of others rooms all night urinating in floors redirection not effective." "6/3/14 16:18 Resident up wandering around unit. In and out of others residents room and refusing to watch tv with other residents. Also attempted 1:1 visit with no success at this time." "6/3/14 20:36 New order to dc amantadine... (see recertification note above)." "6/3/14 22:58 Resident upo wandering in and out of residents rooms trying to get in their beds. Redirected with snack and 1:1 visit. Unsuccessful at this time. Resident still wandering." "6/4/14 02:44 resident up wandering unit, in and out of other residents rooms. uncooperative with redirection. 1/1 given without success..." "6/4/14 02:49 resident trying to urinate all over the unit..." "6/4/14 17:08 Resident attempting to eat objects in unit. Resident attempted to eat glove, staff removed. Resident with wad of kleenex in mouth, writer manually removed with some difficulty..." "6/4/14 22:12 resident wandering unit, three separate times seen messing with resident (1796). trying to touch him and standing over the top of him. resident 1796 extremely agitated with this..." "6/4/14 22:29 resident seen trying to eat a hair brush covered in someone else's hair. several attempts to retrieve hair brush from him before finally getting hair brush. resident angry and cursing staff picked up radio broke antenna and slammed it on the nurses station. 1/1 given..." "6/5/14 09:46 Resident refusing to sit at table to eat...agitated with staff, taking off clothes in dining area, urinating in places other than toilet...1 on 1 not effective." "6/5/14 11:15 Writer caught resident eating paper from another residents room, able to remove paper from side of mouth x 6 attempts x 2 staff members..." "6/5/14 Pharmacy Consultant Note 17:59 medications reviewed for possible side effects of increased behaviors and eating inedible objects. None of the current medications would cause this." "6/6/14 N.O may manually remove inedible objects from resident's mouth as needed." "6/6/14 18:45 resident wandering dining area during supper, trying to take food from other residents trays. yelling, cursing and threatening cna..." "6/6/14 21:19 Resident wandering on unit in others room urinated and had a bowel movement on floor fighting with staff as they attempt to redirect him wandering on unit with no clothes on staff attempted to dress him he pulled brief off took resident to room attempted again to dress him still fighting with staff in room with no clothes on..." "6/7/14 13:07... Staff attempted to toilet resident without success, resident proceeded to remove all clothing and urinate and defecate at entrance door. Staff assisted x3 to bring to room. Resident combative during ADL care. Refusing to sit on toilet..." "6/7/14 19:05 Resident ambulating in and out of other residents rooms taking their belongings, sitting on their beds, redirecting numerous times offered food he took sandwich handled it threw it in floor and stepped on it. Staff trying to provide 1:1 as much as possible, he is not easily redirected nor is he easy to provide 1:1. He took off his pants numerous times staff put them on he would take them off again. He put his legs in the same pant leg, when staff tried to put on right he would get agitated. He is not cooperative with care it takes 3 to change his brief." "6/8/14 01:31 Resident up ambulating around unit trying to take his pants off again, redirection not successful. He gets agitated when approached, he is not cooperative with care. assisted x 3 to change him and put his pants back on." "6/11/14 10:55 Resident woke up at approx. 9:00am. Wandering in others room and around unit while periodically undressing. Residnet attempting to take clothes off of other residents...Currently wandering unit and attempting to open doors..." "6/11/14 18:29 Resident undressing in open area and refusing to put clothes back on. Very agitated when staff attempts. Attempting to pull wires from TV, lift TV, removing cord from EMARs on med carts. Unable to redirect with 1 on 1 or snack." "6/12/14 06:11 ...resident up wandering most of night in others room not easily redirected at times trying to remove power cords from med cart had to lock cart up urinated on floor cna attempted to toilet him several times attempting removing objects from behind desk such trying pick up computer, fax machine and telephone gets very aggressive at times..." "6/13/14 01:56 Resident refuses to go to bed redirected numerous times unsuccessful, he has wandered all over unit went into room (#) ate all of this resident's lollipops. He then tried to pour juice and water on med cart, redirected numerous times, provided 1:1 as much as possible...He then poured liquid soap on Dinamap and on CNA's cart. Staff providing 1:1." "6/13/14 18:38 Resident been in and out of others rooms most of shift, taking belongings from others. Attempting to eat box of gloves, exit seeking. Cursing staff and refusing ADL care..." "6/14/14 04:28...Resident on 2nd shift, 6/13/14 wandering in and out of other resident's rooms taking items that doesn't belong to him, taking clothes off. Staff redressed x4 he became agitated when staff tried to redirect. He pulled his jeans off put on table took another resident's water pitcher and poured water on table and soaked his jeans. He took off his brief and was trying to wipe table with it. Went to room (#) bathroom took her hand soap was sucking on the pump. Staff constantly attempting to redirect and providing 1:1 as much as possible...Resident went to bed at 0115 and is up 0335 urinating on floor in front of bathroom door, he then sat on roommate's bed with roommate in it, he became agitated when staff attempted to escort him back to his bed..." "6/16/14 09:30 Housekeeping made writer aware resident "eating paper." Large amount of paper residents mouth that writer was able to get out. Explained to resident that this could choke him and he should not do this." "6/17/14 04:58 Resident on 2nd shift aimlessly wandering around unit, agitating other residents he was in their personal space,arguing with them. He defecated in brief took it off and got feces all over dining room floor. Staff trying to change him he became agitated pushing and shoving it took 3 staff members to change his clothes. He went to bed at 0200 this writer went to check on him he was in bed with his roommate..." "6/18/14 02:07 Resident wandering around unit in and out of other residents rooms taking blankets and other items, staff redirected numerous times provided 1:1 food and drink, he calms down for awhile and then back at it again...went to check on him he was sitting on roommates bed with his arm around roommate redirected him back to his bed..." "6/21/14 22:26...He has been wandering in and out of other residents rooms, he was in room 314 taking his fist and tapping on resident (room #) chest causing this resident to become agitated. Staff could not redirect him it took assist x4 to get him out of that room..." "6/25/14 00:51 MD in to see resident order written for...start Aricept 5 mg po x 5 days then start Aricept 10 mg (see recertification note above)." "6/26/14 22:50 RP (daughter) called and she said resident is more withdrawn and his cognitive level has regressed. She stated she would like MD to assess him for PTSD, for this has never been addressed by other doctors. He also may have dementia possibly needs med prescribed for this she hopes this will help him." "6/27/14 07:58 MD faxed back and stated that he put him on aricept last visit and resident has a Psych consult." "6/27/14 17:59 Anxious and roams around from room to room even in other resident's room. He takes off his clothes and gets naked in front of the entire dining and living room area." "6/28/14 05:35 Resident has been wandering around unit from room to room all night...He has urinated in floor and took off clothes, he rolled feces around in his hand and was wiping it all over his hands, took assist x 3 to change redress and wash his hands..." "7/5/14 22:50 Resident wandering around unit talking loud rubbing residents, arguing and called a resident an a_s hole. Provided 1:1 gave food and drink he stopped for a while then he was up wandering again. He went into room (#) and tried to urinate on bed, staff redirected to commode he refused to urinate..." "7/6/14 09:41 Resident exit seeking, wandering in others rooms, resisting ADL care..." "7/7/14 00:30 Resident has been wandering around unit in and out of other resident's rooms rubbing on residents making them agitated. Staff trying to change him he refused and he has to be assisted x 3 to change his clothes. He was cursing and swinging at staff. He put chairs on top of tables, staff provided 1:1 as much as possible..." "7/8/14 16:28 Resident wandering from room to room gathers other residents belongs..." "7/9/14 13:55 Resident took another resident's dessert bowl off food cart and began licking bowl consistently. CNA attempted redirection and resident became violent. Writer informed CNA to allow resident to continue to eat dessert because he was not causing any harm to anyone. A few minutes later, resident was in another resident's room wiping his nose with a blanket..." "7/10/14 22:33 Resident ambulating all over unit wandering into other resident's rooms. He went into room (#) he scared a female resident she yelled out then he urinated at hallway in floor...He poured apple juice all over med cart #2 and was rubbing it all over. He was also pulling juices off cart trying to drink out of the jugs and water pitcher..." "7/11/14 01:36 Resident has an appointment with mental health (hospital named) at 0730." "7/11/14 06:27 resident left faculty via wheel chair with van to go. Staff was trying to get resident dressed he became violent starting hitting. kicking and punching. Trying to hit this writer with a wooden rack it took 3 staff members a to get him dressed and in the van..." "7/12/14 15:25 Resident wandering around unit beating his chest like tarzan. Getting in other residents personal space." "7/14/14 08:54 Resident found behind nurses station with pants down urinating on floor and cabinets. also having a bowel movement on floor. Attempted to redirect resident to bathroom, resident became severely agitated punching numerous objects, along with swinging at staff. Resident finally redirected with success to bathroom where he became severely agitated again punching things, and hitting a staff member in mouth..." "7/14/14 10:55 MD approved new orders from psych consult on 7/11/14. (see Psych Consult note above)." "7/14/14 14:53 (2:53 p.m.) Called to rm (#), resident 2 hit this resident on the head with a cane causing a open 2 cm long gash to top of head. Pressure applied to site to help with the bleeding. Assisted resident to chair, at this time resident became severely agitated chasing staff member around calling her names, attempted to redirect and at that time this resident grabbed resident 9 on arm causing bruising to upper and lower left arm, redirected resident. Resident then continued to walk around unit beating chest, resident redirected...When writer ask if he has any pain to his head where he was hit he stated yes...MD/RP aware, RP requesting resident be sent to (hospital named) for CT scan of head." "7/14/14 16:17 (4:17 p.m.) Called to RM (#) by charge nurse at approximately 2:20 p.m., per CNAs this resident had entered RM (#) and sat on bed, CNAs were attempting to remove this resident from RM (#) when he became combative-hitting them, pulling at them, grabbing them, pushing them. Resident 1952 who resides in RM (#) entered the room and struck this resident on the head with his cane. Upon writer entering the room, this resident was observed sitting on the floor at the foot of the bed up against night stand, CNAs were holding a towel to his head and trying to clean blood off his hands and face. An approximately 2 cm shallow laceration noted to left side top of head. Resident allowed staff to clean him and assist him up from the floor into a w/c, writer back to nurse's station when heard resident yelling "I am going to kill you (explicit language), come here (explicit language) you" and was chasing after CNA trying to hit her with closed fists, CNA ran into shower room and shut the door at which point resident began shaking and jerking on shower door, staff was able to distract him away from the door but he began to chase after other residents and staff swinging at them with closed fist and yelling "I am going to kill that (explicit language), come back here". he then ran up behind resident #1459 grabbing her left arm, of which it required 3-4 staff members to remove his hands from her arm. Resident agitated, running around unit, chasing after others, yelling/cursing, swinging closed fist at others, striking self in chest with closed fist; required multiple staff members to distract this resident so that others could be removed from common area. (Physician named) made aware of all of the above by writer, orders given for Ativan 1 mg IM x 1 dose which was not administered per DON (director of nursing) instruction as resident was calmer, seated at dining table, eating meal quietly. RP (responsible party) made aware of all of the above and requested resident be sent to ER (emergency room ) for evaluation. (Physician named) made aware of RP request, orders given to send to (ER named) for evaluation of head trauma and agitation..." "7/14/14 18:02...Resident being discharged back to facility, received 1 continuous stitch to head, which needs to be removed in 10-14 days..." "7/14/14 21:34 Resident behind nurses desk in to everything, refusing to leave. This writer tried to redirect him unsuccessful...he became angry started swinging his arms hitting on the chairs...Administered Zyprexa 2.5 mg po." "7/15/14 02:15 Resident went to bed at 0100 and was resting quietly, this writer was sitting at nurses desk, heard the privacy curtain and then I heard two loud thumps noted resident standing at foot of roommates bed with cane in hand drawed back like a baseball bat he was getting ready to hit again. I called for staff to come quick. This writer ran into room and attempted to take cane away he was trying to strike at this writer but I convinced him to let me see it for a minute and he let go." "7/15/14 19:06 Res d/c to (hospital named)." "7/15/14 18:58 Resident's belongings packed up and placed in med room for p/u by family per social Worker." On 12/11/14 at approximately 9:30 a.m., the director of nursing, administrator, and the regional nurse consultant were in the conference room, in the presence of the survey team to discuss Resident #22 and give a "timeline" of his stay while at the facility. The timeline was reviewed to include the following and evidenced that the resident was admitted on antipsychotic medic

Based on observation, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide care and services as related to an indwelling catheter for two of 27 residents, Resident #1 and Resident #17. 1. a) Resident #1's catheter bag was improperly changed resulting in decreased urinary output and a urinary tract infection requiring 15 days of IM (intramuscular) antibiotics. b) Resident #1 was also not provided proper catheter care for an uncircumcised male. 2. Resident #17 did not have medical justification for an indwelling catheter nor were there physician orders [REDACTED]. Findings were: 1. Resident #1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 09/26/2012. Resident #1 was assessed as having a cognitive summary score of 11, indicating that his cognitive status was moderately impaired. a) A facility reported incident was received at the State Agency on 02/17/2012 which stated, "Acquired UTI (urinary tract Infection) Res (resident) with cath (catheter) was noted to have leakage around insertion @ drainage bag. Res. experienced a decrease in LOC (level of consciousness) and was transported to hosp (hospital). The res. urologist notified the center that the drainage bag not properly connected resulting in decreased urine flow which resulted in a UTI requiring IV antibiotics." The clinical record was reviewed on 11/27/2012 at approximately 10:00 a.m. The following entries were observed in the nurse's notes: 2/9/12 2400 (midnight) New bag applied D/T (due to) bag on drainage tubing broken. 2/10/12 @ 1550 (3:50 p.m.) Resident have (sic) foley catheter in place but is soaking his brief and pads, catheter inserted by (name of doctor) due to be replaced on 2/24/12 @ next visit, resident (sic) urine is expelling around catheter. Notified MD (medical doctor) office waiting for return call. 2/10/12 @ 1715 (5:15 p.m.) Received return call from (name of doctor) with orders to restart Ditropam 5 mg 1 PO TID (one, by mouth, three times per day) for bladder spasms. 2/10/12 @1830 (6:30 p.m.) R.P. (responsible party) (name of R.P.) called no answer @ residence. Left message to call facility if have questions. 2/13/12 @ 1030 (10:30 a.m.) Resident very confused skin warm to the touch, pulling @ catheter low grade temp (temperature) 99 degrees, BP (blood pressure) 162/77, O2 (oxygen) 94% will notify MD of change. 2/13/2012 @1615 (4:15 p.m.) Resident still very confused, skin very dry and very pink, lips dry as well as mucous membrane T 97.4 P (pulse) 67 R (respirations) 22, BP 159/77 02 @94% will notify MD of status. 2/13/12 @1620 (4:20 p.m.) R.P. in bld (building) writer notified her of new order from MD for CBC, Chem 7, start IV D5 1/2 NS @ 100cc/hr. R.P. (name) pleased with plan of care. 2/13/12 @ 1700 (5:00 p.m.) 20 gauge IV cath inserted without difficulty in R (right) forearm infusing D5 1/2 NS @100 cc/hr, resident tolerated insertion well. 2/13/12 @ 2200 (10:00 p.m.) Upon entering residents room, talking to self will not turn head keep (sic) head tilted back keeps pulling at anything he can reach. Abdomen more distended than @ shift beginning. IV patent Temp 98.9 VS (vital signs) 186/78, 76, 22, O2 sat 98%. (Name of doctor) beeped at 2300 (11:00 p.m.) on call for self. Order to send out D/T distended abdomen and decreased level of consciousness. Report by CNA (certified nursing assistant) that at 2245 (10:45 p.m.) resident vomited, Res RP made aware of situation, 911 called, (name of hospital) ER (emergency room ) called. Talked to (name of person at ER) gave report. 3/13/12 (error should be 2/13/12) @2245 (Name of doctor) made aware of resident vomiting. 2/14/12 @ 0120 (1:20 a.m.) Nurse called resident on way back bag replaced urine looking good and draining, low grade temp, IV remains intact, (name of doctor) made aware. 2/14/12 @ 0145 (1:45 a.m.) RP made aware of resident returning. 2/14/12 @ 0225 (2:25 a.m.) Res back in facility via stretcher with pt transport 2/14/12 @ 0230 (2:30 a.m.) Nurse called back stated Resident also has UTI (urinary tract infection). The physician order [REDACTED]. 2/13/12 CBC, Chem 7 IV D5 1/2 NS @100cc/hr, (Name of urologist) will handle cath. 2/13/12 Distended abdomen; decreased level of consciousness 2/14/12 ...Send to (name of hospital) ER for distended abdomen, decreased/altered LOC 2/14/12 1. change IV to same rate 2. Chem 12, CBC, ammonia level in AM 3. [MEDICATION NAME] 1 gm IM (intramuscularly) qd (every day) X (times) 10 days 2/17/12 D/C (discontinue) IV R fa (right forearm) and Chem 7 on Monday, 2/20/12 2/19/12 1. D/C [MEDICATION NAME] 2. [MEDICATION NAME] 60 mg IM q 12 hrs 3. Chem 7 Monday and already ordered, then Chem 7 q 3 days while in gent. 4. Repeat U/A (urinalysis) 3 days after completion of [MEDICATION NAME] 2/20/12 Clarification Order: [MEDICATION NAME] 60 mg IM q 12 hours X 10 days. Resident #1 was on IM antibiotics for a total of 15 days. On 11/27/2012 at approximately 11:30 a.m. the DON (director of nursing) was interviewed regarding the above information and was asked what had happened when the catheter bag was changed on 02/09/2012. The DON stated, "The catheter bag has a blue cap on it. When the nurse changed the bag she didn't remove the cap." The DON was asked what that meant and she stated, "The urine couldn't drain into the bag because the cap had not been removed." The DON stated that all nursing staff had since been inserviced on changing the catheter bags. The DON was asked if any urine had been in the catheter tubing after the bag was changed. She stated, "I don't know." The DON was asked how often catheter bags are emptied at the facility. She stated, "At the end of every shift and the amount is recorded." Documentation regarding the output of urine for Resident #1 from 02/09/2012 until 02/14/2012 was requested. A copy of the ER report was also requested. The ER report was obtained at approximately 2:00 p.m. on 11/27/2012. Under the Progress Note section the following was written: "Update note: Noted by nurse the cap to the drainage bag was not taken off the bag, thus the catheter was not draining. The cap was removed and the catheter started to drain." Also observed in the emergency room notes was a print out strip from a bladder scan done on 02/14/12 at 00:06 (12:06 a.m.) after Resident #1 arrived at the emergency room . There was a total of 834 mls of urine in his bladder at that time. The above information was reviewed with the DON and the administrator during an end of the day meeting on 11/27/2012. A copy of the urine output records were obtained on the morning of 11/28/2012. The DON stated, the amounts are cumulative for the entire day. according to the print out the outputs were as follows: "02/09/2012 2400 02/10/2012 850 02/11/2012 Blank 02/12/2012 Blank 02/13/2012 Blank 02/14/2012 1550" The DON was asked if the blanks meant there was no output for those days or it had not been documented. She stated, "I don't know." The DON was asked what the expectation was for the assessment of an indwelling catheter. She stated, "The nurse's should assess the catheter and the bag when they make rounds...The CNAs should report to the nurses if there isn't anything in the bags." The DON was asked how it was possible for a resident to have a catheter bag changed and four days later no one had noticed that there was no urine draining into the bag. She stated, "I'm right there with you. We asked ourselves the same questions." No further information was recieved prior to the exit conference on 11/28/2012. This is a compaint deficiency. b) During review of the electronic portion of the clinical record on 11/28/2012 at approximately 3:00 p.m. the following nurse's notes were observed: 07/05/2012 18:37 (6:37 p.m.) Resident out of facility to appointment...returned at 1600 (4:00 p.m.) with note to make sure foreskin always pulled down after cleaning, if you can not pull down he must go to ER. 07/31/2012 17:47 (5:47 p.m.) Returned to facility (from appointment) ...Return to clinic in one month for catheter change. Reminder to pull foreskin back after cleaning penis. Foreskin checked at this time and pulled up as ordered..." 08/29/2012 11:56 (11:56 a.m.) Spoke with (name) at (doctor's name) office explained resident foley misplaced, urethra split, blood clots coming from urethra, advised to send to ER. 08/30/2012 00:39 (12:39 a.m.)...(name of doctor) notified that the head of the residents skin (sic) was swollen and the foreskin could not be retracted causing poor circulation flow to his penis. Resident was sent to ER earlier today and was back to facility with no new orders. Resident has an order to keep foreskin pulled down to cover the head of his penis. 08/30/2102 00:43 (12:43 a.m.) ...rescue squad called to transport resident to (name of hospital) 08/30/2012 06:38 (6:38 a.m.) Returned to facility...foreskin has been retracted. 11/26/2012 00:23 (12:23 a.m.) ...when providing foley care observed that resident's foreskin had not been replaced, obtained some surgical lubricant and replaced foreskin. On 11/29/2012 at approximately 11:30 a.m., LPN (licensed practical nurse) #3 was observed providing catheter care for Resident #1. LPN #3 entered the room and explained to Resident #1 what she was going to do. She obtained permission for this surveyor to observe the care. After gathering her supplies, LPN #1 unfastened the sides of Resident #1's brief and folded it back exposing his genital area. The foreskin was covering the glans penis and an indwelling catheter was observed. LPN #1 began to clean the penis and pushed back the foreskin exposing the head of the penis. The urethra was observed to be split and the indwelling catheter was observed inside of the urethra. After cleaning the glans penis and the catheter tubing, LPN #3 attempted to pull the foreskin back over the glans penis. The foreskin was not covering the glans penis when the brief was pulled back up to cover the genital area. LPN #3 was asked if she was through and she stated, "Yes." LPN #3 was asked to fold the brief back again. The exposed glans penis was shown to LPN #3. She stated, "It must have slipped back down." She then pulled the foreskin back over the glans penis. When LPN #3 left the room this surveyor followed her and asked about the catheter care, specifically about the placement of the foreskin. She stated, "You have to get the foreskin back in place or he has to go to the ER." It was pointed out to LPN #3 that she had not returned the foreskin to its position over the head of the penis before pulling his brief up to fasten it the first time. She stated, "No, I didn't." A copy of the facility policy regarding catheter care was obtained. Under the procedure for catheter care the following was written: Male-retract the foreskin on uncircumcised male. During an end of the day meeting on 11/28/2012 the above information was discussed with the DON and the administrator. The DON was asked about proper care of an uncircumcised male during care of an indwelling catheter. She stated, "The foreskin should be pushed back away and the glans penis cleaned. The foreskin should always be pulled back over the glans penis." No further information was obtained prior to the exit conference on 11/28/2012. 2. Resident # 17 was admitted to the facility 9/27/11 with the most recent readmission 11/19/12. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. Resident # 17 was coded as having moderate impairment in cognition with a total summary score of 11 out of 15. During review of the clinical record 11/28/12 at approximately 9:20 a.m.the following documentation was noted in the nurses notes: "11/19/12: Resident arrived on a stretcher via transport.....color good, eyes bright, foley in place." Further review of the clinical record revealed a faxed communication form dated 11/19/12 to Resident # 17's physician with the section "Nurse's Comments: Readmission approve orders?" The physician response section of the form documented "orders ok" and signed by the physician 11/19/12. The attached readmission orders [REDACTED]. The POS (physician order [REDACTED]." There were no orders for the care of the catheter documented on the POS. At 10:30 a.m. on 11/28/12 review of the nurses' notes revealed an admission assessment dated [DATE]. Section "B" of the assessment form "Review of Area(s)" stated "Describe the concerns that are under review." Staff documented "readmitted to facility 11/20/12 from (name of hospital) with dx.(diagnoses) of ARF, hypokalemia, metabolic acidosis, [MEDICAL CONDITION], diabetes, paralysis d/t (due to) [MEDICAL CONDITIONS] fib, [MEDICAL CONDITION] and deconditioning." Further review of the nursing notes documented the following: "11/22/12-Residents glands penis (sic) is erythmatous and [MEDICAL CONDITION] and the urethral opening has been torn a small amount of blood was draining from urethra, I loosened the feed on the catheter so as not to pull on the penis any further. I called (name of doctor) with my concern he said to monitor him hourly (sic)." "11/23/12- CNA called me to patients room to bring my attention that patients foreskin on penis had not been retracted back and was now swollen and red. Called (name of doctor) to inform him and he said to monitor it and make a note for him to see patient when he arrives tonight or tomorrow." "11/23/12- Patients foreskin has been retracted back with the use of some ky jelly and a warm cloth to bring down swelling. Patient tolerated well." "11/26/12- Hour of Administration note when providing foley care observed that resident's foreskin had not been replaced, obtained some surgical luberacant (sic) and replaced foreskin, resident tolerated procedure well." "11/26/12- faxed MD request dx (diagnoses) for foley. waiting for response." On 11/28/12 at approximately 12:30 p.m. registered nurse (RN) # 1, who was the unit manager, was interviewed about the documentation in the nursing notes. RN # 1 was asked about Resident # 17's readmission process. RN # 1 stated the hospital orders were approved by the resident's physician. RN # 1 was then asked about orders for the care of the catheter. RN # 1 stated "whatever was on the hospital orders were what was in place." RN # 1 was then asked what the [DIAGNOSES REDACTED]. RN # 1 stated "He was readmitted from the hospital with it; he had it while he was there for some blood in the urine." This surveyor then asked RN # 1 about the documentation in the nurses' note dated 11/26/12 asking the physician for a [DIAGNOSES REDACTED]. RN # 1 was asked if the physician had been in to see the resident in response to nursing concerns documented. RN # 1 stated she was not sure. On 11/28/12 at approximately 4:05 p.m.this surveyor asked if certified nursing assistant (CNA) # 7 could be observed providing incontinent care for Resident # 17. CNA # 7 stated the resident's brief was not wet or soiled so had no reason to change him or do the incontinent care. CNA # 7 was then asked to describe what is done during incontinent care for the resident, and also how the care is done if the resident had a catheter. CNA # 7 stated she did not work with this resident but was usually assigned to Resident # 1. CNA # 7 went on to say "well, I would wipe from front to back to prevent infection......" This surveyor asked if that was the whole procedure for care. CNA # 7 stated "well, if they have a catheter I would wipe the catheter tubing off and still wipe the resident from front to back." This surveyor then asked CNA # 7 if she would retract the foreskin to clean an uncircumcised male; CNA # 7 stated "no; I don't do that." CNA # 7 stated she had been employed at the facility since July 2012. On 11/28/12 at approximately 4:45 p.m. during a meeting with facility staff the DON (director of nursing) was informed of the above findings. The DON was asked about the nurses notes regarding the hourly monitoring of Resident # 17. The DON was asked what the physician's expectation was for the monitoring, and where the documentation of the monitoring would be located. The DON stated "The physician would expect for the resident to be looked at and assessed every hour; the documentation of that would be recorded in the nursing notes." The DON was then asked what the CNA orientation/education was for the care of male residents for incontinent/catheter care. The DON was asked specifically for CNA # 7's education and training documentation. The DON was also asked if a physician's orders [REDACTED]. The DON stated the standing orders did not include how to care for a catheter and the physician was to write orders for that. No further information was provided prior to the exit conference 11/28/12.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure supervision to prevent an accident for 2 of 27 residents, Resident #6 and #8 and on one of three units, The Garden. 1. Resident #6 was not provided supervision to prevent an accident resulting in a mandible fracture. 2. The door to the clean utility room door in the Garden unit was not closed and locked to prevent residents with Alzheimer's and dementia from entering and accessing potentially hazardous materials. Residents were observed wandering around the unit and there were no safeguards in place to keep them from wandering into the clean utility room. Also, the only licensed nurse on the unit left the area without notifying any of the other staff that she was leaving. 3. Resident #8, was not provided adequate supervision or other interventions to ensure he did not have access to sharp and other objects which he used to attempt exiting the building, or other potentially harmful objects for which the resident could harm himself or other residents. Resident #8 was found several times partially out of his window. The findings include: 1. Resident #6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/12 was a quarterly assessment. The resident was assessed as having short and long-term memory impairments and moderately impaired in decision-making skills. Section G0110 was reviewed to include: "Transfers-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position- 2/2 (limited assistance with the help of one person); Walk in room-how resident walks between locations in his/her room-1/1 (supervision with setup help only)." A comparison MDS with an ARD of 7/23/12 was reviewed to include the following: "Transfers- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position- 2/2 (limited assistance with the help of one person); Walk in room-how resident walks between locations in his/her room-1/1 (supervision with setup help only)." On 11/27/12 at approximately 8:30 a.m., Resident #6 was observed sitting in the dining area on the Garden unit waiting for breakfast. On 11/27/12 at approximately 9:10 a.m., Resident #6 was observed walking with hand held assist by staff to the TV area, which was adjacent to the dining area. Resident #6's room was observed. On the outside of the door was a picture of a leaf and the bed was observed in a low position. At this time, a certified nursing assistant, CNA #6 was walking past the resident's door. CNA #6 was interviewed and asked the meaning of the leaf; CNA #6 stated, "It's for residents who are a high risk for falls." On 11/27/12 at approximately 9:15 a.m., the following "Fall Risk Assessments" were reviewed to include: "5/17/11 Fall Risk Assessment (circle the number that applies and add for total points) History of Falls 15, Confused, Disoriented, Senile, Hallucinating, Confused at night-15, Prescription Drug/ETOH (alcohol) Use-5... If point =10 or more Resident is Fall Risk...Total Points: 35...Fall Leaf Program Initiated/in place-Yes." Another Fall Risk assessment dated [DATE] was reviewed to include the following: "Category: Moderate Risk...Score:14...Fall Risk Assessment: 3. History of falls within last six months...5. Multiple falls...Gait analysis...Assess resident's gait while: standing in one spot, walking straight forward and while making a turn...5b. Change gait pattern when walking through doorways..." On 11/27/12 at approximately 9:17 a.m., a "Falling Leaves Program" form was reviewed to include the following: "Policy: To decrease the number of resident falls in the facility, the Falling Leaves program is designed to facilitate recognition of residents who are at high risk for falls...Procedure: A fall risk assessment will be completed by the Charge Nurse on admission, quarterly, and as needed, and will be addressed on the care plan...9. Each resident on the program will be monitored to assure...c. Pt/OT screen as required..." The clinical record did not contain a quarterly Fall Risk Assessment for August 2012. On 11/27/12 at approximately 9:18 a.m., Resident #6's May 2012 through October 2012 POS's (physician's orders [REDACTED]. 225 mg (1 ) po every morning..." (1) Haloperidol- pages 602-604 ..."Unlabeled / Investigational Use treatment of [REDACTED]. Rivastigmime / Exelon- pages 1095-1096..." Increases acetycholine in the central nervous system through reversible inhibition of its hydrolysis by cholinesterase...Patient education...May cause dizziness, drowsiness or postural hypotension (rise slowly from sitting or lying position...CNS (central nervous system) changes (eg. excessive fatigue, agitation, insomnia, dizziness, confusion, aggressiveness, depression)." Risperdal / Seroquel pages 1088-1091- "Use treatment of [REDACTED]. On 11/27/12 at approximately 9:20 a.m., the clinical record was reviewed to include the following documentation in the nursing notes: "10/31/11 @ 0928 Physician named faxed regarding fall s (without) injury..." "11/8/11 Area of Concern: Falls: 10/22/11 Res (resident) was noted to be laying on the floor at nurse's station @ 2030 (8:30 p.m.)...Recommendation/Interventions: PT screen, Monitor for fatigue and return to bed as needed..." The therapy section of the clinical record was reviewed and did not contain a PT screen for 11/8/11 as recommended. "11/11/11 Area of Concern:Falls: 10/30/12 @2018 (8:18 p.m.) CNA (certified nursing assistant) made nurse aware of res (resident) losing balance and falling while changing clothes...Recommendation/Interventions...None documented." "11/25/11 1355 (1:55 p.m.) A Restorative Nursing Note: Resident named continues to participate in group ROM (range of motion) activity & ambulation...Her gait is unsteady @ times & she has had some falls..." "4/30/12 Area of Concern: Falls: On 4/23/12 @2000 (8:00 p.m.) ...resident ambulating. Resident (number) following resident and pulled resident resulting in her falling to floor...Recommendation/Interventions: Supervise with ambulation..." "5/30/12 @1550 (3:50 p.m.) This writer heard resident yelling "help me" found sitting in floor in Rm (room) 307, Resident stated, "I hit my face on footboard" alert to name resident crying (sic)..." "6/20/12 0349 this writer was passing residents room noted her sitting on floor on buttocks she stated, I sat on floor because my back is hurting (sic)..." "7/12/12 2357 (11:57 p.m.) CNA stated when she entered residents room see saw her on her knees (sic)..." "7/24/12 12:11 A Pharmacy consultant note: fall 7/13/12; Vicodin x 4, Haldol x 1 all eff (effective)...No recs (recommendations) No gdr (gradual dose reduction) at this time. Benefit > (greater than) risk..." "8/7/12 0135 Resident was walking out of her room at 0100 this morning. She then lost her footing and fell to the floor. She went directly down on her right cheek. It immediately started to swell and turn red and blue. She stated, " I think I broke my jaw bone." This writer was the only witness..." "8/7/12 Nurse from hospital named, called and said they are sending res back to the facility. Xray showed that she has a fractured mandible. She is to follow up with md at hospital named in one week..." "8/11/12 0345 ...on 3rd shift resident has been oob (out of bed) several times during night appears to be drowsy and unsteady on feet, faxed MD to get an order for [REDACTED]." "8/13/12 1320 (1:20 p.m.) New order for x-ray right wrist and faxed pharmacy...also new order for bed mat alarm..." "9/17/12 2036 (8:36 p.m.) resident noted sitting in the floor beside of her bed..." "10/10/12 12:12 New order for mat alarm to bed at night..." "11/1/12 0641 New order per physician named and per pharmacy request to d/c (discontinue) haldol 1 mg (milligram) po (by mouth every am for trail dose reduction of psychoactive meds." "11/22/12 0231 Resident in bathroom attempting to sat on toilet missed toilet sat in floor in her bathroom..." On 11/28/12 at approximately 9:00 a.m., Resident #6's clinical record was reviewed to include a fall care plan (CP) initiated on 9/2/11 and updated on 12/7/11, 2/1/12, and 5/9/12 to include the following: "Problem...Fall risk Potential for injury: Unsteady gait, polypharmacy, use of psychotropic medications, impaired mobility, balance problem, unable to ambulate without assistance, unable to transfer without assistance...Actual fall 9/22, 9/24,10/22, 10/30,4/23/12 and 5/30/12...Interventions...Resident: Remind resident to call when needing assistance, Keep call light and most frequently used personal items within reach, assess medications for contributing factors, maintain record of falls, and evaluate for patterns, make sure that all staff members are aware that resident is at high risk for falls, move to room closer to nurse's station if necessary, Falling leaves or other symbol on door, shoes well fitting with non-slip soles, gripper socks as needed, PT (physical therapy) evaluation for strength training, gait, or transfer, OT (occupational therapy evaluation as indicated, PT screen, PT screen, Monitor for fatigue and return to bed..." The CP included the same interventions for each of the above listed falls. A second CP initiated on 7/3/12 was reviewed to include the following: "Focus Resident named had had an actual fall with no injury R/T (related to) pain and fatigue...Interventions Observe for: pain, bruises, Changes in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation-post fall per facility...date initiated 7/3/12...PT consult for strength and mobility needed...date initiated 7/3/12" A third CP initiated on 7/3/12 and updated on 11/14/12 was reviewed to include the following: "Focus Resident named is at risk for falls r/t unsteady gait at times, dementia, and psychoactive med use Actual fall 8/7/12 and 9/17/12...Interventions...Mat alarm to bed...date initiated 8/8/12...PT consult for strength and mobility as needed...date initiated 7/3/12...PT screen post fall...date initiated 9/20/12." On 11/28/12 at approximately 9:27 a.m., the physical therapy assistant (PTA), Other #3, was interviewed regarding the recommendations made for Resident #6. The PTA provided this surveyor with a copy of the resident's "Initial Evaluation dated 9/22/11 to include: Assessment summary...Clinical Impressions: Pt is managing with independent transfers and ambulation but demonstrates unsteadiness with gait with weakness at pelvis/hip/knee and ankle. Pt will benefit from strength training and balance tasks to improve stability and mobility...Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: falls." A "Discharge Summary" was reviewed to include the following: "Date of service: 9/22/11-10/19/11...Summary of Progress: Pt in each session required maximum coaxing and encouragement to participate with much resistance to treatment encountered. Pt currently is ambulatory without AD (assistive device) on her nursing unit with fair balance. Pt would benefit from core and LE (lower extremity) strengthening however we were unable to get consistency in participation. Pt will continue to be a fall risk due to LE weakness. Nursing made aware to encourage daily ambulation with staff to maintain ambulation level. Hip protectors also recommended to minimize risk of injury if fall occurs..." Screen and Discharge Summary." Other #3 was then asked if the resident was picked up on caseload. Other #3 stated, "No but she, the resident, is supervised ambulation to activities with close supervision to try to minimize injury. We also recommended restorative nursing to ambulate her (the resident) using hand in hand assist in a common area on the garden (unit where the resident resides). When Other #3 was asked if the PT screens were performed as careplanned on 11/8/11 and 7/3/12, Other #3 stated, What I gave you is all we have for her." A copy of the "Interdisciplinary Therapy Screen was reviewed to include the following screens for Resident #6: 10/10/11, 6/20/12, 9/27/12 and 11/27/12. The Screens for 11/8/11 and 7/3/12 (the recommendation prior to the fall and fracture on 8/8/12) was not listed on the Interdisciplinary Screen form as being performed. On 11/28/12 at approximately 2:30 p.m., the medical records coordinator was interviewed regarding Resident #6's thinned records and if there was another CP. Other # 9 stated, "This is all that I found for her (Resident #6). The CP was updated here (pointing to the dates on the CP dated 9/2/11) quarterly and again on August 8th (pointing to the bottom of the second care plan)." On 11/28/12 at approximately 3:54 p.m., the licensed practical nurse (LPN #10), who witnessed the fall on 8/7/12, was interviewed regarding the fall and the resident's behavior prior to the fall. LPN #10 stated that the resident "walked out of her room and fell on her face." When asked if the resident was wearing shoes or gripper socks, LPN #10 stated, "She may have had on shoes or socks, I am not sure, it's been so long ago. She (the resident) normally put her own shoes on but not sure if she was wearing them when she fell . She (the resident) is usually up walking around when I get there." When asked of the resident's gait and balance, LPN #10 stated, "She is normally pretty steady on her feet, will lose her balance and we have to catch her. She doesn't fall much." On 11/28/12 at approximately 4:10 p.m., the Assistant Director of Nursing (ADON), whom was also the Restorative Nursing Program Coordinator (RNP), and who will be identified as Admin #3, was interviewed regarding Resident #6's participation in the RNP and her recommendations. Admin #3 stated, "She (the resident) ambulates with restorative sometimes. She is steady sometimes with hand held assist. In an ideal world a walker would be good for her but with her cognitive status she would get tangled and fall." When asked if therapy had made any other recommendations for Resident #6, Admin #3 stated, "No, there hasn't been any other recommendations, she has had multiple falls." On 11/28/12 at approximately 5:25 p.m., the Director of Nursing (DON) was interviewed regarding the quarterly fall risk assessment for August, which could not be located in the clinical record. The DON stated that the fall assessment for August was not done. The DON further stated, "We thought that when we switched over to the computer system that it (the fall risk assessments) would be auto populated but they wasn't. We have been assigning them; we have since then gotten on track. I cannot produce one for August." When asked if a fall risk assessment for Resident #6 should have been done, the DON stated, "Yes ma'am." On 11/28/12 at approximately 5:30 p.m., the administrative staff was made aware that the resident's CP was not updated for new fall interventions to prevent accident and injuries and nor was the CP updated to include the PTA's recommendations. The administrator stated, "I understand, if a recommendation is made, then how come it's not carried through. I understand what you are saying." (1) Turkoski, Beatrice B., Brenda R. Lance and Mark F. Bonfiglio. Drug Information Handbook for Nursing 2007. Hudson, Ohio: Lexi-Comp, 2006. 2. Initial tour of the facility was conducted on 11/27/2012 at approximately 6:15 p.m. There were three units in the facility including a locked ward referred to as the "Garden." The initial tour of the Garden was conducted with LPN (licensed practical nurse) #4. Upon entering the unit, a door to the left was observed propped open with a package of adult disposable briefs. The sign outside the door read, "Clean Utility Room." LPN #4 was asked why the door was propped open. She stated, "We don't have a key. The CNAs (certified nursing assistants) take it home and we don't have a key..." LPN #4 was asked if the door was always propped open and she stated, "We don't have a key. Housekeeping has the key, we would have to call them to get in there if we shut it." LPN #4 was asked if the door was suppose to be shut and locked and she stated, "Yes, I guess, but we don't have a key." This surveyor and LPN #4 entered the clean utility room. The following items were observed: Clean linens on a covered cart, a sharps box attached to the wall, packages of adult disposable briefs, bottles of liquid hand soap and gloves. LPN #4 was asked if the residents ever wandered into the utility room. She stated, "No, they don't come up here...we watch them." While on tour rooms were observed with white pieces of material across the door frames with the shape of a stop sign in the middle of them and the word "STOP." LPN #4 was asked what the material was for and she stated, "To keep other residents out of their rooms. Some of them wander and get confused about which room is theirs." Also while on tour, LPN #4 was giving report on the residents who resided within one of the rooms and pointed both of them out in the common area of the unit. Observed within that room was a bed with someone in it. LPN #4 was asked who was in the bed if both of the residents were in the common area. She looked in the room and found another resident asleep in one of the beds. She woke the resident up and took her across the hall to her assigned room. Another resident was then observed wandering into the same room and was redirected by LPN #4. She stated, "They get confused and don't know where they are suppose to be." Throughout the tour this surveyor had questions regarding colored dots beside resident names and outside of resident doors. LPN #4 stated, "I'm just part time, I don't know what they are for." At the end of the tour this surveyor requested that LPN #4 let her know what the colored dots and colored circles indicated. She stated, "I will find out right now." LPN #4 (the only licensed nurse on the unit) then left the locked unit. She did not tell any of the CNAs that she was leaving nor were any CNAs observed in the common area with the residents when she left the unit at approximately 6:50 p.m. LPN #4 walked up the hallway to the next nurse's station (located on Unit 2). LPN #4 was asked by this surveyor who was taking care of the resident's in the locked unit if she was out on the floor and she stated, "The CNAs are in there. I didn't think I would be gone but a minute." LPN #4 then walked up the hall towards the next nurse's station (Unit 3.) A staff member was observed walking towards the locked unit and this surveyor followed her. Upon entry to the unit the clean utility door was observed closed. LPN #4 returned to the unit at approximately 7:05 p.m. On 11/27/12 from 8:43 a.m. to 8:45 a.m., an observation was made in the unit named "Garden" that there were no staff observing the residents for these two minutes while the residents were eating breakfast in the dining area. At 8:42 a.m., the licensed practical nurse (LPN) #7 was observed to go around the corner to a residents room for a medication pass, leaving one CNA in the dining room with the 19 residents. The CNA took one of the residents, telling the resident while wheeling them that they were going to take them to the bathroom, this was 8:43 a.m. At 8:44 a.m., this surveyor brought the lack of dining room supervision to the attention of another surveyor. The residents continued to eat and at 8:45 a.m. a different CNA came into the dining area. On 11/28/2012 at intervals throughout the day the survey team observed the door to the clean utility room on the locked ward. The door was not observed propped open at any other time. At approximately 3:30 p.m. on 11/28/2012 this surveyor went to the locked unit. LPN #5 was standing at the nurse's station and was asked if there was a key available to the clean utility room. LPN #5 opened a desk drawer at the nurse's station and removed a key. She accompanied this surveyor to the locked door and opened it with the key. Both she and this surveyor stepped inside the clean utility room and shut the door. The door handle on the inside of the door was a lever and the door was not locked when exiting the room from the inside. To get out of the room the lever handle needed to be pushed down and the door pushed open. LPN #5 was asked if she had ever observed the door to the clean utility room propped open. She stated, "Yes, when they are stocking the room. There is a cart here (pointing to an area outside the door) and someone is here. LPN #5 was asked if the key to the clean utility room was ever misplaced. She stated, "Sometimes the CNAs take it home in their pockets by accident...housekeeping has a key and they are here until 11:00 p.m." LPN #5 was asked what happened when the key was missing. She stated, "Mr. (name of maintenance director) makes us a new one." LPN #5 was asked when the last key had been made and she stated, "I will go ask him." LPN #5 returned to the conference room and reported to this surveyor that the last key had been made on 11/06/2012. During an end of the day meeting with the DON (director of nursing) and the administrator on 11/27/2012 the above information was discussed. The DON stated that the door to the clean utility room "should be shut and locked at all times". The DON was asked about the staff leaving the unit. She stated, "Unfortunately there isn't a bathroom back there for staff so the nurse's have to come all the way to the front to go to the bathroom. If they leave the unit it is just for a few minutes and they let the CNAs know that they are gone...She should have let someone know that she was leaving the unit." No further information was received prior to the exit conference on 11/28/2012. 3. Resident #8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 11/16/12 assessed the resident as having both short and long term memory loss and requiring extensive assistance with decision making. The admission MDS with an ARD of 3/30/12 assessed the resident with a brief interview for mental status (BIMS) score of 10 out of 15 meaning he was mildly cognitively impaired. The care area assessment (CAA) which determines what care areas the resident needs care planned, did not show that the resident needed care planning for behaviors The clinical record was reviewed. The nurses notes documented the following regarding Resident #8's behaviors: "4/25/12 at 1500 (3:00 p.m.) Resident approached nurse's station stated 'I want to go home. I could get out of here in 10 minutes'. Was witnessed trying to open window. Wanderguard intact and (symbol) made aware of importance of staying in facility. Stated 'I won't be here in the morning'." "4/27/12 at 1630 (4:30 p.m.) Resident had visitors today and following their departure from the unit, resident became very upset. Began banging on all the doors stating he wanted to get out of here. Attempts to calm the resident unsuccessful..." "4/29/12 at 1515 (3:15 p.m.) Resident attempting to punch numbers on locked box in unit. Stating he was 'going to get out of here no matter what'. also said 'when everyone is asleep, I will climb thru the window or ceiling'." "5/2/12 at 1115 (11:15 a.m.) Resident asking for screwdriver to open window so he can get out. He also broke a coat hanger in half and trying to use that to open window in bedroom." "5/4/12 at 1250 (12:50 p.m.) CNA went into rm (room) (number of room) and resident number (number of another resident) was in room, this resident (#8) was yelling for (number of other resident) 'How many times do I tell you not to come in this room'. When CNA went to get (number of other resident) out of room, this resident smacked him on the chest with (symbol) the back of his right (symbol here) hand." "5/5/12 at 1645 (4:45 p.m.) Resident standing at the exit door attempting to punch in numbers on the lock box wanting to get out. Redirected away from the door and given prn ativan for increased (symbol) agitation." "5/11/12 at 1630 (4:30 p.m.) Resident noted in his room attempting to open the window in his room to get out." "5/11/12 at 1925 (7:25 p.m.) Late entry for 5/11/12 at 1600 (4:00 p.m.) Resident noted upset because another resident (number of other resident) in his room looking through his personal belongings in drawers. Noted holding his cane up in the air with intentions of striking resident (number of other resident) with his cane." "5/17/12 at 1945 (7:45 p.m.) I, nurse (name of nurse) entered room (number of room) to give out medication observed this resident with window open the screen pushed out and prompted with his cane holding the bottom of the window open and a hanger holding the top open. Resident was standing up in chair with one leg out of the window. He stated 'don't tell nobody just let me go'. I yelled for help it was very hard redirecting resident back in window. Got him down trying to talk to him he was very upset gave him his meds and asked him to please take them. He did. Resident was from door to door pressing key pad and pushing on doors. He got out the patio door and then attempted to climb the gate. Redirected resident back in facility. Res. (resident) cursing and making threats to staff. He just kept saying I want out of here. Staff provided one on one with him trying to calm him down." "5/18/12 at 1420 (2:40 p.m.) Resident found in room (number of room) trying to use a spoon to cut window open, re-directed and spoon taken away." "5/18/12 at 1440 (2:40 p.m.) Resident shut his door and was seen trying to get out window. Re-directed to TV area, doing 15 minute checks." "5/20/12 at 1100 (11:00 a.m.) Resident noted at back exit door lock box attempting to unlock door by punching numbers." "5/21/12 at 1515 (3:15 p.m.) called to room by CNA's noted resident unscrewing screw from bottom of window with a spoon. Attempted to redirect resident, resident continued to unscrew until completely removed. Called maintenance to come replace screw. Resident redirected and prn ativan given. "5/21/12 at 1520 (3:20 p.m.) Resident entered room (number of room) again and shut door. Resident unscrewing screw and attempting to exit window, redirected resident verbally and physically abusive." "5/21/12 at 1550 Resident in room with window unscrewed and cursing CNA's, called EV (environmental) services and maintanence, helped to redirect." "5/21/12 at 1830 (6:30 p.m.) Resident attempting to take screen off from window in room (number of resident's room). Quickly redirected to TV area, continues with 1 on 1 care." "5/22/12 at 1830 (6:30 p.m.) Resident sitting in TV area, unable to locate spoon from dinner. Wanderguard and ID (identification) bracelet in place. Checked (symbol) clothes and no spoon." "5/26/12 at 1400 (2:00 p.m.) Resident noted standing at window in room with fingernail clippers. Stated 'please tell me why you won't let me get out of here'. Redirected to TV area." "5/26/12 at 1500 (3:00 p.m.) Resident standing at window with spoon and fingernail clippers. Refuses to give this writer them. Resident sitting at nurses staion..." "5/26/12 at 1810 (6:10 p.m.) Resident up at door pressing buttons, fingernail clippers taken away." "5/27/12 at 1415 (2:15 p.m.) Resident entered room (number of room) and stated was 'getting out' then entered his room and said 'one little screw and I'm gone'. Sat resident at nurse's station." "5/28/12 at 1350 (1:50 p.m.) Resident went into two rooms trying to open windows. Was easily redirected." "5/28/12 at 1700 (5:00 p.m.) Resident had razor trying to cut away a window to exit building." "5/29/12 at 1800 (6:00 p.m.) Resident removed metal piece from bed and tried to open window with it. Hitting and yelling while pulling resident away from window." "5/30/12 at 1600 Resident attempting elopement several times, stealing silverware, behind nurses station in drawers, asking staff and visitors for knives, asking this writer 'want me to grab you again'? redirection not effective. Stated he was 'leaving today or tonight'. Would not let therapy leave unit - wanted a hug. 1 on 1 provided." "5/30/12 at 1605 (4:05 p.m.) (late entry) Resident staed "I'm leaving today or tonight, either I will die getting out or you guys will." "6/1/12 at 11:49 Resident at window in room (number of room) with spoon attempting to unscrew screw from window. Redirected to dining area. Resident stated 'I don't want to hurt you'. Spoon taken away but resident stated he would just 'find another one'." "6/3/12 at 1545 (3:45 p.m.) staff noted resident in his room on the trashcan with one leg out of the window with the window screen off and lying outside on the ground. Resident stated he had to get out of here. Resident redirected by staff into the dining area for continuous visual observation by staff. Given ativan 1 mg po for aggitation and effective." "6/7/12 at 1622 (4:22 p.m.) Called to residents room by cna to be shown resident trying to elope from window, resident has cane up to screws trying to hit them out, resident stated he was going to hurt us if we did not let him out of here, redirected back to tv area." "6/8/12 at 1900 (7:00 p.m.) (late entry) resident noted in his room standing in front of the window attempting to exit the window. The window screen was partially off the window. Redirected with success into the dining area for visual observation. He stated he wanted to go home. Given prn ativan 1 mg po per md order per resident request for a 'nerve pill'." "6/9/12 at 1528 (3:28 p.m.) Resident noted to be at door trying to punch numbers and beating on door." "6/16/12 at 1638 (4:38 p.m.) late entry for 1530 (3:30 p.m.). Resident on the sun porch with cna and other residents. Noted to have climbed on top of the table and attempting to go over the fence. Assisted by staff times (symbol) 4 down from table and assisted back into dining area." "6/21/12 at 1446 (2:46 p.m.) Went to check on resident in room, window open and resident packing clothes up to leave, wire in hand taken from resident without difficulty, resident came to nurse's station demanding staff to give wire back to him or he was going to hurt someone, took keys off nurse's station and refusing to give them back." "6/21/12 at 1500 (3:00 p.m.) Resident came behind nurse's station attempting to find wire that was taken from him to avoid elopement, resident stated to staff that she had the wire in her pocket and to take her clothes off and he could show her wha

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement safety interventions for one of 14 residents in the survey sample. One staff person raised Resident #101 in a mechanical lift when the resident was assessed to require the assistance of two people for lift/transfer. Resident #101 was in bed without a physician ordered protective floor mat in place for injury prevention. The findings include: Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #101 with severely impaired cognitive skills for decision-making. This MDS assessed Resident #101 as always incontinent, requiring the extensive assistance of two people for transfers and toileting, not ambulating and with limited range of motion in her lower extremities. On 1/23/13 at 10:00 a.m. a request was made to inspect Resident #101's coccyx area and feet as part of the re-visit follow up for the resident's previous issues with pressure sores. On 1/23/13 at 10:10 a.m., the certified nurses' aide caring for Resident #101 (CNA #1) brought Resident #101 in a wheelchair to the resident's room. With the resident's permission, CNA #1 proceeded to transfer the resident with a hydraulic "sit to stand" lift. CNA #1 applied/attached the safety harness and positioned the resident's feet on the lift platform. The resident's left leg was slightly contracted with her foot barely touching the standing platform. With the resident holding the grab bars, CNA #1 raised the resident with the lift to a semi-standing position. With the resident in this semi-erect position, CNA #1 pulled down the resident's pants, took off the resident's wet brief then proceeded to wipe the resident's buttock area then the perineal area with cleansing wipes. CNA #1 applied a clean brief, pulled up the resident's pants and then lowered the resident back into the wheelchair. The resident was positioned in the lift in a semi-standing position during the entire brief change. CNA #1 performed this lift without assistance or presence of any other staff members. On 1/23/13 at 1:40 p.m. Resident #101 was observed in bed in her room without protective floor mats in place by her bed. Resident #101's clinical record documented a physician's orders [REDACTED].#101's plan of care (revised 12/12/12) documented the resident was at risk for falls due to impaired mobility, cognitive loss, impaired balance, contractures and Parkinson's disease. Included under interventions for fall/injury was a "fall mat." On 1/23/13 at 1:15 p.m. the registered nurse unit manager (RN #2) was interviewed about CNA #1 raising/holding Resident #101 in the mechanical lift during incontinence care. RN #2 stated Resident #101 required the assistance of two staff people during lifts and transfers. RN #2 stated, "Normally if the resident can't assist (with standing), you need two people for safety with the lift." On 1/23/13 at 1:40 p.m., accompanied by RN #2, Resident #101 was observed in bed unattended without protective floor mats in place. RN #2 was interviewed at this time about the mats. RN #2 located the mat leaning against the wall between the resident's closet and the wall. RN #2 stated Resident #101 was supposed to have a mat in place when in bed. RN #2 stated, "They (CNA's) all know she's (Resident #101) supposed to have them (mats)." On 1/23/13 at 1:55 p.m. the director of nursing (DON) was interviewed about one person using a lift to raise Resident #101 during incontinence care. The DON stated Resident #101 required the "hydraulic" sit to stand type lift. The DON stated two people were supposed to assist with the lift/transfer of residents using a hydraulic lift. The facility's procedure titled, "(Hydraulic) Lift" revised 2/3/09 stated under the purpose of the lift procedure, "To enable two people to lift and move a resident safely and with as little effort as possible." This policy stated, "Any resident who weights (weighs) greater than 150 lbs. and is unable to bear weight to assist with the transfer must be transferred with the Hydraulic Lift to ensure the safety of the resident and the employee." (sic) These findings were reviewed with the administrator, DON and clinical nursing consultants on 1/23/13 at 3:10 p.m.