Every finding on record at Crescent Manor Care Ctrs

Per interview and record review, the facility failed to notify resident representative of alleged abuse of 1 of 1 residents (Resident #1). Findings include:Per review of the Facility's 5-day internal investigation dated xx, an allegation that Licensed Nursing Assistant #1 slapped Resident #1 was investigated. A progress note dated 5/25/26 at 10:16 PM written by the Nursing Supervisor stated a report was received from a Licensed Nursing Assistant (LNA) who witnessed an altercation between LNA #1 and Resident #1, and that the Director of Nursing (DON) and Power of Attorney were notified.Per record review of the Facility's Incident Report prepared by the Nurse Supervisor, the residents Family Member was notified of the incident at 7:35 PM on 5/25/26.Per record review, Resident #1's family member is their Power of Attorney.Per interview on 6/16/26 9:42 AM with Resident #1's Power of Attorney, they stated they were notified of an altercation. They described the notification to include Resident #1 had increasing behaviors that night, was aggressive towards staff, and was then redirected. The Power of Attorney confirmed they were not informed of the allegation that LNA #1 slapped Resident #1. They further stated they have been to a care plan meeting since the incident on 6/9/26 and the alleged abuse was not discussed in the meeting.Per interview on 6/16/26 at 10:37 AM with the Nurse Supervisor who prepared the Incident Report, they confirmed they called the residents Power of Attorney and notified them of an altercation between staff and Resident #1. The Nurse Supervisor confirmed they did not notify the Power of Attorney of the allegation of staff to resident physical abuse.Per interview with the Administrator and Director of Nursing on 6/16/26 at approximately 11:30 AM, they confirmed that the residents responsible party should be notified of alleged abuse.

Based on interviews and record reviews, the facility failed to support the residents' right to file grievances anonymously. This has the potential to affect all residents at the facility. Findings Include:Per observation, the facility's bulletin board in the lobby area displayed the grievance policy and procedure in a document protector, with only the first page visible. The document included the grievance officer and contact information, but did not provide details on how to file a grievance anonymously. There is no evidence of the option to file an anonymous grievance, nor is there any indication on the grievance forms that this is an option. Review of the facility policy, titled Crescent Manor Rehabilitation Grievance Policy and Procedures, no date, found that the procedures state the resident must sign the form. The form attached to the policy also requires a resident's signature. Per interview on 1/6/26 at 1:10 PM with three residents, Resident #7, a resident at the facility for several years, stated that if a resident wants to file a grievance, they use the facility-provided form and give it to the Social Worker. S/he does not know of a system within the facility that allows the resident to file the grievance without revealing the writer's identity. Resident #81, who has been a resident for the past several months, was also unable to identify the process for filing an anonymous grievance. Neither resident can recall a system to keep the process anonymous. Per interview on 1/6/26 at approximately 2:34 PM with the Social Worker, identified in the policy and procedure as the designated Grievance Official, she indicated the facility uses the envelope located by the grievance forms for anonymous grievances. She confirmed that the policy and procedure document on display doesn't include a process for filing a grievance anonymously. The Social Worker confirmed she was unable to locate it in the policy and procedures and stated it was very difficult if someone files an anonymous grievance, and confirmed it is a requirement to have the option of filing a grievance anonymously.

Based on observations, interviews, and policy reviews, the facility failed to store food in accordance with professional standards for food service safety. This deficiency has the potential to impact all residents in the facility. Findings include:1. During initial tour of the kitchen's dry storage area on 1/5/26 at approximately 11:00 AM with the Food Service Manger (FSM), revealed boxes of condiments containing individual servings of saltines, salad dressings, and catsups that did not have expiration dates on the boxes. Also observed in the dry storage room were (5) 5# bags of Devil's Food cake, (4) 5# bags of brownie mix, (12) 5# bags of white cake mix, (2) 5# bags of basic muffin mix, all with no expiration dates on the packages. The FSM stated that they did not know what the expiration dates of these food items were because the original boxes had been thrown away. There were 4 racks of bread in the hall of the dry storage area that had no expiration dates. Per interview with the FSM on 1/5/26 during the tour of the dry storage area, confirmed that the condiments did not have expiration dates on the boxes and they could not provide them. The FSM confirmed the mixes did not have expiration dates and the boxes that the mixes came in had been thrown away. The FSM confirmed that the (4) racks of bread did not have expiration dates. 2. Observation of the kitchen area on 1/5/26 at approximately 11:15 AM it was noted that a commercial can opener and meat slicer were not clean. The can opener blade was covered in a thick, sticky, wet, black substance, and dried red substance near blade and on the bracket of the can opener. The meat slicer appeared to have been wiped down, however upon further inspection the meat tray was noted to be dry but with gritty residue and specks of a dried light pink substance. The back of the blade was noted to have a dried light pink colored substance dried/stuck on that was easily scraped off. Per interview on 1/5/26 at approximately 11:17 PM, the FSM confirmed the can opener was not clean and should have been put through the dishwasher and stated the staff probably used the meat slicer this morning and that it was not clean. 3. Observation of the freezer on 1/5/26 at approximately 11:40 AM revealed (4) packages of 12 count hot dog rolls with no expiration dates, and 1 box of [NAME] fish sticks with no expiration date. Interview on 1/5/26 at approximately 11:41 AM, the FSM and dietician confirmed the hot dog rolls and box of [NAME] fish sticks had no expiration dates. 4. Observation on 1/5/26 at approximately 2:45 PM, the South Unit kitchenette refrigerator freezer contained a pink substance in a clear plastic cup with a dome lid containing a straw that was covered with a piece of paper towel that was not labeled with a resident's name or an expiration date. Interview on 1/5/26 at approximately 2:50 PM with the Activities Director, they confirmed the pink substance in the cup should not be in the resident's refrigerator freezer and should be thrown out as it did not belong to a resident and could have been brought in by family or may have belonged to staff. 5. Observation on 1/6/26 at approximately 8:15 AM observation of the [NAME] Unit kitchenette revealed (2) containers with lids containing foods that were not dated with preparation date or expiration date. Also identified was a loaf of white bread that was not dated with either an expiration date or an opened date. Various individual sized condiments and snacks (Oreo's, Fig Newtons, oatmeal bars, saltines, graham crackers, catsup, maple syrup, mayonnaise, honey, and peanut butter) were noted in bins with no expiration dates. Interview on 1/6/26 at approximately 8:20 AM with an LPN working on the [NAME] Unit confirmed the above findings.

Based on observation and interview, the facility failed to ensure a safe clean homelike environment for the residents who reside on the licensed memory care unit. Findings include:1. During the initial tour of the licensed memory care unit (North Unit) on 1/5/2026 at 11:30 AM, there was a sharps container fastened to the wall in the shower room. The container was full and unable to close properly. There was a bundle of disposable razors on the top of the sharps container held together with a rubber band and three of the razors had no covers on them. Per interview with a Licensed Practical Nurse (LPN) on 1/7/2026 at approximately 1:00 PM, she confirmed that the sharps container was full and should have been removed. She also confirmed that the disposable razors should not have been left on top of the sharps container. 2. During observations of the North Unit 1/5/2026 at 12:44 PM in the dinning/activity room located near the nursing station, the baseboard radiator was noted to have three areas at different points of the system that were uncovered exposing the sharp fins. Per interview on 1/7/2026 at 9:20 AM, the Unit Manager (UM) confirmed the areas of the radiator were not covered and the sharp pieces were exposed. The UM contacted the Maintenance Director who responded to the dining room and stated that the radiators will be replaced soon and that the covers get bumped off.

Based on observations and interviews, the facility failed to ensure medications were removed from the medication storage rooms and treatment rooms when expiration dates were reached for 3 out of 3 rooms. Findings include: Per review of the facility policy titled Storage of Medication dated 1/24, it states that Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock .Per observation and interview on [DATE] at approximately 9:56 AM in the west wing medication room, the Unit Manager confirmed the following items were expired: three administration sets of priming IV tubing kits with an expiration date of [DATE], eight containers of ten milliliter sterile water for injection with an expiration date of [DATE], Piperacillin and Tazobactam for injection 3.375 grams for IV use with an expiration date of 3/25, Epinephrine 0.3 mg single auto injectors with an expiration date of 3/25, BD Vacutainer safety-lok blood collection set with an expiration date of [DATE], four BD max plus clear needleless connectors with an expiration date of [DATE]. The Unit Manager also confirmed a bottle of glucose tablets that did not have an expiration date and stated that anything without a date should be thrown out.Per observation and interview on [DATE] at 10:13 AM in the north wing medication room, a Licensed Practical Nurse confirmed that a bottle of Vitamin B-Complex did not have an expiration date and that it should be thrown out.Per observation and interview on [DATE] at 10:20 AM, in the medication treatment room near the south/west nursing station, the Nursing Manager confirmed the following items were expired: four Proven (Post insertion foley care wipes) with an expiration date of [DATE], ninety skin protectant ointments with an expiration date of 5/25, and one Intermittent 14 French catheter kit with an expiration date of [DATE].

Based on observation and interview, the facility failed to ensure staff were appropriately wearing Personal Protective Equipment (PPE) for 2 of 2 units. This is a repeat deficiency for this facility, with violations cited during the previous recertification surveys, dated 10/2/24.Findings include:1. Per observation on 1/5/26 at approximately 2:15 PM, LNA #1 was noted sitting behind the west nurse's station without a mask. LNA #1 left the nurses station, proceeded down the hall with LNA #2, engaging in conversation. LNA #1 was noted to have a disposable mask swinging from their wrist and mid hallway placed the mask on and worn under their chin. Per interview on 1/5/26 at approximately 2:25 PM with LPN #1, they confirmed LNA #1 was not wearing their mask correctly and that masks were required at that time due to an active Covid outbreak. 2. Per observation on 1/6/26 at approximately 4:35 PM of the west unit nurse's station, RN #1 was noted to be wearing their mask under their chin. Per interview on 1/6/26 at 4:47 PM, the Administrator confirmed that all staff are required to wear masks when on the units, even behind the nurse's station. 3. Observations on 1/5/26 on the facility's memory care unit revealed multiple direct care staff [licensed nurses' aides] wearing face masks incorrectly, with the face masks positioned below their noses. An interview was conducted with the Infection Preventionist on 1/7/26 at 9:15 AM. The IP confirmed that due to an outbreak of COVID 19 [Coronavirus disease] in the facility there was universal masking for the building [all staff wearing medical masks at all times] to prevent the spread of infection. The IP confirmed that there were multiple observations of facility staff not wearing masks or wearing them incorrectly where the masks do not provide protection from infection for the residents or the wearer. According to the Mayo Clinic: The virus that causes COVID-19 spreads mainly through the air when a person coughs, sneezes, sings, talks or breathes.face masks or respirators are products that cover the nose, mouth and chin. Most research finds that these products can slow the spread of the virus that causes COVID-19 when they are worn consistently, fit properly and are worn correctly. (https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-mask/art-20485449)

Based on observation and interview and record review, the facility failed to ensure a call system allowing residents to call for staff assistance is accessible to residents while in their bed or other sleeping accommodations within 5 out of 6 rooms for residents Care Planned for call bell use. The facility also failed to ensure that an alternate means of communicating with staff was provided after removing the call light from the resident's room for Resident #35. Findings include: 1). Per observation on 1/5/25 at 11:46 AM and again on 1/6/26 at 4:08 PM, the corded call bells for both resident beds in rooms #1, #4, and #5, were hanging on the walls out of reach of the residents in their beds, and the call bell out of reach for 1 resident in room [ROOM NUMBER]. An interview was conducted with the residents' Unit Manager [UM] on 1/7/26 at 8:25 AM. The Unit Manager stated that most residents in the Special Care Unit are not able to use the call bell system. Per record review, the Care Plans for at least one resident in rooms 1 [Resident #68 and Resident #53], room [ROOM NUMBER] [Resident #20], room [ROOM NUMBER] [Resident #22] and room [ROOM NUMBER] [Resident #54] contain interventions that include Be sure the resident's call light is within reach and encourage the resident to use it and/or Be sure call light is within reach and respond promptly. An interview was conducted with Resident #68 on 1/5/26 at 12:10 PM. Resident #68 was asked how s/he alerts staff when s/he needs assistance. The resident replied There is a button here somewhere. I don't know where it is. Per record review, a nursing admit/readmit note on 8/13/25 at 1:20 PM, reads [Resident #68] verbalizes/ demonstrates the use of the call bell. Per observation, both Resident #68's and Resident #53's call bells were hanging on the wall between the resident's and the roommate's bed, hidden behind a curtain. Per record review, progress notes dated 10/10/25 reveal Resident #22 demonstrated use of their call bell. The progress note records Resident pulled [her/his] bathroom call bell, so an LNA [Licensed Nursing Assistant] checked [her/him] . An interview was conducted with Resident #22 on 1/5/26 at 12:22 PM. The resident was asked how s/he alerts staff when s/he needs assistance. Resident #22 replied, There is a thing you push. The resident was unable to locate the call bell. Per observation, both Resident #22's and their roommate's call bells were hanging on the wall between the resident's and the roommate's bed, hidden behind a curtain. An interview was conducted with the Unit Manager [UM] on 1/7/26 at 8:23 AM. The UM confirmed that the call bells for the 5 residents in the 4 rooms listed above were out of reach and unavailable for use to the residents. The UM confirmed that the 5 residents were care planned to ensure the resident's call light is within reach and encourage the resident to use it and that residents #68 and #22 had documented ability to use the call bells. 4 . Per record review Resident #35 has diagnoses that include dementia, wandering, delusional disorders, adjustment disorders, depression, anxiety disorder, and major depressive disorder. Review of her/his care plan reveals that s/he is incontinent of bowel and bladder and self-transfers and ambulates. During unit observations on 1/6/2025 at 12:30 PM, Resident # 35's call light cord was noted to be missing from the call light box on their wall. Further observation of the room revealed that there was no alternate means for the Resident to communicate with the staff if needed. Review of Resident #35's care plan reveals a focus initiated on 7/31/2023 states that the Resident is at risk for a communication problem r/t dementia with an intervention also initiated on 7/31/2023 of Ensure/provide a safe environment: Call light in reach,,, A progress Note dated 5/25/2024 reads Resident was observed this shift to be disconnecting [her/his] call light from the wall x3 and when nursing staff redirected resident to give the writer the extension cord to plug back into the wall, resident became verbally aggressive towards nursing staff. Resident was yelling and using abusive language making it difficult to communicate. physical attempt to approach resident to retrieve extension cord were met with punches from resident to nursing aide. resident stated if this writer doesn't leave [s/he] will hit her too. writer kept a safe distance from resident. resident was given time to calm down and writer re-approached after couple of minutes. writer contacted [on call provider] to inform her of resident's behavior and to seek further instructions. NP [Nurse Practitioner] gave orders to administer one time dose of olanzapine [antipsychotic medication] 5mg po for agitation. orders initiated. A care plan focus that was last revised on 7/31/2023 states that the Resident is at risk for an ADL [activities of daily living] self-care performance deficit r/t dementia, and has an intervention initiated on 9/19/2024 of [Resident] cannot use call bell appropriately. Staff must anticipate needs. Resident #35's Kardex (a document that is based on the care plan and is used to communicate resident specific care needs) also states that the Resident cannot use call bell appropriately. Staff must anticipate needs. Further review of the care plan and Kardex revealed that there was no alternate means of communicating with the staff if needed put into place when the call light was removed. Per interview on 1/6/2026 at 1:50 PM the Maintenance Director confirmed that Resident #35's call light had been removed from the wall. He stated that it was removed a long time ago because s/he was pulling it out of the wall constantly. 2. During a Resident interview on 1/6/2026 at 1:30 PM Resident #9 was asked how s/he would get help from staff if s/he needed it. The Resident stated that s/he would use their call light and went to reach for it. The call light was noted to be on the floor under the bed. The Resident asked if I could pick it up and give it to her/him. The Resident then pushed the button to demonstrate that s/he can utilize the call light. 3. During unit observations on 1/7/2026 at 9:25 AM Resident #81 was observed sleeping in their bed. The bed was positioned with the left side against the wall. The call light was noted to be hanging from the wall behind the side of her bed out of reach from the Resident. A Licensed Nursing Assistant (LNA) who was passing by the room was asked how the Resident would call for assistance the LNA confirmed that the call light was not in the Resident's reach. Per interview with the Staff Development Coordinator (SDC) on 1/07/2026 at 11:20 AM, staff are educated that when they bring residents to their rooms they need to make sure that the call light is in the resident's reach. Staff are also educated to answer call lights immediately and provide the needed assistance. The SDC confirmed that call light cords should not be pinned up out of reach or completely removed from the wall.

Based on interview and record review, the facility failed to promptly notify the provider of laboratory results that fell outside of clinical reference ranges for 1 of 1 residents (Resident #27). Findings include: Per review of the facility's policy titled Notification of Changes Policy dated 11/25, it states The purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the residents representative when there is a change requiring notification. The policy additionally identifies that when a resident has a significant change in physical condition that the provider should be notified.Per review of the facility's policy titled Laboratory Services and Reporting dated 2020, it states to Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.Per record review, a progress note dated 1/5/26 at 7:15 PM, identified that Resident #27 had a critical sodium level of 161. There is no note indicating that the provider was notified immediately after nursing staff were informed of the critical lab value. A Nurse Practitioner note dated 1/6/26 at 8:30 AM, identified that Resident #27 had severe hypernatremia with sodium of 161 and that this was a critical condition and that s/he was sent to the emergency department for expedited evaluation and management.Per interview with a Licensed Practical Nurse (LPN) on 1/7/26 at 8:32 AM, she confirmed that the provider and Director of Nursing (DON) were not immediately made aware that Resident #27 had a critical lab value, and that as soon as the Nurse Practitioner was made aware, she sent out the Resident to the Emergency Department. The LPN confirmed that a provider should be notified right away of critical lab values.Per interview with the DON on 1/7/26 at 8:37 AM, she confirmed that the provider should have been notified of the critical lab value at the time the nurse was notified of the lab value.

Based on observation, interview, and record review, the facility failed to implement care plan interventions to reflect an identified concern for 1 of 3 sampled residents (Resident #1) related to the use of wheelchair leg rests. Findings include:Per record review, Resident #1 has diagnoses that include multiple sclerosis, (MS; a disease that heavily affects postural control, predisposing patients to accidental falls and fall-related injuries), dementia, anxiety disorder, and major depressive disorder. Resident #1 has a BIMS score (Brief Indicator for Mental Status, a test to check if thought processes are intact) of 12 out of 15, indicating moderate cognitive impairment.Per record review, Resident #1 has limited physical mobility related to her/his MS and weakness. Resident #1's care plan states LOCOMOTION: [She/he] requires (Extensive assistance) by (1) staff for locomotion using standard chair and bilateral footrests PRN [as needed], created on 10/27/25. A 12/8/25 risk management report reveals that Resident #1 had a fall while being pushed in a wheelchair because his/her foot got caught under the wheelchair. See F689 for more information. Resident #1's care plan was revised to include ensure leg rests are on when in w/c.Per observation of Resident #1 on 12/17/25 at 12:35 PM, Resident #1 was in her/his room, sitting in her/his wheelchair, with no leg rests attached. Per interview, when asked about the incident, Resident #1 stated that the staff member was pushing his/her wheelchair very fast, and they could not keep up, and fell.Per interview with LPN #1 on 12/17/25 at 12:40 PM, she/he confirmed that the resident was sitting in their wheelchair and did not have leg rests attached. LPN #1 additionally confirmed that Resident #1 was to have leg rests on when in her/his wheelchair.Per interview on 12/17/25 at 12:00 PM, the DON (Director of Nursing) confirmed that Resident #1 does not self-propel in her/his wheelchair. The DON stated it is facility policy that residents who cannot self-propel in their wheelchair must be ambulated using footrests. The DON confirmed that Resident #1 was care planned to use bilateral footrests and she/he cannot self-propel, the footrests should have been in place at the time of the fall on 12/8.

Based on interview and record review, the facility failed to ensure residents remained as free from accidents as possible related to falls for 1 of 3 sampled residents (Resident #1) by failing to ensure assistive devices were provided and failing to implement interventions that would reduce the likelihood of future falls. As a result, Resident #1 suffered a fall that resulted in redness, swelling, and abrasions to the front of the left knee and back of the right hand. Findings include:Per record review, Resident #1 has diagnoses that include multiple sclerosis, (MS; a disease that heavily affects postural control, predisposing patients to accidental falls and fall-related injuries), dementia, anxiety disorder, and major depressive disorder. Resident #1 has a BIMS score (Brief Indicator for Mental Status, a test to check if thought processes are intact) of 12 out of 15, indicating moderate cognitive impairment.Per record review, Resident #1's care plan reveals that she/he needs assistance or is dependent on staff to perform activities of daily living (ADLs) and uses a wheelchair. Her/his care plan includes the focus [Resident #1] has the potential for falls related to: dx [diagnosis] of multiple sclerosis, syncope (fainting) and collapse, disorder of the autonomic nervous system, and HTN (high blood pressure), created on 10/28/25. Additionally, Resident #1's care plan states LOCOMOTION: [She/he] requires (Extensive assistance) by (1) staff for locomotion using standard chair and bilateral footrests PRN [as needed], created on 10/27/25.Per a risk management report of a witnessed fall dated 12/8/25 reads, LNA [Licensed Nursing Assistant] was driving resident in the wheelchair and resident's foot got caught on the wheelchair and [she/he] fell from the wheelchair. The LNA's statement from the risk management report reads, While I was pushing the resident in wheelchair to shower room, resident's foot got caught underneath wheelchair with resident going to floor.In an interview with Resident #1 on 12/17/25 at 12:35 PM, when asked about the incident, s/he stated that the staff member was pushing his/her wheelchair very fast, and they could not keep up, and fell.A progress note written by the Practitioner, dated 12/8/25, notes the injuries sustained in the fall included abrasions to the left knee and right hand.In an interview with the DON (Director of Nursing) on 12/17/25 at 11:50 AM, the DON stated that it is facility practice to have leg rests in place when ambulating residents that do not self-propel. The DON confirmed that Resident #1 requires assistance and does not self-propel. The DON was unable to produce evidence that facility staff had been educated about the use of wheelchair leg rests as a facility practice for residents that do not self-propel.(National Institutes Of Health, Spotlight on postural control in patients with multiple sclerosis 4/3/2018)

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 residents sampled [Resident #2]. Findings include:Per record review, Resident #1's diagnoses include unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, Anxiety, and cognitive communication deficit. Resident #2's diagnoses include Alzheimer's and dementia. Both residents had a BIMS score (Brief Interview for Mental Status) of 99, which indicates they were unable to answer questions to determine their cognitive functional level. Per regulation guidelines Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions . it is important to remember that abuse includes the term willful. The word willful means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach.Per review of the facility's investigation of the resident-to-resident incident on 8/18/25, A Licensed Nursing Assistant [LNA] saw Resident #1 standing over Resident #2's bed. When the LNA asked Resident #1 what s/he was doing, Resident #1 turned to Resident #2 and made contact with Resident #2's forehead with a closed fist. Resident #1 was immediately re-directed to another area. Resident #2 is unable to speak h/her needs. Per facility report the allegation was verified, as it was witnessed to have occurred by a staff Licensed Nursing Assistant.An interview was conducted with the facility's Director of Nursing [DON] on 9/8/25 at 12:46 PM.The DON confirmed that the facility failed to ensure Resident #2 was free from physical abuse when Resident #1 struck Resident #2 on 8/18/25.

Based on observations, interviews, and record review, the facility failed to ensure that 1 of 25 residents in the applicable sample (Resident #87) received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. As a result, Resident #87's pressure ulcer worsened to stage four, developed an infection, the resident required hospitalized and surgical debridement of the wound, and was not stable enough to be discharged . Findings include: Per record review Resident #87 was admitted to the facility in July 2024 with a goal to discharge home. An admission Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) dated 7/30/2024 revealed that Resident #87 had a BIMS (brief interview for mental status; a cognitive assessment) of 15 on admission, indicating that s/he is cognitively intact. S/he was frequently incontinent of urine and always continent of bowel, requiring supervision or touching assistance with toileting hygiene. The MDS also revealed that s/he was admitted with an existing stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an open/ruptured serum-filled blister). A health status note dated 8/6/2024 reveals that Resident #87 was independent with transfers and utilized a wheelchair for mobility. A wound consult progress note dated 8/1/2024 revealed that on exam the Resident had moisture associated skin damage (MASD) measuring as Length (L) 5.5 centimeters (cm), Width (W) 4.5cm, and 0.1cm depth (D). An active problem is listed as irritant contact dermatitis due to friction or contact with body fluids. On 8/9/2024 the wound care Nurse Practitioner (NP) recommended a Flexi Seal (a temporary containment device indicated for immobilized, incontinent patients with liquid or semi-liquid stool) to minimize contamination of the wound. Review of a wound consult progress note dated 8/9/2024 revealed that the wound had declined since 8/1/2024, related to constant stool contamination of wound. The note also states Unable to secure dressing due to constant loose stool contamination . Concern that this wound will not heal with no way to prevent stool contamination. Please refer to PCP [primary care provider] for evaluation. ? [Question] Flexi Seal and/or need for [antibiotics]. A new active problem was added as full incontinence of feces. The wound was not measured during this visit however, the NP wrote, Will re-eval size next week. A Physician progress note dated 8/9/2024 reads The patient was seen by wound care today, where a stage 1 decubitus ulcer was identified in the intergluteal area. This ulcer appears to be exacerbated by fecal material. [The] patient denies any pain in the affected area, which is likely due to decreased sensation in the gluteal region. There is no drainage noted from the ulcer site . Previously, the wound was being treated with Medihoney and a barrier dressing, but this approach has not been successful in managing the ulcer. The wound care team is now recommending a Flexi Seal System for improved fecal management . Agree w/ Flexi Seal System for fecal management . - Order placed for further recommendations - Follow as chronic condition Orders: -Flexi Seal System The facility did not obtain the Flexi Seal as recommended, the wound worsened and became infected . There is no documentation in the medical record regarding follow-up to obtain the Flexi Seal. A NP progress note dated 8/16/2024 indicates that the reason for the visit is a worsening sacral wound. The note states History: - Previously [diagnosed with] moisture associated skin dermatitis - Progressed significantly due to chronic stool contamination - Flexi-seal fecal management system ordered, not arrived - Significant sacral skin breakdown - Unstageable ulcer [a type of ulcer that has full thickness tissue loss but is covered by slough or eschar [dead tissue], which prevents the assessment of the true depth of the ulcer]: top of sacrum to rectal area, ~8-9 inches - L [Left] intergluteal fold: necrotic area w/significant malodor - R [Right] upper gluteal cleft: surrounding warmth, induration, hardened fluctuant area . There are also measurements for MASD Buttock bilateral 6.5cm L x 10cm W x 0.3cm D. Per a Health Status Note written on 8/16/2024 Resident #87 had been seen in the emergency department (ED) for treatment of a wound infection of her/his coccyx. S/he returned with orders for Amoxicillin (antibiotic) for seven days. A Physician Progress note dated 8/20/2024 states Patient seen for follow- up of worsening sacral ulcer in the intergluteal area. The ulcer continues to be contaminated with stools. Flexi Seal System for fecal management is pending arrival. Patient reports no pain. Seen by wound care today. Patient was placed on antibiotic therapy over the weekend after ED visit for possible debridement and treatment . ASSESSMENT AND PLAN: 1. Stage 2 acute sacral ulcer/intergluteal superimposed infection with sloughing tissue - Continue wound care - Santyl ointment for chemical debridement - Consider mechanical debridement if necessary - Awaiting Flexi Seal system to manage fecal material - Switch to IV antibiotics (Zosyn). On 8/25/2024 Resident #87 was seen by a provider via telehealth for evaluation of diarrhea. A new order to hold Bisacodyl (laxative), and an order for Loperamide (antidiarrheal medication) as needed was obtained. The facility still had not obtained the Flexi-Seal that was recommended on 8/9/2024. A Nurse Practitioner (NP) Progress Note dated 8/29/2024 revealed an unstageable wound to coccyx and gluteal cleft extending down bilateral gluteal folds approximately 4.5 x 8 inches. The NP wrote, - Request wound care provider assessment for bedside debridement - Consider wound VAC [vacuum assisted closure, a type of therapy that helps wounds heal] to facilitate healing - Hold antibiotics, monitor closely - Chronic incontinence (urine and loose stools) causing contamination which is complicating healing and creating constant risk of infection. 1.- Requested Flexi-seal stool diversion system (not yet arrived) - Not stable for discharge due to wound complexity and infection risk - Continue close monitoring 2. Chronic incontinence - Requested Flexi-seal stool diversion system (multiple times, not yet arrived) Per a nurse health status note written on 9/4/2024, Resident #87 had an increase in redness to peri wound along with an odor to the wound. New orders for a wound culture and blood work were obtained. A wound consult note dated 9/6/24 states, Wound Care is consulted for evaluation and treatment of a pressure ulcer of the buttocks, present on admission. Initially with rapid deterioration. Concern for frequent stool contamination. Significant in severity . Incontinent of urine and frequent loose stool leading to recurring stool contamination of the wound . Per staff - Concern that wound has new onset odor. WBCs [white blood cells, indicating possible infection] showing elevations again. PCP [primary care provider] to start IV Abx [intravenous antibiotics]. Per Staff Nurse - PCP wonders if a wound vac would be an option. At this time I would discourage use of wound vac provided the wound bed is still [approximately] 50% slough. Still trying to manage frequent stool contamination of wound. Prior discussion about a flexi seal - at this time the facility is still waiting for the equipment. The biggest concern is preventing the wound from constant fecal contamination to prevent infection/sepsis. A NP progress note also dated 9/6/2024 reads follow-up for unstageable sacral/coccyx gluteal wound - Recently completed IV antibiotics course, off for ~1 week - Nursing concerns: returning wound malodor- requested wound swab and lab work. At that time according to nursing vital signs were stable and patient was afebrile. - Denies fevers/chills - Reports increased fatigue and weakness - Appears weak, requires assistance to stand (new in last 10-12h) . - Skin: - Significant malodor from sacral/coccyx wound - Increased surrounding induration and warmth extending to outer gluteal area and lower back - Coccyx/sacral wound: - Significant necrotic slough at top of wound (gluteal cleft/coccyx area) - Tunneling at 2 and 3 o'clock Impression & Plan: 1. Worsening sacral/coccyx wound - Elevated WBC - Continued contamination from feces due to chronic incontinence. Flexi-seal still has not arrived. - Failed recent IV antibiotics - Significant changes: increased weakness, expanding induration/warmth, malodor - Plan: - Immediate, urgent transfer to hospital for surgical evaluation and likely debridement - Communicated with nursing staff and ED - Requested surgical consult for debridement . Hospital discharge notes dated 9/12/2024 indicate that Resident #87 was admitted to the hospital on 9/6/2024 with a necrotic infected stage IV (full thickness) pressure ulcer that required surgical debridement to the bone, and prolonged antibiotic therapy due to osteomyelitis (infection of the bone). A Nurse Practitioner progress note dated 9/13/2024 reveals that the NP continued to recommend a fecal management system due to loose stool contaminating the wound bed and increasing infection risk. Per review of NP progress notes and wound consult progress notes written between 8/9/2024 and 9/13/2024 the NP mentions the need for, and lack of availability of a Flexi Seal to minimize wound contamination from stool on 8/16, 8/20, 8/29, 9/6, and 9/13/2024. During an interview on 10/2/2024 at 4:20 PM the Director of Nursing (DON) confirmed that the facility did not obtain the Flexi Seal per wound care recommendations and physician orders. recommendations . *https://learning.lww.com/files/BacktotheBasicsWoundAssessmentManagementandDocumentation-1662480009184.pdf ** https://www.ncbi.nlm.nih.gov/books/NBK593201/ *** https://www.hhs.texas.gov/sites/default/files/documents/pi-care-plan-highlights.pdf

Based on observation, interview, and record review, the facility failed to provide safe and effective skin and wound care for 4 of 25 sampled residents (Residents #25, #30, #34, and #51) by failing to regularly and accurately perform and document weekly skin checks and non-pressure ulcer wound evaluations consistent with professional standards of practice. The facility also failed to ensure that a Resident with a wound vac received treatment and care in accordance with professional standards of practice and the person-centered care plan for 1 of 2 ( Resident # 291) of the applicable sample. Findings include: 1. Resident #25's weekly skin evaluations do not include documentation of a skin alteration on the hip and there is no wound assessment of Resident #25's skin alteration on the hip or the moisture-associated skin (MASD) damage on the leg. Per record review, Resident #25's care plan reads, [Resident #25] has potential for impairment to skin integrity r/t [realted to] PVD [peripheral vascular disease], immobility, HX [history]: dermatophytic skin lesions He has chronic poor skin integrity of lower extremities r/t [realted to] immobility and diabetes, revised on 8/20/24, with interventions that include, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD, revised on 1/11/23 and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, initiated on 9/10/22. Additionally, Resident #25's care plan reveals that s/he has a self-care performance deficit requiring an extensive 2 person assist for bed mobility and care. Per interview on 9/29/24 6:31 PM, Resident #25 explained that s/he had sores on his/her left leg and bottom that have been there for a while. S/He explained that sometimes the sores heal but they always open right up again. Per observation and interview on 10/1/24 at 2:00 PM, a Licensed Nursing Assistant (LNA) showed this surveyor Resident #25's bottom. There was compromised, red skin on the left backside of his/her thigh and bottom. While the area was covered in an ointment, there were visible open spots, some being two inches long. This LNA explained that these wounds were not new for Resident #25. Per record review, a 9/13/24 wound care progress note reads, Currently being seen for ongoing treatment of MASD of the left hip which tends to recur. This has not been present for many weeks with fluctuations week to week. This week the area remains closed . Though the area remains fragile there is no visible open area for consecutive weeks now. Facility to manage moving forward. A 9/13/24 weekly skin evaluation reveals that a head to toe assessment was performed but the question Does the resident have any impairments in skin integrity, is left blank. A comment reads, no new skin findings. There is no documentation of Resident #25's cluster of blisters to the left hip area. This skin evaluation is not accurate as a 9/13/24 progress note reads, Resident noted to have a cluster of small clear blistered areas to left hip area. A skin evaluation was not completed the following week. Two weeks later, a 9/27/24 weekly skin evaluation reveals that a head to toe assessment was performed but the question Does the resident have any impairments in skin integrity, is left blank. A comment reads, no new skin findings. A 9/30/24 nurse note reveals that Resident #25 is still being treated for his/her wound to his/her hip. Resident #25's medical record does not show any weekly wound assessments since 9/13/24 and there is no documentation of his/her current wound status. A 10/1/24 Physician note reveals Skin: 4x5 cm MASD over intergluteal area (upper and lower parts). Left posterior inner thigh: 2x3 cm MASD area. Barrier cream noted. 2. Resident #30's weekly skin evaluations do not include documentation of a rash. Per record review, Resident #30's care plan reads, [Resident #30] has potential for impairment of skin [related to diagnosis] of Diabetes Mellitus with neuropathy [nerve damage]. incontinence, falls, excoriation, revised on 9/4/24, with an intervention that reads, monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, macerations etc. to MD, revised on 10/31/22. Additionally, Resident #30's care plan reveals that s/he has a self-care performance deficit requiring a total 2 person assist for toileting and incontinence care. Per observation on 9/29/24 at 4:45 PM, Resident #30 is seen from the hallway sitting in a wheelchair in his/her room. S/He is not wearing any pants and his/her groin area is dark red on the edges of his/her brief. Per observation and interview on 10/1/24 at 2:49 PM, two LNAs are helping Resident #30 with incontinence care. The LNAs remove Resident #30's brief and his/her groin area has a red rash at least two inches on each side of his/her legs. When the LNAs wash Resident #30's groin area, Resident #30 begins to yell out in pain. The LNAs explained that Resident #30's groin area had been like that for at least a month and it does seem to hurt him/her when they provide him/her incontinence care. Per record review, Resident #30 has a physician order for Miconazole Nitrate Powder . Apply to buttocks, groin legs topically two times a day for fungal rash, with a start date of 7/9/24. Resident #30's care plan does not address the actual skin impairment to his/her groin area or the need for treatment. Record review reveals that Resident #30's skin evaluations do not have documentation of his/her fungal rash. Resident #30's last skin evaluation, dated 9/23/24, reveals the only documented skin alteration is a left lower leg excoriation. 3. Resident #34 does not have weekly skin evaluations and there is no evaluation of his/her multiple bruises. Per record review, Resident #34's care plan reads, [Resident #34] has potential for impairment to skin integrity r/t decreased mobility, fragile skin, incontinence bowel/bladder. [Resident #34] is at high risk for injury, such as bruising due to [his/her] impulsive behavior and poor safety awareness. [S/He] can become easily agitated and ambulate hurriedly causing contact injury with walker, furniture, bed, etc. 8/16/24 right upper arm bruising, revised on 8/16/24. Per observation on 9/30/24 at 10:49 AM, Resident #34 is sitting in a chair by the nursing station. A couple scabs and a couple small open spots that are freshly open and bright red are noticeable on his/her arms. Per interview on 10/1/24 at 9:23 AM, an LNA explained that in addition to the scabs that can be seen on Resident #34's arms, he has some scabs on his legs and bruises which have been there for a while. Per observation and interview on 10/2/24 at 4:04 PM, an LNA was providing care to Resident #34. Resident #34 had three dark bruises about 1 inch in diameter and multiple faded bruises on both legs. The LNA explained that the bruising has been there for a long time. Per a list of standard assessments in Resident #34's electronic medical record, Resident #34's last weekly skin evaluation was completed on 8/15/24. There was no documentation of Resident #34's skin alterations in his/her medical record. 4. Resident #51 does not have weekly skin evaluations. Per record review, Resident #51 was admitted [DATE] following a hip surgery. An 8/16/24 Nurse Practitioner note reads that Resident #51 has multiple open lesions (various healing stages) on fingers, arms, torso, pubic area, beltline [and a] right surgical incision. Resident #51's care plan reads [Resident #51] has potential for impairment to skin integrity r/t decreased mobility, fragile skin, incontinence bowel/bladder, surgical wound, pickers pustules, revised on 9/4/24 with the following intervention, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD, initiated on 8/17/24. Per a list of standard assessments in Resident #51's electronic medical record, Resident #51 does not have any completed weekly skin evaluations since his/her admission on 8/16/24. 5. The facility does not have a system to ensure that residents are getting accurate weekly skin assessments and weekly wound evaluations. There are no written procedures for staff to follow. Per interview on 10/1/24 at 10:44 AM, the Director of Nursing (DON) confirmed that skin evaluations and wound evaluations should be completed weekly. S/He confirmed that when they are done, all skin impairments will be entered into the weekly skin evaluation form and any non-pressure wound and any wound not being followed by the contracted wound team would have a weekly wound evaluation which would also be included in the weekly wound evaluation. When asked how a nurse would know that skin and wound management has been transferred to the facility, s/he replied that s/he was unsure. Per interview on 10/2/24 at 2:27 PM, the DON confirmed that weekly skin evaluations should include documentation of any compromised skin including surgical, moisture, fungal, rash, skin tear, bruising and was unable to produce evidence that skin evaluations for Residents #25, #30, #34, and #51 that documented the actual status of their skin. Per a review of facility policy titled Preventive Skin Care Policies, dated 2020, the policy does not provide guidance on how often a nurse should complete a comprehensive skin assessment and how to document findings. Facility policy titled Wound Care and Dressing Changes, last revised 9/2020, does not provide guidance on monitoring or evaluating wounds. Per an email dated 10/2/24, the Administrator explained that they follow evidence based practices provided by the contracted wound team in addition to the polices above for pressure injuries. The facility did not provide this surveyor with evidence based practices to follow for non-pressure injuries. 48017 5. Per record review, Resident # 291 was admitted to the facility on [DATE] with diagnoses of Chronic Osteomyelitis, Diabetes, and Peripheral vascular disease. Per interview on 10/1/2024 at approximately 11:30 AM, Resident # 291 expressed concerns about the staff's knowledge of how to use and apply a wound vac (a device used to close wounds by use of suction), s/he stated the nurses are unsure, and I have to explain it to them. Per observation on 10/2/2024 at approximately 8:15 AM, the dressing to the wound vac was not intact, and the apparatus was not attached to suction. Several observations throughout the day revealed that the apparatus remained unattached to suction until approximately 2:30 PM. Per record review, of the treatment record for Resident # 291 revealed an order: wound vac dressing to left foot: gently cleanse the area, place xeroform over wound followed by black foam, cover with dressing. Wound vac settings 125 mmHg to continuous suction. Per review of a facility policy titled Wound Care and Dressing changes, page three, #3, Obtain an order for secondary dressing to be placed if unable to maintain vacuum seal. Per interview on 10/2/2024 at approximately 2:15 PM with the Facility Educator, s/he indicated s/he was unaware of the policy indicating a need for secondary dressing if suction could not be maintained. S/he trains the floor nurses on using a wound vac by demonstrating its use, but s/he has not yet developed a competency for the staff. When asked if the facility had a standard of practice for using a wound vac, s/he replied that they call the doctor or the vac manufacturer if they have questions but do not have a standard of practice. Per interview on 10/2/2024 at approximately 3:30 PM with the Nursing Supervisor, s/he states that if there is a question about using the wound vac, the DON is contacted, or they call the on-call provider. S/he confirmed she had not completed a competency for using the wound vac apparatus. Per an interview with the Director of Nursing (DON) on 10/03/24 at approximately 11:00 AM, s/he confirmed the wound vac dressing should be removed if the vac cannot be returned to suction at any time, s/he also confirmed that the staff does not have competencies for the use of the wound vac.

Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to the use of personal protective equipment for 3 of 12 residents on precautions (Residents #51, #25, and #30). Findings include: Per observation on 10/1/24 at 1:55 PM, roommates Resident #51 and Resident #25 have a personal protective equipment caddy on their door. Per record review, Resident #51's care plan reads [Resident #51] has dx [diagnosis] of MRSA+ [Methicillin-resistant Staphylococcus aureus positive, a bacteria that can cause infections] right hip surgical wound, revised on 9/3/24 with an intervention for CONTACT ISOLATION [wearing gowns and gloves when touching the patient or their environment], initiated on 9/3/24. Resident #25's care plan reads, [Resident #25] has ESBL [extended-spectrum beta-lactamase; bacteria resistant to antibiotics] to left hip and is on Enhanced Barrier precautions [wearing gowns and gloves during high-contact resident care activities], revised 9/17/24, with an intervention that reads, resident to be maintained on Enhanced Barrier precautions, revised 9/17/24. Per observation on 10/1/24 at 1:55 PM, a Licensed Nursing Assistant (LNA) assisted Resident # 51 with toileting and was not wearing a gown. A few minutes later, at 2:00 PM, this LNA was observed touching a wound on Resident #25 and was not wearing a gown. Per interview on 10/1/24 at 2:08 PM a Licensed Practical Nurse confirmed that Residents #51 and #25 were both on precautions and the LNA should have been wearing a gown while doing any kind of personal care for Residents #51 and #25. Per observation on 10/1/24 at 2:45 PM, Resident #30 had a personal protective equipment caddy on his/her door. Per record review, Resident #30's care plan reads, [Resident #30] has potential for impairment of skin [related to diagnosis] of Diabetes Mellitus with neuropathy [nerve damage]. incontinence, falls, revised on 9/4/24, with an intervention that reads, Enhanced Barrier Precautions for [lower left extremity] open areas, initiated on 7/25/24. Per observation on 10/1/24 at 2:49 PM, two LNAs were observed assisting Resident #30 with toileting. Neither of the LNAs were wearing gowns. Per interview on 10/2/24 at 9:31 AM, the Infection Preventionist confirmed that Residents #25, #30 and #51 were on precautions and that the LNAs should be wearing gowns and gloves for personal care.

Based on staff interview and record review, the facility failed to ensure that all licensed nurses have the specific competencies and skill sets necessary to care for the resident's needs identified through resident assessments and the care plan for 2 of the 2 sampled residents (Resident # 291and Resident # 87). Findings include: Per record review, both Resident # 291 and Resident # 87 had wound vacs while admitted to the facility. (A wound vac is an apparatus that promotes wound healing using suction). Per record review, 5 of 5 records sampled for direct care staff caring for the residents did not contain competencies for using a wound vac. Per interview on 10/2/2024 at approximately 2:30 PM, the facility Nurse Educator stated that the facility had not yet developed a competency for wound vacs. S/he stated that s/he had shown some of the staff nurses how to change the dressing and use the specific dressing materials that are required in the vac application, but they have not developed a competency checklist for each nurse for wound vac use that outlines the facility's procedure for wound vac use.

Based on interviews and employee files, the facility failed to ensure that Licensed Nursing Assistants ( LNAs) received annual performance evaluations for 2 of the 2 LNAs employee files reviewed. Findings Include: Per review of employee files for LNAs who have worked at the facility for longer than a year, no nurse aide performance evaluations were completed within the past year. Per interview on 10/2/2024 at approximately 11:00, the Administrator confirmed that employee annual performance evaluations for the LNAs had not been completed.

Based on interview and record review the facility failed to ensure that a resident was assessed for injuries and complications in accordance with professional standards and per facility policy after sustaining a fall for 1 of 6 residents in the sample (Resident #1). Findings include: Per record review Resident #1 was admitted to the facility on [DATE] with a history of falling at home. On 3/24/2024 Resident #1 reported to a licensed nursing assistant (LNA) that they had an unwitnessed fall. The LNA then reported the fall to a nurse working on the unit. The nurse asked the LNA to report it to the Registered Nurse (RN) who was assigned to Resident #1's care, as the RN could assess. Per statement given by the RN, s/he had not been informed that the resident had reported a fall. Because the RN was not aware, Resident #1 had not been assessed for injury or complications on 3/24/24 after reporting that they had fallen. A nursing progress note dated 3/29/2024 indicates that Resident #1 was noted to have a large bruise of unknown origin on the back of their head. Review of the facility incident report includes witness statements that reflect that although the resident reported having a fall, nursing staff did not complete an assessment of their condition. A witness statement provided by the LNA on 3/29/24 that states When I went in to [Resident #1's] room [s/he] was sitting on the side of [her/his] bed. [S/he] told me that [s/he] had fallen and said [her/his] neck and head hurt. I had not seen [her/him] fall or on the floor at all. I notified my nurse right away. A statement completed by the nurse on 3/29/24 states LNA came to me to about resident reporting that resident told [her/him] [s/he] had a fall. I asked [the LNA] to tell the patients nurse as [s/he] is a RN (registered nurse) and can complete RN assessment. I was working on upper end of hallway and had not seen [Resident #1] yet that morning. The RN statement written on 3/30/24 states I did not receive a report that the resident fell . The facility procedure titled Accident/Incident Reports states: 1. All accidents and incidents must be reported and completed in point click care. 2. All accidents and incidents should be reported immediately to the RN Supervisor for assessment . Per interview with the Director of Nursing (DON) on 4/2/24 at 4:10 PM, during the facility investigation of the bruise of unknown origin identified on 3/29/24 it was discovered that on 3/24/24 Resident #1 had reported to a LNA that s/he had fallen. The RN who was assigned to Resident #1 reported that s/he was not aware of the fall. The DON confirmed that the resident should have been assessed at the time of the fall and was not. Sandr M. [NAME], MSN, ANP-BC, ed.2019. Lippincott Manual of Nursing Practice- 11th Ed. Philadelphia, PA. [NAME] & [NAME]

Based on interview, staff education record review, and the facility assessment, the facility failed to ensure that licensed nurses were assessed for competency and skill sets to provide care and respond to each resident's individualized needs. This has the potential to affect all residents. The facility assessment, last reviewed by the facility on 4/2023, states on page 11 that All staff attend general orientation as well as departmental training and associated competencies required for their position. Included in the list of staff competencies are Wound Care/Treatment Administration, and Specialized Care (ostomy care, catheter management/insertion, blood glucose testing, oxygen administration, dialysis care, tube feeding). Per interview with the North Unit Registered Nurse Manager (UM) on 11/14/23 at 1:00 PM there are two Residents on the North Unit who have extensive pressure ulcers that require dressing changes. The UM confirmed that the nursing staff provide wound care. Per review of 5 sampled employee education records, 2 contracted Licensed Practical Nurses (LPNs) and 2 Registered Nurses did not have documentation of the above-listed competency evaluation to demonstrate that they had the necessary skills to provide care needed. Per interview on 11/14/23 at 1:13 PM with the Staff Educator each nurse has a Medication Pass competency completed by the nurse who is orienting them. However, s/he has not been completing any competency evaluations during orientation or annually. At 2:58 PM the Staff Educator confirmed that the 2 LPNs and 2 RNs reviewed had not been assessed for competency in the skills needed to provide care based on the Resident care needs and the facility assessment.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one applicable resident (Resident #1). Findings include: Record review reveals that Resident #1 has a diagnosis of dementia with psychosis and was assessed on 8/22/23 to have a BIMS of 4 (brief interview for mental status; a cognitive assessment score indicating severe cognitive impairment). Resident #1's care plan states that s/he wanders throughout hall/facility/into others room R/T [related to] dementia and independent mobility, revised on 9/5/23, and has interventions that include, Distract [Resident #1] from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 2/15/23, and Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, created on 12/16/21. Resident #2 has a diagnosis of vascular dementia and was assessed on 9/19/23 to have a BIMS of 9 (indicating moderately impaired cognition). Resident #2's care plan states that s/he has potential to be physically aggressive r/t Dementia, revised on 7/7/23, and [Resident #2] wanders throughout hall R/T dementia, confusion, revised on 7/7/23, and has interventions that include Anticipate [Resident #2's] needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., revised on 11/3/22, and Distract [Resident #2] from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 11/3/22. Review of a facility incident report dated 10/2/23 at 9:30 PM for Resident #1 reveals that Resident #1 was found in another resident's room with bruising on his/her face, blood on his/her clothing, and blood on the floor of the room. Review of a facility resident to resident altercation investigation summary dated 10/9/23 reveals that Resident #1 was wandering the hallway around 10:00 PM when Resident #2 joined Resident #1 in wandering the halls. While walking past Resident #2's room, Resident #1 tried to move a locked wheelchair in the hall. Resident #2 took the wheelchair and hit Resident #1 in the legs with it. Resident #2 then took his/her closed fist and struck Resident #1 in the nose, which then began to bleed. The summary states that this altercation was not witnessed by staff. A nursing note dated 10/5/23 reveals that discoloration continued to be present to Resident #1's nose and bilaterally around the eyes. A social service note dated 10/5/23 reveals that while Resident #1 could not recall how s/he got the bruise on his/her nose, s/he did report that it was sore. Per interview on 10/23/23 at approximately 1:30 PM, the Director of Nursing stated that the altercation between Resident #1 and #2 reported in the investigation summary was confirmed by watching video footage of the event while investigating the cause of Resident #1's bloody nose. S/He stated that the video revealed that when Resident #2 punched Resident #1 in the face, Resident #1 fell to the floor. S/He stated that the investigation determined that the root cause of the altercation was due to the wheelchair being left in the hall and a lack of supervision of residents. See F689 for more information.

Based on interview and record review, the facility failed to ensure that all known and foreseeable hazards in the resident's environment were eliminated and failed to provide sufficient supervision to each resident for 2 applicable residents (Resident #1 and #2) resulting in Resident #1 being physically abused. Findings include: Record review reveals that Resident #1 has a diagnosis of dementia with psychosis and was assessed on 8/22/23 to have a BIMS of 4 (brief interview for mental status; a cognitive assessment score indicating severe cognitive impairment). Resident #1's care plan states that s/he wanders throughout hall/facility/into others room R/T [related to] dementia and independent mobility, revised on 9/5/23, and has interventions that include, Distract [Resident #1] from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 2/15/23, and Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, created on 12/16/21. Resident #2 has a diagnosis of vascular dementia and was assessed on 9/19/23 to have a BIMS of 9 (indicating moderately impaired cognition). Resident #2's care plan states that s/he has potential to be physically aggressive r/t Dementia, revised on 7/7/23, and [Resident #2] wanders throughout hall R/T dementia, confusion, revised on 7/7/23, and has interventions that include Anticipate [Resident #2's] needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., revised on 11/3/22, and Distract [Resident #2] from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 11/3/22. Review of a facility resident to resident altercation investigation summary dated 10/9/23 reveals that Resident #1 was wandering the hallway around 10:00 PM when Resident #2 joined Resident #1 in wandering the halls. While walking past Resident #2's room, Resident #1 tried to move a locked wheelchair in the hall. Resident #2 took the wheelchair and hit Resident #1 in the legs with it. Resident #2 then took his/her closed fist and struck Resident #1 in the nose, which then began to bleed. The summary states that this altercation was not witnessed by staff. A nursing note dated 10/5/23 reveals that discoloration continued to be present to Resident #1's nose and bilaterally around the eyes. A social service note dated 10/5/23 reveals that while Resident #1 could not recall how s/he got the bruise on his/her nose, s/he did report that it was sore. Per interview on 10/23/23 at approximately 1:30 PM, the Director of Nursing (DON) stated that the altercation between Resident #1 and #2 as described in the 10/9/23 investigation summary was confirmed by watching video footage of the event. The DON explained that the video footage revealed that Residents #1 and #2 were wandering for approximately 10 minutes without supervision. S/He stated that a staff member should be monitoring the hallway at all times during the off shifts (indicating that this took place during an off shift) and that if the residents were supervised, this incident would not have occurred because staff would have been able to intervene. S/He stated that resident equipment, such as wheelchairs, should not be left in the hallway when not in use. S/He confirmed the root cause of the altercation was due to the wheelchair being left in the hall and a lack of supervision of residents.

Based on observations, staff interviews and review of facility policies, the facility failed to ensure infection control measures were carried out to maintain resident safety from the spread of potential infections. This is cited at the Immediate Jeopardy severity level. Findings include: 1. Per observation on 06/09/21 at 11:00 AM, during a medication administration pass, a staff nurse checked the blood glucose of a resident prior to giving insulin using a device called a glucometer, which is used for multiple residents and utilizes a sample of resident blood to obtain a blood glucose level. S/he returned to the medication cart, removed the test strip from the glucometer and placed the device in the top drawer of the cart without cleaning the device. After a few more medications were delivered to other residents, the nurse proceeded to use the same, potentially contaminated glucometer to check the blood glucose level of another resident, without cleaning the glucomter prior to or after the procedure, and once again placed the potentially contamiated glucometer in the cart. Per interview on 06/09/21 at 11:20 AM with the staff nurse, s/he stated that the glucometer is a shared device for all residents and that the test strip is what comes in contact with the resident's blood and not the device itself, therefore the device does not need to be disinfected after each use. S/he stated that the device is cleaned with Cavi-wipes prior to each shift. These Cavi-wipes were found at the nurses' station and not at the medication cart. A review of the facility policy: Crescent Manor Rehabilitation Policy and Procedure Blood Glucose Monitoring by Resident (06/25/2018) specifies if meter is dirty, use a moist dampened cloth to remove debris. This policy also pertains to monitoring by residents who are cognitively able to perform self-glucose testing with their own glucometers and not to those who require assistance. The residents observed during the medication pass required assistance and did not have their own glucometers. Review of the ASSURE PRISM blood Glucose Monitoring System manufacturer instruction/user manual indicates on page 38 that the meter should be cleaned and disinfected after use on each patient. On page 39 it states to use Clorox Healthcare, Bleach Germicidal Wipes, Dispatch, Hospital Cleaner Disinfectant, Towels with Bleach, CaviWipes 1 and PDI Super Sani-Cloth Germicidal Disposable Wipes with contact times listed. The Center for Disease Control (CDC) indicates the following: Blood glucose meters are devices that measure blood glucose levels. -Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. -If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html Per interview on 06/09/21 at 1:30 PM the nurse educator/infection preventionist confirmed facility wide use of this glucometer. S/he also indicated that s/he was not aware that the meters needed to be cleaned between each person. After discussion re: glucometer manual instructions and the CDC guidance, s/he acknowledged that this is a breach of the infection control process. 2. On 6/7/21 at approximately 3:20 PM while doing observations on the North side/hall (Dementia Unit) a staff nurse was observed sitting behind the nurses station wearing her surgical mask under her/his nose. On 6/8/21 at approximately 1:45 PM a staff nurse was observed in the nurses station on the South side/hall wearing her/his surgical mask under her/his nose. This same nurse was observed at the medication cart, at 2:24 PM on the South side/hall wearing her/his surgical mask under her/his nose and again, this staff nurse was observed to be wearing her/his surgical mask under her/his nose at 2:30 PM. On 6/8/21 at 2 PM 2 staff (unknown disciplines) were noted to be wearing their surgical masks under their chin and 2 other staff (unknown disciplines) were observed to be wearing their masks under their noses. On 6/8/21 at approximately 2:05 PM an interview with the staff nurse on the South side/hall, who had been observed at 1:45 PM wearing her/his mask under her/his nose was asked for the full names of the 4 staff members observed wearing their masks either under their nose or under their chin, as well as her/his full name. The staff nurse confirmed that the 4 other staff members were LNA's (Licensed Nurses Aides). The staff nurse explained that she/he was having a hard time keeping the mask up on her/his nose as it kept sliding down. It was noted the metal bar at the top of the mask had not been form fitted to her/his nose. The staff nurse confirmed that appropriate use of the masks was to wear them over the nose and the mouth. On 6/8/21 at approximately 2:40 PM a conversation with the DON (Director of Nursing) specific to the South hall/Unit, while sitting at the nurses station, it was noted that the DON was wearing her/his mask under her/his nose throughout the conversation. On 6/9/21 at 9:15 AM on the South side/hall outside of room [ROOM NUMBER], an LNA was gathering linen from the linen cart and was noted to be wearing her/his mask under her/his nose. Interview on 6/9/21 at approximately 9:17 AM with this LNA revealed that she/he has been taught that the mask is only effective if worn to cover the nose and mouth. On 6/9/21 at approximately 1:30 PM, a staff member was noted to wearing her/his mask under her/his nose while working at the linen cart on the South side/hall outside of room [ROOM NUMBER]. Interview on 6/9/21 at approximately 1:32 PM with a staff nurse on the South side/hall, confirmed that the person at the linen cart was a laundry person and she/he should be wearing her/his mask over her/his nose and mouth. On 6/9/21 at 1:30 PM an interview with the Nurse Educator/Infection Preventionist regarding the wearing of mask, she/he confirmed that masks are to be worn to cover the nose and mouth and are required to be worn throughout the facility regardless of vaccination status.

Based on interview and record review, it was determined that the facility failed to maintain acceptable nutritional supports to residents at risk and who had significant weight loss for 1 of 20 residents in the survey sample (Resident #56). Findings include: Review of the electronic medical record (EMR), revealed that Resident #56 was admitted to the facility in June 2020. The resident has had a significant avoidable weight loss while in the facility. The resident has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident lost 18.5 pounds, which is 15.23% of her/his body weight within a 90 day period. On 2/11/21 her/his weight was 121.5 and on 5/13/21 her/his weight was documented as 103.0. She/he is significantly below her/his IBW (Ideal Body Weight), per a dietician assessment that revealed her/his BMI to be 18.8 and her/his IBW is documented as being between 131 and 159 pounds. An annual FCC2 Mini Nutritional Assessment was completed on 4/5/21and the dietician scored the resident at an 8.0. The legend at the bottom of this assessment revealed that an 8.0 means at risk of malnutrition. At the time of this assessment the residents weight is documented as being 115.9 pounds, moderate decrease in food intake, weight loss between 1 and 3 kg (2.2 pounds to 6.6 pounds), the resident has severe dementia or depression, and the residents BMI is 21 to less than 23. On 5/6/21 the FCC2 Mini Nutritional Assessent was completed as a quarterly assessment and scored as a 3.0. The legend at the bottom of this assessment revealed that an 3.0 means the resident is malnourished. At the time of this assessment the residents weight is documented as being 105.4 pounds, severe decrease in food intake, weight loss greater than 3 kg (6.6 pounds), severe dementia or depression and a BMI of 19 to less than 21. This resident has an ADL care plan that includes: Eating: Assistance varies Set-up to dependent to dine at meal. I have a dining NRP. At times, I prefer to be fed. I required additional time to dine. This piece of the care plan was last updated on 3/23/21. There is care plan for for Nursing Rehab/Restorative that reveals, Eating/Swallowing Program #1 to maximize safety and independence at meals. 1.) Encourage out-of-bed seating (TV room or Main Dining Room whe open) as tolerated. 2) Cut-up all foods into bite-size pieces. 3) Remove items for tray and place within [Resident #56's] reach. 4) Monitor for pocketing. Alternate textures (e.g., ground meat and potatoes) and/or solid/liquids to clear residue. 5) Provide 1:1 assistance with meals as tolerated 6.) Provide pureed French toast as an alternative if I refuse my meal. This part of the care plan was last updated on 4/15/21. Interview on 6/8/21 at approximately 1:30 PM, with the dietician, revealed that she/he was aware of this residents weight loss and that staff know that the resident requires someone to feed her/him for all meals. The dietician confirmed that she/he has not completed a care plan to address this residents weight loss and didn't realize she/he needed to do a seperate care plan for weight loss. See also F656.

Based on observation, staff interview and record review, the facility failed to adhere to professional standards for 4 of 25 applicable residents regarding safe medication administration practices, documentation in the Narcotic book, physician orders, and implementation of physician orders. (Residents #15, 30, 36 & 76) Findings include: 1. Per record review, Resident #36 was sent to the Emergency Department (ED) for possible improper medication administration, without notifying the physician at that time. Resident #36 required hospitalization , oxygen and 2 treatments of [MEDICATION NAME] (for narcotic overdose) on 11/04/15. Per review of the 11/04/15 morning nursing progress note, the Resident was observed shaking, acting not (him/herself) and the eyes rolled back. In addition, the hospital notes of 11/04/15 shows the emergency medical service (EMS) stating that it was reported (by nursing home staff) that the resident was unresponsive for about 30 minutes. The hospital report shows that the resident's presentation was consistent with narcotic ingestions and the toxicology report was positive for [MEDICATION NAME] and other opiates. Staff later in the evening sent a fax to the physician to review and verify the medication list, in which the physician replied did not know pt (patient) was sent to ED . In addition, review of the night nurse's statement on 11/05/15 showed that the nurse was having problems with the electronic medication administration record (eMAR), had pre-poured medications and then later in the shift signed off that the medications were given. The statement notes at 5 AM I could not sign on poured meds for the six residents who get 5 AM meds .the cups were clearly labeled with resident's names .when the day nurse came in .I signed for all the meds given, at that time. Per interview on 11/17/15 at 2:54 PM the SDC (Staff Development Coordinator) stated that the medications are not to be pre-poured for all the residents but given individually and documented at that time. Per interview DNS on 1:22 PM on 11/17/15 stated the night nurse did not have total access (to the medication record) via eMAR and acknowledged that there is one resident on that side of the unit who has orders for [MEDICATION NAME] and [MEDICATION NAME]. The DNS further that the night nurse denied giving the wrong medication but had resigned after this incident. The facility's investigation was inconclusive, however, the DNS stated the thought was that (Resident #36) had possibly received the other resident's medication. 2. During investigation of the emergency medical treatment required for Resident #36 on 11/4/15, it was found that staff are pre-signing the Narcotic Book and that discontinued medications are not being disposed of in a timely manner. Per review of the Narcotic Book shows Resident #36 had one dose of Tylenol w/ [MEDICATION NAME] on 10/28/15 and was discontinued on 11/05/15, however the medication was still in the facility, 3 weeks later. Documentation in the Narcotic book shows evidence of pre-signatures and/or missing co-signatures for the month of November on the west and east sides of the unit. The special care unit (SCU), North 1 & 2, had missing and/or pre-signed signatures. Per interview at that time, the West second shift staff nurse stated we sign ahead of time so we don't forget to sign off and we tend to get rid of the narcotics within a week, while the SCU nurse stated I'm new so I am not sure the protocol for destroying meds but we all sign our names before the other nurse counts with us, so we don't forget. Per interview on 11/17/15 at 2:54 PM the SDC (Staff Development Coordinator) stated that although the policy states to dispose of narcotics in a timely manner and that the expectation is within a week, that did not happen. The SDC confirmed the above findings that staff failed to adhere to professional standards. Also see F-333. 3. Per review of medical records, Residents #15, 30 and 76 had no physician orders in place for November 2015. The physician orders in the medical records, signed by the physician and dated 9/27/15, state, All orders are valid from [DATE]st to [DATE]st unless otherwise indicated. Per interview with the Licensed Practical Nurse (LPN) coordinator for the [MEDICAL CONDITION]'s Unit, the process for monthly orders is to copy the orders sent from the pharmacy and then send them to the physicians for review and signature. Confirmation from the Registered Nurse on 11/18/15 at 1:40 PM that the physician had not signed the current orders for November and that the orders in the chart are dated to be valid only until October 31. 4. Resident #15 has a [DIAGNOSES REDACTED]. Per review of the safety checks surrounding the release of the support, it is to be done every 2 hours and there is no evidence that it has been consistently released for the past three days. Confirmed by the LPN on 11/17/15 at 4:18 PM, that the documentation is incomplete and there is no evidence that the support has been released per the physician orders. Per observation on 11/18/15 at 7:53 AM, Resident #15 was observed being taken to the dining room and chest strap and pelvic support were in place. Resident was fed breakfast and at 9:19 AM was brought to the unit and was placed in the sitting room. At 9:32 AM s/he was brought into the Crescent Club (an area specified for the [MEDICAL CONDITION]'s residents). The chest strap was removed at 10:00 AM for less than 1 minute to reposition the resident. The pelvic support strap was not released and per interview with the Physical Therapist at this time, the straps are loose enough and don't need to be released. S/he confirmed that they keep the resident from getting out of the chair and are used for safety and support because of choreic movements. The resident was then taken to occupational therapy. Per the LNA, the resident spends most of his/her day in the Crescent Club and the supports are not released. Per the [MEDICAL CONDITION]'s coordinator, at 10:15 AM, the physician orders were not followed. Reference: Lippincott Manual of Nursing Practice (9th edition) Wolters Kluwer Health/Lippincott Williams and Wilkins

Based on medical record review and staff interviews the facility failed to ensure that 1 applicable sampled resident (Resident #36), was free of any significant medication errors. The findings include: Resident #36 was sent to the Emergency Department (ED) on 11/04/15 in which the hospital report shows that the resident's presentation was consistent with narcotic ingestions and the toxicology report was positive for [MEDICATION NAME] and other opiates. The resident needed two doses of [MEDICATION NAME] (antidote for opioid overdose). Review on 11/16/15 of the current medications shows no narcotics nor other opioids ordered for this resident. Tylenol #3 (with [MEDICATION NAME]) was discontinued and last given on 10/28/15. Per review of the night nurse's statement on 11/05/15 showed that the nurse was having problems with the electronic medication administration record (eMAR), had pre-poured medications and then later in the shift signed off that the medications were given. The statement notes at 5 AM I could not sign on poured meds for the six residents who get 5 AM meds .the cups were clearly labeled with resident's names .when the day nurse came in .I signed for all the meds given, at that time. Per interview DNS on 1:22 PM on 11/17/15 stated the night nurse did not have total access (to the medication record) via eMAR and acknowledged that there is one resident on that side of the unit who has orders (for opioids) [MEDICATION NAME] and [MEDICATION NAME]. The DNS further that the night nurse denied giving the wrong medication but had resigned after this incident. The facility's investigation was inconclusive however, the DNS stated the thought was that (Resident #36) had possibly received the other resident's medication.

Based on staff interview and record review the facility failed to provide services that meet professional standards of quality regarding following physician orders [REDACTED]. The findings include the following: Per medical record review Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1, No, may not leave the building on pass. This order is confirmed by Unit Manger on 9/14/15. Per Care Area Assessment (CAA) dated 7/27/15 completed by the Licensed Practical Nurse (LPN) who completed the assessment and signed by the Registered Nurse (RN), Director of Nurses (DNS) on 7/31/15, identifies care planning necessary for Resident #1 due to the following concerns: -Known to leave against medical advice at two (2) other facilities, -Bilateral [MEDICAL CONDITION], is to have surgery scheduled, -Receiving Physical Therapy due to general weakness and difficulty walking, -Altered balance/chronic pain requiring the use of a walker, putting Resident #1 at risk for falls, -Resident has poor safety awareness, -Resident receives antipsychotic medication (medication used to treat [MEDICAL CONDITION] Disorder/[MEDICAL CONDITION] Disease) and has episodes of verbal abuse and aggression towards others. Nurses notes dated at various intervals beginning on 7/20/15 through 9/14/15, evidence that the resident left the facility unattended approximately on 39 separate occasions. The leave of absences varied from fifteen (15) minutes to as long as seven (7) hours in duration and during the day, evening and night hours. Refer to details at F323. References: Per review of the American Medical Association Code of Medical Ethics states One of the duties in providing reasonable care is fulfilled by a nurse who carries out the orders of the attending physician. (http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion302.page) Per review of the American Nursing Association Code of Ethics states The primary bond between the practices of medicine and nursing is mutual ethical concern for patients. One of the duties in providing reasonable care is fulfilled by the nurse who carries out the orders of the attending physician. (American Nursing Association Code of Ethics Issued June 1983 and updated June 1994. http://www.nursingworld.org) Lippincott Manual of Nursing Practice (9th Edition) Wolters Kluwer Health/Lippincott Williams and Wilkins Page #17.

Based on medical record review and confirmed by staff interview, the facility failed to assure that 1 of 69 residents residing in the facility, receives adequate supervision by facility staff to prevent and/or avoid accidents. For Resident #1 the findings include the following: Per medical record review Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1, No, may not leave the building on pass. This order is confirmed by Unit Manger on 9/14/15. Per Care Area Assessment (CAA) dated 7/27/15 completed by the Licensed Practical Nurse (LPN) who completed the assessment and signed by the Registered Nurse (RN), Director of Nurses (DNS) on 7/31/15, identifies care planning necessary for Resident #1 due to the following concerns: -Known to leave against medical advice at two (2) other facilities, -Bilateral Cataracts, is to have surgery scheduled, -Receiving Physical Therapy due to general weakness and difficulty walking, -Altered balance/chronic pain requiring the use of a walker, putting Resident #1 at risk for falls, -Resident has poor safety awareness, -Resident receives antipsychotic medication (medication used to treat Schizoaffective Disorder/Bipolar Disease) and has episodes of verbal abuse and aggression towards others. Per medical record review, nurses notes dated at various intervals beginning on 7/20/15 through 9/14/15, evidence that the resident left the facility unattended on approximately 39 separate occasions. The leave of absences varied from fifteen (15) minutes to as long as seven (7) hours in duration and during the day, evening and night hours. 7/20 through 7/24/15: Resident #1 left the facility without supervision on 5 separate occasions. The resident was seen ambulating with a walker down Crescent Boulevard, heading downtown. Neighbors called the facility to alert the missing resident. 7/28 through 8/5/15: Resident #1 left the facility without supervision on 7 separate occasions. On 2 occasions the resident appeared in the Emergency Department (ED) for complaints of chest and left arm pain. ED treated and released the resident back to the nursing facility with instructions. Nurses documentation evidences that the resident was out of the facility unattended for durations lasting up to 7 hours. 8/6 through 8/13/15: Resident #1 left the facility without supervision on 4 separate occasions. On one of the 4 occasions, the resident appeared at the rescue squad building partially clothed, in a T-Shirt and adult pull-ups. 8/14 through 8/22/15: Resident #1 left the facility without supervision on 5 separate occasions. The resident appeared in the ED inappropriately dressed. Nurses documentation evidences that the resident was out of the facility unattended for durations lasting up to 5 hours. 8/23 through 8/31/15: Resident #1 left the facility without supervision on 8 separate occasions. The two following episodes documented in the nurses notes, evidence that lack of supervision by facility staff, that placed Resident #1 in situations of severe danger. On 8/28/15 at 5:45 AM the facility was notified by the attendant of a local Gas Station/Minimart, (at the bottom of the hill) that Resident #1 has been directing traffic on Route #7, a major highway. S/he is removing his/her clothing in the Minimart. The establishment would like the resident picked up. Nursing home staff informed Minimart staff they could not meet their request to provide the resident with transportation back to the nursing facility. On 8/28/15 at 2 PM, Resident #1 was walking in the circle/driveway in front of the facility, s/he became tired and just stopped. Oncoming vehicles were redirected and the resident was moved by facility staff to the grass where s/he rested. 9/1 through 9/14/15: Resident #1 left the facility without supervision on 9 separate occasions. The following episode, documented in the nurses notes, evidence that lack of supervision by facility staff, that placed Resident #1 in situation of severe danger. On 9/1/15 the facility received a call reporting that Resident #1 was seen walking on the yellow line on South Street. Resident was returned to the facility by the rescue squad. Per observation on 9/14/15 the State Surveyor identified that Resident #1 did not have a wander-guard bracelet on his/her person or attached to the walker, therefore the security alert was not in place. Interdisciplinary Care Plan (ICP), dated 8/5/15 identifies that Resident #1 has a history of leaving facilities Against Medical Advice and leaving the facility and grounds without informing staff. Interdisciplinary Care Plan identifies that the resident is at risk for elopement and to have wander-guard bracelet on walker as he allows to alert staff that the resident is leaving the building. On 8/28/15 an initiative on the ICP evidences that Resident #1 has been known to remove clothing and attempt to direct traffic downtown and signed by the Director of Nurses (DNS). On 9/14/15 at approximately 4 PM Surveyor informed the DNS that a plan needed to be put in place to ensure the safety of Resident #1 while s/he is in the facility or out of the premises. A plan was developed and accepted by the surveyor. 9/14/15 Resident #1 left the facility unsupervised at 9:45 PM. Administrator, DNS, United Counseling Service and Bennington Police Department notified. The resident returned around 10:15 PM. Nurses notes identify the following: - Concerned citizens have returned the resident to the facility. - Facility staff silence alarm while resident exited the building. - Facility staff do not consistently identify when the resident leaves or returns. - On several occasions resident called the facility, taxi, EMS or Police to be returned to the facility. - Nurses Notes evidence that facility staff will not pick up resident when he or a local establishments requests transportation back to the nursing facility. Per interview with the DNS and the Nursing Home Administrator confirmation was made that the resident has left the faciity on 39 documented episodes and at various times of the day, evening and night as noted in the nurses notes. All of the occurrences were without supervision therefore placing the resident in severe danger.

Based on observation, staff interviews and medical record review, the facility failed to provide goods and services necessary to avoid physical harm, mental anguish and/or mental illness for 1 resident (Resident #1) by not administering an ordered (PRN) as needed medication for escalating and aggressive behaviors as directed by physician orders [REDACTED]. Per medical record review on 03/08/2012 at 1:10 pm, the facility administration placed a notice in the record and on the nurses' unit on or about 01/05/2012 or 01/06/2012 instructing staff to not give Resident #1 the ordered PRN medication, [MEDICATION NAME], for escalating behaviors, which is contrary to MD orders and directions in the care plan dated 12/06/2011. The notice further instructed the staff to call the police department, the ambulance, facility personnel, the physician and the POA (Power of Attorney), to send the resident to the hospital and not accept him/ her back into the facility if hospital admission did not occur. See below for exact wording of notice. The notice is not signed or dated and there is no evidence to support that the physician was included in formulating this change in the treatment plan. This is confirmed by facility staff during interview on 03/09/2012 between 10 and 11 AM. Per review of nurses notes and documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An entry in the nurses' notes dated 01/06/2012 at 1300 hours states "resident in the hall with radio, no swearing or negative behaviors, no slamming doors." Per entries from 1415 to 1635 the resident's behaviors had escalated to where "the resident attacked a nurse...attempted to choke the nurse...call placed to MD-made aware of situation, received order to sent to ER." There is no evidence in the medical record that indicates that Resident was given or attempted to be given the PRN [MEDICATION NAME] I/M that was ordered. Per telephone interview with Resident #1's POA on 03/12/2012 at 10:30 AM, s/he confirms that s/he was not notified of this plan until after it was implemented. S/he attended a care plan meeting on 12/06/2011 and recalls from notes made at the time that there was no mention of Resident #1 not being appropriately placed at this facility, nor that it was the facility intent to discharge Resident #1 from the facility. Further, there were no indications that any changes were made in the care plan. This is supported in the medical record notes from the care plan meeting in [DATE]. Notice contents: "(Resident #1's name). When behavior escalates to a level that PRN [MEDICATION NAME] WOULD NEED TO BE GIVEN, DO NOT give. Provide 1:1, clear hallways of residents, close Activity Room Door and ensure staff & resident safety until Emergency Personnel arrive. IMMEDIATELY call: Police; Bennington Rescue Squad; (staff name); MD; POA. Ship to SVMC ER - DO NOT ACCEPT RETURN TO FACILITY!!!"

Based on medical record review, staff and Power of Attorney (POA) interviews, the facility failed to fully inform 1 resident or his/her legal representative about changes in the treatment plan by not informing them that an as needed (PRN) medication would be withheld for escalating behaviors, that the resident would be sent to the hospital and would not be accepted back at the facility. The findings are as follows: Per medical record review on 03/08/2012 at 1:10 PM, the facility administration placed a notice in the record and on the nurses' unit on or about 01/05/2012 or 01/06/2012 instructing staff to not give Resident # 1 the ordered PRN medication, [MEDICATION NAME], for escalating behaviors, which is contrary to MD orders and directions in the care plan dated 12/06/2011. The notice further instructed the staff to call the police department, the ambulance, facility personnel, the physician and the POA, to send the resident to the hospital and not accept him/her back into the facility if hospital admission did not occur. The notice is not signed or dated and there is no evidence to support that the physician was included in formulating this change in the treatment plan. This is confirmed by facility staff during interview on 03/09/2012 between 10 and 11 AM. Per telephone interview with Resident #1's Power of Attorney (POA) on 03/12/2012 at 10:30 AM, s/he confirms that s/he was not notified of this plan until after it was implemented. S/he attended a care plan meeting on 12/06/2011 and recalls from notes made at the time that there was no mention of Resident #1 not being appropriately placed at this facility, nor that it was the facility intent to discharge Resident #1 from the facility. Further, there were no indications that any changes were made in the care plan. This is supported in the medical record notes from the care plan meeting in [DATE].

Based on medical record review and staff interviews the facility failed to meet professional standards of care by not following physician orders [REDACTED]. The findings include: Per medical record review on 03/08/2012 at 1:10 pm, the facility administration placed a notice in the record and on the nurses' unit on or about 01/05/2012 or 01/06/2012 instructing staff to not give Resident #1 the ordered PRN medication, [MEDICATION NAME] (an anti-psychotic medication), for escalating behaviors, which is contrary to MD orders and directions in the care plan dated 12/06/2011. The notice further instructed the staff to call the police department, the ambulance, facility personnel, the physician and the POA (Power of Attorney), to send the resident to the hospital and not accept him/ her back into the facility if hospital admission did not occur. The notice is not signed or dated and there is no evidence to support that the physician was included in formulating this change in the treatment plan. This is confirmed by facility staff during interview on 03/09/2012 between 10 and 11 AM. Per review of nurses notes and documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An entry in the nurses' notes dated 01/06/2012 at 1300 hours states "resident in the hall with radio, no swearing or negative behaviors, no slamming doors." Per entries from 1415 to 1635 on the same day the resident's behaviors had escalated to where "the resident attacked a nurse...attempted to choke the nurse...call placed to MD-made aware of situation, received order to send to ER." There is no evidence in the medical record that indicates that the Resident was given or attempted to be given the PRN [MEDICATION NAME] I/M that was ordered, nor was there documentation that the order was rescinded by the MD when the order to send Resident #1 to the emergency room was received. Per telephone interview with Resident #1's POA on 03/12/2012 at 10:30 AM, s/he confirms that s/he was not notified of this plan until after it was implemented. S/he attended a care plan meeting on 12/06/2011 and recalls from notes made at the time that there was no mention of Resident #1 not being appropriately placed at this facility, nor that it was the facility intent to discharge Resident # 1 from the facility. Further, there were no indications that any changes were made in the care plan. This is supported in the medical record notes from the care plan meeting in [DATE].

Based on observation and staff interviews the facility failed to assure that one applicable Resident (Resident # 1) was treated in a manner that maintained the highest practicable mental and psychosocial well being, by the facility planning to not follow the physician orders [REDACTED]. Per medical record review on 03/08/2012 at 1:10 PM, the facility administration placed a notice in the record and on the nurses' unit on or about 01/05/2012 or 01/06/2012 instructing staff to not give Resident #1 the ordered PRN (as needed) medication, [MEDICATION NAME], for escalating behaviors, which is contrary to MD orders and directions in the care plan dated 12/06/2011. The notice further instructed the staff to call the police department, the ambulance, facility personnel, the physician and the POA (Power of Attorney), to send the resident to the hospital and not accept him/her back into the facility if hospital admission did not occur. See below for exact wording of notice. The notice is not signed or dated and there is no evidence to support that the physician was included in formulating this change in the treatment plan. This is confirmed by facility staff during interview on 03/09/2012 between 10 and 11 AM. Per interview with the facility administrator on 03/08/2012 and 03/09/2012 s/he reported that a 30-day notice was not given to this resident or his/her legal representative because "you know as well as I do (s/he) would still be here. And I have to think of the safety of the other residents." Per electronic mail received from the facility administrator dated 03/22/2012 at 10:54 am, s/he clarified that s/he was the administrator of record at the time of the discharge. Notice contents: "(Resident #1's name). When behavior escalates to a level that PRN [MEDICATION NAME] WOULD NEED TO BE GIVEN, DO NOT give. Provide 1:1, clear hallways of residents, close Activity Room Door and ensure staff & resident safety until Emergency Personnel arrive. IMMEDIATELY call: Police; Bennington Rescue Squad; (staff name); MD; POA. Ship to SVMC ER - DO NOT ACCEPT RETURN TO FACILITY!!!" Refer also to F147, F224, F280, and F281.

Based on interview and record review, the facility failed to ensure that 1 applicable resident in the targeted sample received adequate supervision to prevent an accident that resulted in serious injury (Resident #1). Findings include: 1. Per interview and record review, Resident #1, who wandered about the unit on an almost daily basis, did not receive adequate supervision to prevent accidents. Per interviews and review of Nurses' Notes (NN) on 12/1/10, Resident #1 was found on the floor in Resident #2's room, along with Resident #2, on 11/24/10 at 5:45 PM. Per staff interview, Resident #2 was heard yelling "get (him/her) out of here" immediately prior to staff finding the residents on the floor. Resident #1 was transferred to the local hospital for treatment of [REDACTED]. These behaviors continued, as evidenced by NN and Behavior/Intervention Monthly Flow Records throughout the resident's admission. Per review of the care plan and staff interviews on 12/1/10, Resident #1 was not on any scheduled/structured monitoring or safety checks to assure adequate monitoring of the resident's whereabouts. Per staff interviews and record review on 12/1/10, Resident #1 had a history of [REDACTED].#2's room in the recent past. The care plan that addresses Resident #1's risk for falls and injury related to poor safety awareness states to "Monitor OOB (out of bed) activity" and "Be aware of Resident's whereabouts." The care plan that addresses increased behaviors related to altered thought process states to "increase surveillance during evenings and nights when confusion and safety needs increase." These interventions do not provide staff with any specific timeframes or monitoring parameters. There is no documentation to support daily increased surveillance during evening hours, nor is there any daily documentation regarding the resident's whereabouts or monitoring of OOB activity. During an interview on 12/8/10 at 11:20 AM, the Assistant Director of Nursing confirmed that there is no documentation to support increased surveillance or knowledge of resident whereabouts during evening hours, and that staff were not given specific guidance on how often to check the location of Resident #1 to ensure safety.