Every finding on record at Dunbar Village Terrace

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to a comfortable and homelike environment for one (1) of (14) sampled residents (Resident #30) by failing to adequately accommodate the prolonged loss of a bathroom sink for approximately one (1) month.Findings include:A review of the facility's policy, Resident Rights, revised 1/2026, revealed, .Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the village .8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .A record review of the admission Record revealed the facility admitted Resident #30 on 9/3/24 with diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/26 revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of (12), which indicated her cognition was moderately impaired. Section GG revealed Resident #30 used a walker and required setup assistance with oral hygiene and toileting hygiene and supervision or touching assistance for showering and ambulation.On 5/26/26 at 2:30 PM, during an observation and interview, Resident #30 reported the facility removed the sink from her bathroom several weeks earlier and she had not received a replacement. Resident #30 explained she had been using water from the shower to wash her face and brush her teeth because she had not been provided water, a wash basin, hand sanitizer, or other hygiene alternatives in her room. Resident #30 stated she was short and had difficulty obtaining water from the shower for daily hygiene tasks.On 5/27/26 at 10:25 AM, during an observation and interview, Resident #30 reported she continued to use shower water for daily hygiene and stated she had gone almost (1) month without a sink in her room. Resident #30 stated this was her home and she should not have to go without a sink for such a prolonged period. Observation revealed no hand sanitizer, or alternative hygiene supplies available in the room.On 5/27/26 at 4:25 PM, during an interview, Certified Nurse Aide (CNA) #1 explained the sinks had been removed from resident rooms for more than three (3) weeks and (1) month. CNA #1 reported Resident #30 complained daily about the missing sink and confirmed residents were directed to use the staff bathroom or shower rooms. CNA #1 reported no additional hand sanitizer, or alternative hygiene supplies were provided to residents affected by the renovation.On 5/27/26 at 4:45 PM, during an interview, Licensed Practical Nurse (LPN) #2 confirmed the sinks had been removed for more than (3) weeks and residents were expected to use either the staff bathroom or shower rooms while awaiting replacement sinks. LPN #2 explained Resident #30 had a shower and toilet in her room but no sink.On 5/28/26 at 9:30 AM, during an interview, Housekeeping/Maintenance Staff #1 reported the sinks had been removed for almost (1) month while the facility waited for contractors and replacement sinks. Housekeeping/Maintenance Staff #1 confirmed residents were provided access to the staff bathroom and shower rooms while awaiting installation. On 5/28/26 at 9:50 AM, during an observation and interview with Resident #30 and CNA #2, Resident #30 reported she had been without a sink for almost (1) month. CNA #2 confirmed Resident #30 brushed her teeth while in the shower and confirmed no hand sanitizer had been provided. Observation revealed no hand sanitizer, or alternative hygiene supplies available in the room.On 5/28/26 at 10:15 AM, during an interview, Housekeeping/Maintenance Staff #2 explained the sinks had been removed from resident rooms for almost one (1) month and residents had expressed frustration regarding the prolonged loss of the sinks.On 5/28/26 at 10:30 AM, during an interview, CNA #3 explained she was not informed in advance of the sink removals and recalled obtaining water from another sink for resident care after discovering a resident room no longer had a sink. CNA #3 reported she believed some residents had received small packets of hand sanitizer but acknowledged they could not be left in resident rooms due to safety concerns.On 5/28/26 at 11:00 AM, during an interview, Resident #30 reported she had only recently been informed that a replacement sink might be installed the following week. Resident #30 stated she had not been offered water or a wash basin for daily hygiene and had been instructed to use bathrooms located outside her room if needed. Resident #30 reported she was (85) years old and should not have to leave her room to perform basic hygiene activities because her bathroom sink had been unavailable for almost (1) month.On 5/28/26 at 4:57 PM, during an interview, the Administrator reported she understood residents had experienced inconvenience related to the prolonged loss of normal in-room hygiene access and stated she hated that the renovation project had taken as long as it had.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident was free from a significant medication error when facility staff administered undiluted Sertraline Hydrochloride (Zoloft) Oral Solution to a resident for one (1) of six (6) residents reviewed for medication review. (Resident #62) Findings include:A review of the facility's policy, Medication Errors, Date Reviewed/Revised 9/2025, revealed, Policy Explanation and Procedure: 1. The village shall ensure medications will be administered as follows.b. Per manufacturer's specifications regarding the preparation, and administration of the drug. A record review of the admission Record revealed the facility admitted Resident #62 on 2/27/26 with diagnoses including Aftercare Following Joint Replacement Surgery.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/26 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact.A record review of the Pharmacy Requisition Report dated 03/02/2026 revealed the resident was ordered Sertraline Hydrogen Chloride (HCI) Oral Concentrate 20 milligrams (mg)/milliliter (ml) (Sertraline HCl) - Route: by mouth. A record review of the Medication Administration Record (MAR) for March 2026 revealed Resident #62 was administered Sertraline Hydrochloride Oral Concentrate 20 mg/ml on 3/6/26.A record review of the facility's Medication Incident Report Form dated 3/6/26 revealed the Type of Incident was documented as Other not mixed in liquid. The section titled What is the outcome or result of the incident? was documented as Other irritation to mouth. The Description of error was documented as, Liquid Zoloft not mixed in liquid. Mix in liquids no on apothecary directions . Corrective actions documented, spoke with pharmacy representative.regarding need for special instructions directly on pharmacy label .A review of the medication package revealed instructions on the front and back of the package stated, Must Be Diluted Before Use (see side panel for instructions). The side panel revealed, Mixing Instructions.mix with 4 oz (ounces) (1/2 cup) of water, ginger ale, lemon/lime soda, lemonade or orange juice ONLY .A review of the medication package insert revealed, Highlights of Prescribing Information.Zoloft (sertraline hydrochloride) oral solution.Dosage and Administration.Oral solution: Must be diluted .Preparation of Zoloft Oral Solution Zoloft oral solution must be diluted before use.Mix with 4 ounces (1/2 cup) of water, ginger ale, lemon/lime soda, lemonade, or orange juice ONLY.A record review of the Progress Notes, Type: Discharge summary, dated [DATE] revealed, A care partner alerted this nurse this afternoon at around 1300 that elder earlier received liquid sertraline without mixing in liquid, which resulted in elder complaining of a 'burning tongue' and 'sore throat.' Reported that the elder was given water after medication administered as well as soft foods to soothe the throat. Elder went to therapy and requested to return to room r/t sore throat and burning tongue. Reported that elder called her children to come to the village and she requested discharge today.On 5/27/26 at 8:10 AM, during an interview with the Resident Representative (RR), she reported that on 3/6/26 shortly after 1:00 PM, she received a phone call from Resident #62 and had difficulty understanding her. The RR stated she arrived at the facility approximately (25) minutes later and observed Resident #62 walking down the hall holding her neck while accompanied by a nurse. The RR reported Resident #62 told her that her throat was burning because the nurse did not mix her liquid medication. The RR stated she asked staff what had been done for the resident and was informed of the medication error. The RR reported she and her brother gathered Resident #62's belongings, transported her to the emergency room for evaluation, and then took her home because they did not intend for her to return to the facility.On 5/27/26 at 12:10 PM, during an interview with Registered Nurse (RN) #1/RN Supervisor, she reported the facility completed an incident report and medication error review after Resident #62 received liquid Zoloft without proper dilution. RN #1 explained the nurse administering medications gave the resident liquid Zoloft that should have been diluted and Resident #62 complained that her mouth was burning afterward. RN #1 reported the family arrived at the facility and was informed of the error. RN #1 stated Resident #62 complained of discomfort and was provided water, ice cream, and pudding. RN #1 reported the facility's Nurse Practitioner was notified.On 5/27/26 at 1:10 PM, during an interview with the Nurse Practitioner (NP), she stated she recalled being notified regarding Resident #62 receiving liquid Zoloft without dilution. The NP explained she contacted the pharmacy and was informed the medication should be diluted with at least four (4) ounces of liquid. The NP reported administration of undiluted liquid Zoloft could cause numbness, tingling, mouth soreness, throat soreness, and a burning sensation. The NP stated the recommendation was to continue fluids to help alleviate the symptoms.On 5/28/26 at 2:34 PM, during an interview with the Director of Nursing (DON), she recalled the incident involving administration of undiluted liquid Zoloft to Resident #62. The DON reported the family was upset regarding the medication error. The DON stated the medication arrived from the pharmacy without dilution instructions on the pharmacy label. The DON reported she contacted the pharmacist following the medication error and discussed the need for administration instructions to accompany medications. The DON stated nurses should look up administration instructions and obtain additional information when administering medications that are unfamiliar to them.On 5/28/26 at 2:54 PM, during a phone interview, Licensed Practical Nurse (LPN) #1 reported she recalled administering the medication to Resident #62. LPN #1 stated this was the first time she had administered liquid Zoloft. LPN #1 reported the medication packaging she reviewed contained dosing information, but she did not recall instructions regarding dilution before administration. LPN #1 stated she was later advised by her supervisor to look up administration instructions when administering a medication that was unfamiliar to her.

Based on staff interview and record review, the facility failed to comply with state nursing facility staffing requirements by failing to designate a charge nurse responsible for supervision of the total nursing activities in the facility during the 3:00 PM to 11:00 PM shift, separate from the medication/treatment nurse assignment for one (1) of three (3) shifts reviewed for charge nurse supervision. Findings include:A record review of the Minimum Standards for Institutions for the Aged or Infirm for Rule 45.4.1 Nursing Facility, revealed, .To be classified as a facility, the institution shall comply with the following staffing requirements.2. Each facility shall have the following licensed personnel as a minimum.D. A registered nurse or licensed practical nurse shall serve as a charge nurse and be responsible for supervision of the total nursing activities in the facility during the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift. The nurse assigned to the unit for the 11:00 p.m. to 7:00 a.m. shift may serve as both the charge nurse and medication/treatment nurse.A record review of the Facility Assessment, dated 8/7/25, revealed, Facility Assessment and Staffing Needs.This facility assessment will be used to.Consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary. On 5/26/26 at 3:35 PM, during an interview with Registered Nurse (RN) #3, she explained the facility had Licensed Practical Nurses (LPNs) and RNs serving as supervisors on the day shift who worked eight (8)-hour shifts, while the medication cart nurses and Certified Nurse Aides (CNAs) worked (12)-hour shifts. RN #3 explained the facility did not have an appointed nurse serving as a supervisor or charge nurse on the evening shift as the medication cart nurses remained after the supervisors left.On 5/28/26 at 3:39 PM, during an interview with the Director of Nursing (DON) and RN #3, they explained the facility staffed three (3) medication nurses on the day shift and two (2) medication nurses on the evening shift. They explained the RN supervisors typically left the facility between 4:00 PM and 5:00 PM. The DON confirmed the facility did not designate a charge nurse responsible for supervision of the total nursing activities in the facility after the RN supervisors left the building. The DON explained there was always a nurse on call when a supervisor was not present. The DON and RN #3 stated they were not aware state regulations required a designated charge nurse responsible for supervision of nursing services during the 3:00 PM to 11:00 PM shift that was not a medication/treatment nurse.On 5/28/26 at 4:30 PM, during an interview with CNA #3, she explained she had transferred from the night shift approximately three (3) weeks earlier. CNA #3 explained the evening and night shifts did not have supervisors in the building but had medication cart nurses. CNA #3 explained if a resident issue occurred, she reported it to the medication cart nurse, who would then contact the nurse on call if needed.On 5/28/26 at 4:45 PM, during an interview with the Administrator, she explained the medication cart nurses functioned as charge nurses and staff were aware of this practice. The Administrator explained if additional supervision or assistance was needed, an on-call nurse was available to be contacted. The Administrator further explained the facility did not have a staffing policy.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure services were provided in accordance with professional standards of practice observed during medication administration when the nurse allowed Resident #11 to self-administer two (2) different prescribed nasal sprays without assessing whether he was capable of doing so safely for one (1) of four (4) residents observed. (Resident #11). Findings include:A review of the facility's policy titled Resident Self-Administration of Medication, with a reviewed/revised date of 5/2025, revealed, .It is the policy of this village to support each residents' right to self-administer medication. A resident may only self-administer medications after the village's interdisciplinary team has determined which medications may be self-administered safely. Policy Explanation and Compliance Guidelines.4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record.On 7/30/25 at 8:32 AM, during a medication administration observation, Licensed Practical Nurse (LPN) #2 was observed administering two (2) nasal spray medications to Resident #11: Azelastine Hydrochloride (HCL) Solution 137 micrograms (mcg)/spray and Fluticasone Propionate Nasal Suspension 50 mcg/actuation. LPN #2 instructed Resident #11 to self-administer one (1) spray to each nostril for both medications. Resident #11 was observed administering two (2) sprays to each nostril of the Fluticasone. LPN #2 stated that the resident usually administered his own nasal sprays but confirmed she was unsure whether the resident had been assessed to self-administer. She acknowledged that the resident used two (2) sprays of Fluticasone, although the order specified one (1) spray to each nostril.On 7/30/25 at 10:10 AM, during an interview with Resident #11, he stated the nurse always gave him his nasal sprays, but he administered them himself. He explained he always gave himself two (2) sprays of each medication because it made it easier for both him and the nurse.On 7/31/25 at 9:37 AM, during an interview with the Director of Nursing (DON), she stated there were no residents in the facility who had been assessed or had physician orders to self-administer medications. She acknowledged being aware that Resident #11 administered his own nasal sprays but explained that if a resident could not follow dosage instructions, they would not qualify for self-administration. She confirmed it was her expectation that all nurses ensure a resident has been assessed for self-administration and that medications are administered in accordance with physician orders.A record review of the admission Record revealed the facility admitted Resident #11 on 11/6/24 with diagnoses including Dementia.A record review of the Order Summary Report with active orders as of 7/31/25, revealed Resident #11 had a Physician's Order for Fluticasone Propionate Nasal Suspension, dated 3/14/25 for 1 (one) spray in both nostrils two (2) times a day for Rhinitis, and there were no orders noted for self-administration.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/30/25 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated he was cognitively intact.A review of the electronic health record (EHR) and paper chart revealed there was no Self-Administration Assessment Form completed for Resident #11.

Based on observation, interview, and the facility's ServSafe (a food safety training and certification program) documentation review, the facility failed to ensure that food was stored in a safe and sanitary manner to prevent contamination and deterioration for one (1) of two (2) kitchen observations.Findings include:A review of the facility's ServSafe document The Flow of Food: Purchasing, Receiving and Storing, dated 2020, revealed, . Receiving and Inspecting.make sure enough trained staff are available to receive and inspect food items promptly . Food Quality.Appearance Reject food that is moldy or has an abnormal color . Do not overload coolers or freezer to prevent good air flow, use open shelving .On 7/28/25 at 10:15 AM, during an observation of the kitchen and an interview with the Dietary Manager (DM), seven (7) pints of strawberries with visible mold were observed on a cardboard flat between two (2) flats of grapes in the walk-in cooler. Additionally, eight (8) oranges with a dried appearance, mold, and soft texture, and two (2) lemons with green and black mold were observed. The DM confirmed the fruit was stored for resident consumption and explained that the fruit was typically inspected at the time of use. He acknowledged that the oranges were from that morning's snack cart. In the dry storage room, a drinking cup was observed stored inside the flour bin and a measuring cup was observed stored inside the sugar bin. Both cups were in direct contact with the food product and were being used as scoops. The DM immediately removed the cups and confirmed they had been in use.On 7/28/25 at 11:40 AM, during an interview with the Registered Dietitian (RD), she stated that she had been informed of the kitchen findings by the DM. She explained that the molded fruit was discarded immediately and confirmed that the cups were removed from the flour and sugar bins.On 7/31/25 at 10:31 AM, during an interview with the Administrator, she stated that the fruit found in the cooler had not been served to residents. After being informed that the oranges were found on the morning snack cart and that fruit is routinely served with meals, the Administrator acknowledged that kitchen staff had daily opportunities to identify and remove unfit fruit. She also confirmed she had been made aware of the findings of cups being used as scoops and being stored in the flour and sugar bins.

Based on observation, interview, and record review, the facility failed to ensure that all clinical records, including nurse practitioner (NP) visit notes, were readily accessible to licensed nursing staff responsible for resident care for one (1) of 15 sampled residents, Resident #5, with the potential to affect fifty-seven (57) residents who reside in the facility. Findings include:On 7/28/25 at 1:54 PM, during an observation and interview, Resident #5 was observed wearing a right wrist splint. The resident explained she fell at home and broke her femur and wrist. She stated she continued to have some pain but received pain medications as ordered and that the nurse practitioner recently changed how often she could receive them.On 7/29/25 at 1:10 PM, during an interview with Licensed Practical Nurse (LPN) #1 she stated Resident #5's pain medication frequency was recently changed from every four (4) hours to every six (6) hours. She explained she typically reviewed progress notes in the EHR for any changes related to residents and confirmed there were no progress notes from the NP in the EHR for Resident #5.On 7/29/25 at 1:15 PM, during an interview with the Director of Nursing (DON), she reviewed EHRs on her computer and explained the NP visited Resident #5 on 7/11/25 because the resident was discharged from the hospital with a ten (10)-day supply of Norco. She stated the NP notes were entered into a separate system that was only accessible to facility management. She confirmed the notes were not accessible to floor nurses and stated that if a nurse needed information regarding what occurred during a NP visit, they would need to call the NP directly or contact the on-call nurse. She acknowledged this process was unconventional but was a method that could be used for clarification if a nurse had a question about what occurred during a NP visit. The DON confirmed the NP sees all residents in the facility upon admission, annually, and as needed.On 7/30/25 at 8:30 AM, during an interview with the Administrator, she stated the facility communicated changes in resident care, including new physician orders, during morning meetings and through messaging within the EHR system. The Administrator explained the facility transitioned to an EHR system that was not compatible with the NP's software and therefore could not be viewed by the floor staff. The provider's progress notes not being readily accessible in resident charts were something that had fallen through the cracks during the software transition. A record review of the admission Record revealed the facility admitted Resident #5 on 6/25/25 with current diagnoses including Aftercare Following Joint Replacement Surgery.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/25 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact.

Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk and had moderate cognitive impairment, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 Resident #1 was observed by a therapy staff member to be in the lobby of the facility at approximately 12:00 PM on 4/6/24. The therapy staff member left the facility to pick up lunch and as she returned to the facility, she observed Resident #1 near the side of the main road, approximately 100 feet from the facility grounds at approximately 12:08 PM. The facility staff were unaware that Resident #1 had exited the facility. The facility's failure to provide supervision resulted in Resident #1's elopement and has the likelihood to result in serious harm, serious injury, serious impairment, or death for Resident #1 and all other cognitively impaired residents who leave the facility unsupervised. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 4/6/24. The SA notified the Administrator of the IJ on 4/11/24 at 4:35 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 4/6/24, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 4/7/24, prior to the SA's entrance on 4/11/24. Findings include: A review of the facility's, Missing Resident Policy, dated 5/2018, revealed the facility had a process in place regarding missing residents. A record review of the Admission Record revealed the facility admitted Resident #1 on 3/24/23 with current diagnoses including Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date of 3/13/24 revealed Resident #1 required a staff interview to asses her cognition and her cognitive skills for daily decision making was moderately impaired. Record review of the facility's Investigative Report, dated 4/8/24, revealed on 4/6/24 at 12:00 PM, Resident #1 left the facility unwitnessed with a wander guard (device worn by a resident to trigger an alarm near exit doors) on and was found approximately 100 feet off campus by Certified Occupational Therapist Assistant (COTA) and Certified Nurse Assistant (CNA) #1. The resident had been having exiting behavior earlier that day and was redirected. Upon leaving the facility, the COTA noticed the resident was engaging in conversation in the front room of the facility. She drove to a local restaurant to pick up her lunch and upon her return CNA #1 was looking for Resident #1 in the front room. The COTA asked CNA #1 if Resident #1 was their resident and pointed in the direction of the resident. CNA #1 retrieved Resident #1 and brought her back to the facility. The resident was dressed in pants, a top, an overcoat, a hat, and slip-on shoes, and the weather was 71 degrees and sunny. Record review of the local weather history revealed on 4/6/24 at 11:53 AM, the temperature was 71 degrees Fahrenheit and the weather conditions were fair. During an interview on 4/11/24 at 12:33 PM, CNA #1 confirmed Resident #1 was approximately 100 feet from the facility grounds, sitting on the lawn next to the street. CNA #1 stated on 4/6/24, she last observed Resident #1 at approximately 11:45 AM while she was passing out lunch trays to the residents. CNA #1 reported that at approximately 12:08 PM she went to look for Resident #1 when the COTA entered the facility and asked if the lady wearing the white hat was the facility's resident. CNA #1 immediately ran towards the resident to bring her back to the facility and reported the incident to the Director of Nurses (DON). On 4/11/24 at 12:50 PM, during an interview with CNA #1 and observation of the route from the front door of the facility to the location where Resident #1 was located, there was an incline from the front door down to the parking lot. The parking lot was paved to the roadway, but there were no sidewalks beside the roadway. The grass was short, and the ground was even. CNA #1 pointed out the cement slab where Resident #1 was sitting. The cement slab was slightly raised from the ground, approximately six (6) inches high and was within five (5) feet of the main roadway, across from a residential driveway. In the area behind the cement slab where she was sitting, there was a steep embankment. The traffic was light with one (1) car observed passing by on the roadway at the time of the observation. The resident was located approximately 220 yards from the front door and approximately 50 yards down the road from the facility grounds. On 4/11/24 at 1:15 PM, during an interview with the Director of Nurses (DON), she confirmed on 4/6/24 after lunch, CNA #1 informed her of finding Resident #1 outside the facility. The DON was at the facility and immediately assessed the resident and notified the Administrator. The DON stated she found no physical injuries and no psychosocial harm when she assessed Resident #1. The facility began their investigation and reported the event to the required agencies. On 4/11/24 at 2:22 PM, during an interview with the Maintenance Director, she stated she had been informed Resident #1 had exited the building on 4/6/24 while she was wearing a wander guard device. She came to the facility on [DATE] to check the door alarms and wander guard devices and did not find an issue. The Maintenance Director stated she routinely checked both exit doors two times daily, and checked the wander guards to ensure the alarms were functioning properly. She explained the housekeeping staff were responsible for checking the doors on weekends. The door alarm vendor came to the facility on [DATE] and determined there was radio static interference (service interruptions caused by external radio waves or electrical activity). Prior to the elopement, the doors at the front entrance were not locked, but now the doors are locked, and a code must be entered in the keypad to open the doors. On 4/11/24 at 3:00 PM, during an observation and interview, Resident #1 was ambulating in the hallway with a fast-paced and steady gait. She was unable to recall anything that occurred on 4/6/24 when she left the facility, and she was unable to recall how or why she exited the facility. During a phone interview on 4/11/24 at 4:00 PM, with the COTA, she confirmed on 4/6/24 she was at work at the facility. She explained that she worked part-time and did not know all the residents at the facility. On 4/6/24 at 12:00 PM, she noticed a person in the front lobby wearing a white hat. The COTA left the facility and went through a drive through at a local sandwich shop to pick up her order. On the way back to the facility, at approximately 12:08 PM, she noticed the same woman, wearing a white hat, sitting on the ground on a sidewalk on the side of the road. The COTA walked into the facility and asked CNA #1 if the person sitting on the side of the road was a resident and informed her where she was sitting. CNA #1 immediately ran to Resident #1 and brought her back to the facility. On 4/11/24 at 4:15 PM, during an interview with the Administrator, she confirmed on 4/6/24 at approximately 12:00 PM, the COTA, who worked part-time at the facility was not knowledgeable of all the residents. The COTA happened to notice Resident #1 because of her white hat in the front room before going to a local restaurant to get lunch. Upon her return, she observed Resident #1 sitting on a sidewalk about 100 feet from the facility grounds, but since she was not aware she was a resident, she did not stop. She informed CNA #1 and questioned if Resident #1 was the facility's resident, and pointed to the direction of where she was sitting. CNA #1 immediately ran to her and brought her back to the facility. The DON was present in the facility at that time and immediately assessed the resident for injuries, of which she had none. The Administrator confirmed Resident #1 was a wandering risk and was wearing a wander guard device. The Administrator was notified of the incident, came to the facility, and reported to the required agencies within two (2) hours of the incident. The facility began the investigation, which they felt was a faulty wire of the wander guard system since the system worked when tested . The facility submitted a corrective action plan as follows: 1. On April 11, 2024, the Administrator (ADM) and Director of Nurses (DON) were notified of an immediate jeopardy for F689 for failure to provide supervision to prevent an elopement for Resident #1 who was identified as an elopement and wandering risk. 2. On April 6, 2024, when Resident #1 was retrieved and re-entered the building at approximately 12:08pm, she was immediately assessed by the DON. A body audit was completed with no injury noted. Resident was interviewed by the DON. The DON verified that her wander guard was properly placed and functioning. 3. Resident #1 was immediately placed on alert charting by the DON on 4/6/2024 to identify location every hour. 4. The DON immediately notified the ADM of the elopement on 4/6/2024 by 12:20pm. The DON then notified the responsible party of the resident and the Medical Director by 12:30pm. The ADM notified the Maintenance Director 1:00pm. 5. The ADM notified the State Agency on 4/6/2024 by 2:00pm 6. The ADM notified the Attorney General on 4/6/2024 4:00pm. 7. On 4/6/2024, all residents were checked and accounted for in the building by the Certified Nursing Assistants (CNAs) and reported to the ADM. Staff was interviewed by the DON and the ADM to determine if any resident was exit seeking that had not already been identified. None were identified. 8. The DON and ADM began investigation and collection of statements from all staff present on 4/6/2024. 9. All residents with wander guards were checked for proper placement and function by the Licensed Practical Nurse (LPN) Supervisor on 4/6/2024. All were found to be properly placed and functioning. 10. All exit doors and alarms were checked for proper functioning by the Maintenance Technician on 4/6/2024 by 1:15pm. 11. Vendor #1, the door alarm provider, was called by the Maintenance Director on 4/6/2024 to schedule an onsite visit. 12. The ADM began a 24-hour door monitoring schedule on 4/6/2024 until Vendor #1 could conduct an on-site visit. 13. The notice to visitors on the door was revised by the ADM to be bigger and brighter instructing to not let any resident out of the door without notifying staff on 4/6/2024. 14. ADM began inservicing all staff on the Missing Resident policy and the Safe Guarding the Wandering Resident policy on 4/6/2024. Staff to be inserviced before returning to work. 15. The plan of care of Resident #1 was updated to reflect the elopement by the Registered Nurse on 4/6/2024. 16. All tasks in the electronic healthcare record of residents with wanderguards were updated by the LPN Supervisor on 4/6/2024 to include the task of the Certified Nursing Assistant to check the proper placement of the wanderguard every shift. On 4/6/2024 the CNAs began to be inserviced on this by the LPN Supervisor. Staff to be inserviced before returning to work. 17. The Elopement Risk Evaluation began being updated on all residents on 4/6/2024 by the nurse supervisors. No new residents with risk of elopement were identified. 18. The Elopement Risk Binder was created for all residents with wanderguards to include their picture, name, date of birth and medical record number by the LPN Supervisor on 4/6/2024. The staff was inserviced on these binders and their location at each nurse desk beginning 4/6/2024. Staff to be inserviced before returning to work. 19. All nurses were inserviced and completed a competency check-off on how to test a transmitter (wanderguard) every shift as indicated on the Medication Administration Record (MAR) beginning 4/6/2024 by the LPN Supervisor. Staff to be inserviced before returning to work. 20. Daily Stand Up Agenda in which all staff attends on two shifts was updated by the ADM on 4/6/2024 to include identifying what residents have wanderguards. Note that the agenda previously included to identify any doors/alarms not working properly and any elder who is at risk for elopement. 21. On 4/7/2024, Vendor #1 serviced the door and installed keypads in which the door remains locked. A code is required in order to enter and exit the door. 22. Quality Assurance and Performance Improvement (QAPI) committee met on 4/6/2024 that included the Administrator, Director of Nurses, Medical Director, RN Consultants, Infection Preventionist, LPN Supervisor, Maintenance Director, President/Co-Owner, and Chief Operating Officer to discuss the elopement of Resident #1 and updating the plan of care. Reviewed the Missing Resident policy. No recommendations for changes were made. 23. QAPI committee met again on 4/10/2024 to include Administrator, Director of Nurses, RN Consultant, Nurse Practitioner, Social Service Director, LPN Supervisor, Maintenance Director, Activities Director, Admissions Coordinator, Administrative Assistant, and Infection Preventionist as a follow up to ensure all interventions that were put in place were effective. No concerns were noted. All findings will be discussed at the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months or until the compliance is maintained. 24. The Elopement Risk Evaluation is to be completed by the Registered Nurse (RN) Supervisor on all new residents upon admission and quarterly thereafter beginning 4/6/2024. 25. Beginning 4/6/24, visual checks to be initiated for all residents by the medication cart nurse for the first 72 hours upon admission and a wanderguard to be placed if deemed necessary. 26. Missing Resident and Safeguarding the Wandering Resident policies continue to be inserviced upon hire and quarterly thereafter. Monitoring to be completed as follows: Elopement Drill to continue to be completed quarterly. The wanderguard audit will continue to be completed monthly by LPN supervisor. Maintenance Director/Housekeeping to continue with daily door checks 2x/day. Wanderguard proper placement and functioning to be checked every shift on the MAR. The Village alleges that all corrective actions were completed by April 6, 2024, and the Immediate Jeopardy is removed as of 4/7/2024. The SA validated the corrective action plan: On 4/12/24, the SA validated through interview and record review, on April 11, 2024, the Administrator (ADM) and Director of Nurses (DON) were notified of an immediate jeopardy for F689 for failure to provide supervision to prevent an elopement for Resident #1 who was identified as an elopement and wandering risk. On 4/12/24, SA validated through interview and record review, on April 6, 2024, when Resident #1 was retrieved and re-entered the building at approximately 12:08pm, she was immediately assessed by the DON. A body audit was completed with no injuries noted. Resident was interviewed by the DON. The DON verified that her wander guard was properly placed and functioning. On 4/12/24, the SA validated through interview and record review Resident #1 was immediately placed on alert charting by the DON on 4/6/2024 to identify location every hour. On 4/12/24, the SA validated through interview and record review the DON immediately notified the ADM of the elopement on 4/6/2024 by 12:20pm. The DON then notified the responsible party of the resident and the Medical Director by 12:30pm. The ADM notified the Maintenance Director at 1:00pm. On 4/12/24, the SA validated through interview and record review the ADM notified the State Agency on 4/6/2024 by 2:00pm. On 4/12/24, the SA validated through interview and record review the ADM notified the Attorney General on 4/6/2024 4:00pm. On 4/12/24, the SA validated through interview and record review on 4/6/2024, all residents were checked and accounted for in the building by the Certified Nursing Assistants (CNAs) and reported to the ADM. Staff was interviewed by the DON and the ADM to determine if any resident was exit seeking that had not already been identified. None were identified. On 4/12/24, the SA validated through interview and record review the DON and ADM began investigation and collection of statements from all staff present on 4/6/2024. On 4/12/24, the SA validated through interview and record review all residents with wander guards were checked for proper placement and function by the Licensed Practical Nurse (LPN) Supervisor on 4/6/2024. All were found to be properly placed and functioning. On 4/12/24, the SA validated through interview and record review all exit doors and alarms were checked for proper functioning by the Maintenance Technician on 4/6/2024 by 1:15pm. On 4/12/24, the SA validated through interview and record review that Vendor #1, the door alarm provider, was called by the Maintenance Director on 4/6/2024 to schedule an onsite visit. On 4/12/24, SA validated through interview and record review the ADM began a 24-hour door monitoring schedule on 4/6/2024 until Vendor #1 could conduct an on-site visit. On 4/12/24, SA validated through interview and record review The notice to visitors on the door was revised by the ADM to be bigger and brighter instructing to not let any resident out of the door without notifying staff on 4/6/2024. On 4/12/24, SA validated through interview and record review ADM began inservicing all staff on the Missing Resident policy and the Safe Guarding the Wandering Resident policy on 4/6/2024. Staff to be inserviced before returning to work. On 4/12/24, the SA validated through interview and record review the plan of care of Resident #1 was updated to reflect the elopement by the Registered Nurse on 4/6/2024. On 4/12/24, the SA validated through interview and record review all tasks in the electronic healthcare record of residents with wander guards were updated by the LPN Supervisor on 4/6/2024 to include the task of the Certified Nursing Assistant to check the proper placement of the wander guard every shift. On 4/6/2024 the CNAs began to be in-serviced on this by the LPN Supervisor. Staff to be in-serviced before returning to work. On 4/12/24, the SA validated through interview and record review the Elopement Risk Evaluation began being updated on all residents on 4/6/2024 by the nurse supervisors. No new residents with risk of elopement were identified. On 4/12/24, the SA validated through interview and record review the Elopement Risk Binder was created for all residents with wander guards to include their picture, name, date of birth and medical record number by the LPN Supervisor on 4/6/2024. The staff was in-serviced on these binders and their location at each nurse desk beginning 4/6/2024. Staff to be in-serviced before returning to work. On 4/12/24, the SA validated through interview and record review all nurses were in-serviced and completed a competency check-off on how to test a transmitter (wander guard) every shift as indicated on the Medication Administration Record (MAR) beginning 4/6/2024 by the LPN Supervisor. Staff to be in-serviced before returning to work. On 4/12/24, the SA validated through interview and record review Daily Stand-Up Agenda in which all staff attends on two shifts was updated by the ADM on 4/6/2024 to include identifying what residents have wander guards. Note that the agenda previously included to identify any doors/alarms not working properly and any Elder who is at risk for elopement. On 4/12/24, the SA validated through interview and record review on 4/7/2024, Vendor #1 serviced the door and installed keypads in which the door remains locked. A code is required to enter and exit the door. On 4/12/24, the SA validated through interview and record review Quality Assurance and Performance Improvement (QAPI) committee met on 4/6/2024 that included the Administrator, Director of Nurses, Medical Director, RN Consultants, Infection Preventionist, LPN Supervisor, Maintenance Director, President/Co-Owner, and Chief Operating Officer to discuss the elopement of Resident #1 and updating the plan of care. Reviewed the Missing Resident policy. No recommendations for changes were made. On 4/12/24, the SA validated through interview and record review QAPI committee met again on 4/10/2024 to include Administrator, Director of Nurses, RN Consultant, Nurse Practitioner, Social Service Director, LPN Supervisor, Maintenance Director, Activities Director, Admissions Coordinator, Administrative Assistant, and Infection Preventionist as a follow up to ensure all interventions that were put in place were effective. No concerns were noted. All findings will be discussed at the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months or until compliance is maintained. On 4/12/24, the SA validated through interview and record review the Elopement Risk Evaluation is to be completed by the Registered Nurse (RN) Supervisor on all new residents upon admission and quarterly thereafter beginning 4/6/2024. Beginning 4/6/24, visual checks to be initiated for all residents by the medication cart nurse for the first 72 hours upon admission and a wander guard to be placed if deemed necessary. On 4/12/24, the SA validated through interview and record review Missing Resident and Safeguarding the Wandering Resident policies continue to be in-serviced upon hire and quarterly thereafter. On 4/12/24, the SA validated through interview and record review Monitoring to be completed as follows: Elopement Drill to continue to be completed quarterly. The wander guard audit will continue to be completed monthly by LPN supervisor. Maintenance Director/Housekeeping to continue with daily door checks 2x/day. Wander guard proper placement and functioning to be checked every shift on the MAR. All corrective actions were completed by 4/6/24, and the Immediate Jeopardy was removed as of 4/7/2024.

Based on observation, interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions related to a resident with full length bed rails (Resident #1) and a resident with an indwelling catheter (Resident #52) for two (2) of 17 sampled residents. Findings include: Review of the facility's policy, Comprehensive Care Plans, revised 7/29/2019, revealed, Policy Statement: An individual comprehensive care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident . Resident #1 During an observation on 01/17/24 at 12:08 PM, Resident #1 had full length bed rails on both sides of the bed. The resident explained she does not remember how long she had the bed rails. She stated she was not able to lower the rails on her own and asked staff to lower them for her at times, but there were times that she wanted to have the bed rails raised as well. She said she was unable to get up without assistance and she was unable to walk. A review of the medical record revealed there was no care plan for Resident #1 regarding the use of full-length bed rails. A record review of the Admission Record revealed the facility admitted Resident #1 on 11/29/2018 with diagnoses that included Spastic Diplegic Cerebral Palsy. A record review of the Quarterly Minimum Date Set (MDS,) with an Assessment Reference Date (ARD) of 11/09/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. On 01/19/24 at 01:15 PM, an interview with Licensed Practical Nurse (LPN) #2 (Minimum Data Set/Care Plan Nurse) revealed Resident #1 did not have a care plan addressing the full-length bed rails. LPN #2 explained the resident uses her own bed and she was unaware that the resident's bed had full length bed rails. On 01/19/24 at 03:00 PM, an interview with the Director of Nursing (DON) and the Administrator revealed they both expected the Care Plan nurse to develop a care plan to include all the resident's concerns and needs. Resident #52 During an observation on 1/17/24 at 12:38 PM, revealed Resident #52 had an indwelling catheter, and the catheter tubing was not anchored to the resident's leg to stabilize the catheter and prevent possible trauma. On 1/18/24 at 10:35 AM, during an observation and interview with the DON and Resident #52, Resident #52 stated she did not have a catheter anchor strap attached to her leg and no one at the facility had provided her with one. The resident revealed she had been using the leg straps from the leg drainage bag to try to hold the tubing in place. The DON provided the resident with a leg anchor to hold the tubing in place and the resident stated, This feels good. A record review of the medical record revealed there was no Care Plan intervention for staff to apply a leg strap to secure the indwelling catheter tubing to prevent possible trauma. Record review of the Admission Record revealed the facility admitted Resident #52 on 10/5/2023 with diagnoses that included Chronic Kidney Disease and Obstructive Reflux Uropathy. Record review of the Admission MDS with an ARD of 10/16/23 revealed Resident #52 had a BIMS score of 14 which indicated she was cognitively intact. On 1/19/24 at 1:06 PM, an interview with LPN #2 confirmed she was responsible for developing and updating the comprehensive care plans and the updates. She stated that an indwelling catheter leg strap or anchor was not addressed on Resident #52's care plan and it should have been addressed. LPN #2 stated care plans were developed and were individualized for residents to ensure consistency of care, which helped improve services for the residents. 43283

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure an indwelling catheter tubing was stabilized to prevent trauma and failed to provide incontinence care in a manner to prevent complications for two (2) of three (3) residents observed for incontinence and catheter care. Resident #29 and #52. Findings Include: A review of the facility's policy Perineal Care, dated 10/2023, revealed . Peri (Perineal) care helps prevent skin breakdown of perineal area, itching, burning, odor, and infections. Perineal care is very important in maintaining the resident's comfort . Policy . 8. Gently clean the skin of the perineal area moving from front to back. Do not move from back to front due to the risk of introducing germs . Males: Retract foreskin in uncircumcised male. Grasp penis, clean tip of penis using a circular motion, wash down shaft of the penis and wash testicles. Replace foreskin of uncircumcised male . A review of the facility's policy Indwelling Catheter Use and Removal, undated, revealed, Policy: It is the policy of this village to ensure that indwelling urinary catheters that are inserted or remain in place are justified according to regulations and current standards of practice .Compliance guidelines .7. Additional care practices include .d. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter . Resident #29 On 01/19/24 at 09:25 AM, during an observation and interview with Certified Nurse Aide (CNA) #4, she reported Resident #29 was usually incontinent in the mornings and used a urinal during the daytime while he was awake. There was a strong urine odor in the resident's room and the resident's brief was saturated with urine. CNA #4 assisted Resident #29 to the toilet, removed the saturated brief, and performed incontinence care as he stood up in the bathroom. CNA #4 used an incontinence disposable wipe and cleaned the genital area, including the left and right groin area, and the scrotum and did not use a new wipe or change the position of the wipe with each stroke. CNA #4 did not clean the penis. After CNA #4 completed the incontinence care, she confirmed that she did not discard the disposable incontinence wipe or change the position of the wipe to ensure a clean area of the wipe was used with each stroke. CNA #4 also confirmed she did not clean the penis. On 01/19/24 at 10:10 AM, during an interview with Lead CNA #1, she explained CNA #4 should have used a new wipe with each stroke and should have cleaned the penis as part of incontinence care. She explained CNA#4 received training and a competency check-off when hired. On 01/19/24 at 03:00 PM, during an interview with the Director of Nursing (DON), she explained she expected the CNAs to follow the proper procedures with incontinence care. A record review of the Admission Record revealed the facility Resident #29 on 05/19/21 with diagnoses that included Benign Prostatic Hyperplasia (BPH) without Lower Urinary Tract Symptoms. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/23 revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated his cognition was moderately impaired. A record review of the Perineal Care Competency Audit, dated 10/19/23, revealed CNA #4 completed training with Lead CNA #1 regarding perineal care. Resident #52 On 1/17/24 at 12:38 PM, during an observation, Resident #52 had an indwelling catheter, and the catheter tubing was not anchored to the resident's leg to stabilize the catheter and prevent possible trauma. During an observation and interview with the DON and Resident #52, on 1/18/24 at 10:35 AM, Resident #52 stated she did not have a catheter anchor strap attached to her leg and no one at the facility had provided her with one. The resident revealed she had been using the leg straps from the leg drainage bag to try to hold the tubing in place. The DON provided the resident with a leg anchor to hold the tubing in place and the resident stated, This feels good. On 1/18/24 at 10:53 AM, an interview with the DON confirmed that Resident #52 did not have a leg strap to anchor and stabilize the catheter tubing and the resident confirmed that she liked the support of the leg strap when the DON placed it on the resident. The DON stated the indwelling catheter anchors were to be placed on residents' legs so that the catheter is anchored to prevent tension on the catheter and bladder. Record review of the Admission Record revealed the facility admitted Resident #52 on 10/5/2023 with diagnoses that included Chronic Kidney Disease and Obstructive Reflux Uropathy. Record review of the Admission MDS with an ARD of 10/16/23 revealed Resident #52 had a BIMS score of 14 which indicated she was cognitively intact. 43283

Based on observation, interviews, record review, and facility policy review, the facility failed to date and label a tube feeding bag for one (1) of (1) residents reviewed for tube feeding management. (Resident #4) Findings include: A review of the facility's policy Care and Treatment of Feeding Tubes, undated, revealed, Policy: It is a policy of this village to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . On 01/17/24 at 12:36 PM, during an observation, Resident #4 was lying in bed with the head of the bed elevated. There was a tube feeding running at 70 cc (cubic centimeters)/hour (hr). The tube feeding formula bag did not contain a date, time, or label indicating when the bag of tube feeding was started. The bag had a manufacturer's label indicating the type of feeding as Isosource. There was a bag of water that did not contain a date, time, or label indicating when the water flush was started. On 01/17/24 at 4:16 PM, during an observation and interview with Licensed Practical Nurse (LPN) #6, she confirmed that the feeding and water did not contain a date, time, or label indicating when the bag of tube feeding or water was started. She stated that the bags should include a label with the date and time so staff will know how long the tube feeding has been flowing and to ensure a resident does not receive old formula. LPN #6 said that it was the facility's policy to label the tube feeding daily when a new bag was hung. On 01/19/24 at 04:05 PM, during an interview with the Director of Nursing (DON), she explained she expected staff to follow standard procedures for labeling tube feeding and all nurses had been educated on proper labeling. A record review of Admission Record revealed the facility admitted Resident #4 on 02/07/23 with a diagnoses that included Acute Respiratory Failure with Hypoxia and Gastrostomy Complication. A record review of the Quarterly Minimum Data Set with an Assessment Reference Date of 12/05/23 revealed Resident #4 was coded as having a feeding tube. A record review of the Order Summary Report, with active orders as of 01/18/2024, revealed Resident #4 had a Physician's Order, dated 8/31/23 for Enteral Feed Order .Continuous Feed: Isosource 1.5 to 70 ml (milliliter)/hr.

Based on observation, record review, and interviews the facility failed to inform a resident or the Resident Representative (RR) of the risk and benefits of full length bed rails prior to bed rail installation for one (1) of 17 sampled residents. Resident #1 Findings include: Record review of the facility's statement, dated 1/19/2024, provided by the Administrator revealed, (Proper Name of Facility) does not have a policy on bed rails. On 01/17/24 at 12:08 PM, during an observation, Resident #1 had full length bed rails on both sides of the bed. The resident explained she does not remember how long she had the bed rails. She stated she was not able to lower the rails on her own and asked staff to lower them for her at times, but there were times that she wanted to have the bed rails raised as well. She said she was unable to get up without assistance and she was unable to walk. On 01/18/24 at 03:00 PM, during an observation and interview with Licensed Practical Nurse (LPN) #3, she confirmed Resident #1 had full length bed rails and has had them for as long as she could remember. On 01/19/24 at 11:30 AM, during an interview with the Maintenance Director, she confirmed Resident #1 had her own bed that was donated to her from another resident and the bed had full length bed rails. A review of the medical record revealed there was no informed consent indicating the risk and benefits of full-length bed rails signed by the resident or RR. On 01/19/24 at 03:00 PM, during an interview with the Administrator, she confirmed Resident #1 had full length bed rails and there was no signed informed consent related to the bed rails. She said the facility did not have a policy regarding bed rails and the facility was planning on addressing the problem but had not gotten to it yet. A record review of the Admission Record revealed the facility admitted Resident #1 on 11/29/2018 with a diagnoses that included Spastic Diplegic Cerebral Palsy. A record review of the Quarterly Minimum Date Set (MDS,) with an Assessment Reference Date (ARD) of 11/09/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic medications were discontinued after 14 days or had a documented indication for continued use by the prescriber, with a designated time frame for one (1) of five (5) residents reviewed for unnecessary medications. Resident #44 Findings include: Review of the facility's policy, Use of Psychotropic Medication, undated, revealed, Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . Policy Explanation and Compliance Guidelines: 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e.14 days) a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order . Review of Resident #44's Order Summary Report, with active orders as of 01/01/24, revealed orders for Lorazepam Concentrate 2 mg/ml (milligram/milliliter) give 0.5 ml by mouth every 4 (four) hours as needed for anxiety with an order date of 9/28/23, Lorazepam Injection solution 2 mg/ml inject 2 millimeters intramuscularly every 6 (six) hours as needed for agitation, with an order date of 9/27/23, and Lorazepam oral concentrate 2 mg/ml give 0.5 ml by mouth every 6 (six) hours as needed for agitation and shortness of breath, with an order date of 9/27/23. None of the above psychotropic medications had a stop date. Review of the Admission Record, for Resident #44 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Senile Degeneration of the Brain, not elsewhere classified, Vascular Dementia, Unspecified Psychosis, and Depression. Review of the Comprehensive Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 12/5/23, revealed Resident #44 had been unable to complete the Brief Interview for Mental Status (BIMS) and the staff documented that the resident's cognitive skills for decision making were moderately impaired. On 01/19/24 12:54 PM, in an interview with Assistant Director of Nursing (ADON), she confirmed that Resident #44's orders for Lorazepam should have been discontinued after 14 days, as that is the facility policy. On 01/19/24 at 1:47 PM, in an interview with the Nurse Practitioner (NP), she stated she was aware that psychotropic medications needed to have a stop state date of 14-days, but for some reason, the Lorazepam had been missed on Resident #44.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain the kitchen in a manner to prevent cross contamination and food borne illnesses as evidenced by: Two (2) unclean hand towels placed on the tray line during the tray line temperature checks, Dietary Staff failed to clean the thermometer with an alcohol pad after each food temperature item was checked on the tray line, failed to wash hands upon entrance to the kitchen and contact with kitchen items, and failed to wear a hair net and/or failed to wear a hair net that covered/secured all of the staff's hair. These concerns were identified for two (2) of five (5) kitchen observations. Findings include: A review of the facility's policy, dated 1/13, and titled, Food Service Operational Standards for Purchasing, Cooking, and Storage, revealed the facility stores, prepares, distributes, and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. The policy stated under 6. Cooking. d. Wash hands before handling food, and after handling raw food, and after any interruption that may contaminate hands. Review of the policy revealed there were no procedures for wearing hair nets or cleaning the thermometer between food item temperature checks on the tray line. On 7/23/19 at 11:49 AM, an observation revealed Dietary Staff #2 checked the tray-line temperatures. Dietary Staff #2 checked the mashed potatoes, and then wiped the thermometer with an unclean, dingy white hand towel she had placed on the tray line before she began checking the tray line temperatures. Dietary Staff #2 checked the green bean temperature and continued to check the following food temperatures: [NAME]atoes mixed with zucchini, white rice, gumbo, and chopped meat. There were no concerns identified with the food temperatures. After Dietary Staff #2 checked the chopped meat, she wiped the thermometer with the unclean, dingy white hand towel she had placed on the tray line earlier, and then checked the gravy temperature. It was observed Dietary Staff #2 had placed two unclean, dingy, white hand towels on the tray line during the tray line service. On 7/24/19 at 11:00 AM, an observation revealed Dietary Staff #2 checked the tray-line temperatures for the ham and beans, rice, and gravy. Dietary Staff #2 used the same alcohol prep to wipe the thermometer before she checked the temperatures of the mashed potatoes, Brussel sprouts, cup of fruit, chicken pot pie, and okra and tomatoes. There were no concerns identified with the food temperatures. During the follow up visit, on 7/24/19 at 11:34 AM, an observation revealed as Dietary Staff #4 was checking the food temperatures, he dropped an alcohol prep into the brown gravy. Dietary Staff #1 removed the brown gravy from the tray line and placed it on a table near where the dishes are washed. She then went into the dry storage room area, retrieved a packet of brown gravy, returned to a preparation table, opened the packet of dry gravy, poured the dry brown gravy into a pitcher, ran some cold water into the dry gravy from the sink and stirred it together. Dietary Staff #1 then applied clean gloves, however she did not wash her hands. She poured the brown gravy mixture into some boiling hot water that was on the stove and discarded the gravy that the alcohol prep had dropped into. On 7/24/19 at 2:17 PM, an observation revealed Certified Nursing Assistant (CNA) #1 walked into the kitchen without wearing a hair net and did not wash her hands upon entering the kitchen. She then turned around shortly after that and left the kitchen. On 7/24/19 at 2:19 PM, an observation revealed CNA #1 walked into the kitchen again, wearing a hair net, walked over to the ice chest, opened it up and looked inside of it. CNA #1 did not wash her hands after entering the kitchen or before opening the ice chest. On 7/24/19 at 2:39 PM, an observation revealed Dietary Staff #5 was wearing a hair net that left the braids at the back of her hair uncovered, and Dietary Staff #6 was observed to have a bandana on with part of the hair around the outer parts of her head uncovered, she did not have a hair net on. On 7/24/19 at 2:42 PM, an interview with Dietary Staff #1, revealed Dietary Staff #2 should not have wiped the thermometer with a towel because lint could get in the food and because of cross contamination. She stated she (referring to herself/Dietary Staff #1) just did not wash her hands in between removing the contaminated gravy and making the new gravy. Dietary Staff #1 stated CNA #1 should have washed her hands between putting the ice in the cooler and when she entered the kitchen. Dietary Staff #1 stated, both Dietary Staff #5 and Dietary Staff #6 should have had a hair net on, and all of their hair should have been underneath the hair net. On 7/24/19 at 5:35 PM, an interview with the Dietary Manager, revealed Dietary Staff #5 should have worn a hair net large enough to restrict all of her hair, and Dietary Staff #6 should have had a hair net on with all of her hair restricted as well. The Dietary Manager stated CNA #1 should have had a hair net on when she entered the kitchen the first time and washed her hands and should have washed her hands after entering the kitchen the second time. The Dietary Manager stated Dietary Staff #2 said she had gotten nervous, and that is cross contamination for Dietary Staff #2 to have hand towels on the tray-line.

Based on staff interviews, record review, and facility policy review, the facility failed to complete Resident #45's comprehensive Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment within 14 days of determining the resident's status change was significant, for one (1) of 19 residents reviewed. Findings include: A review of the facility's policy titled, Completion of MDS Assessments, undated, revealed it was the policy to complete the MDS assessments for all elders within the village by use of the Resident Assessment Instrument (RAI) Manual 2.0 to accurately reflect the elder's status and to complete within the mandated timeframe per Centers for Medicare and Medicaid Services (CMS) regulations. A review of the most recent comprehensive Significant Change (SC) MDS assessment, with an Assessment Reference Date (ARD) of 6/21/19, revealed the MDS was coded to include hospice services. A review of the (MONTH) 2019 physician's orders [REDACTED]. A review of the Comprehensive Care Plan revealed the Problem/Need for the [DIAGNOSES REDACTED]. Interventions included hospice care will be provided as ordered by the physician. A review of the medical record revealed the facility did not complete the comprehensive SC MDS assessment within 14 days of determining the status change was significant. Review of Resident #45's SC MDS, with an ARD of 6/21/19, revealed the completion date was 7/5/19 as evidenced by the staff signature dates for the Registered Nurse (RN) Assessment Coordinator for completion of the assessment, the RN Coordinator for the CAA (Care Assessment Areas) Process, and the Signature of the Person Completing the Care Plan was all dated 7/5/19. The resident was admitted to hospice services on 6/8/19, and the comprehensive SC MDS had an ARD of 6/21/19. On 7/25/19 at 12:13 PM, an interview with the Director of Nurses (DON) revealed the resident was transferred to the hospital in (MONTH) and (MONTH) of 2019 [MEDICAL CONDITION]. She stated the resident was placed on hospice services after the last hospital stay. Review of the Transfer and Discharge sheet dated, 3/25/19, and an Effective Date of 3/23/19, revealed Resident #45 was transferred to the hospital for higher level of care. Review of the hospital Discharge Summary revealed Resident #45 was admitted to the hospital, on 3/23/19, due to a decrease in her abilities and mental status over the past two days. The principal problem was [MEDICAL CONDITION], Alzheimer's Dementia without behavioral disturbance and Weakness. Resident #45 was discharged back to the nursing home on 3/26/19, in fair condition, and continuation of antibiotics by mouth. Review of the Transfer and Discharge sheet dated 5/20/19, and an Effective Date of 5/17/19, revealed Resident #45 was transferred to the hospital for a higher level of care. Review of the hospital Discharge Summary revealed Resident #45 was admitted to the hospital, on 5/17/19, due to altered mental status. The principal problem [MEDICAL CONDITION], Acute [MEDICATION NAME] without hematuria, and [DIAGNOSES REDACTED]. Resident #45 was discharged back to the nursing home on 5/22/19 in good condition, and to continue antibiotics by mouth. On 7/25/19 at 2:15 PM, an interview with Registered Nurse (RN) #1/MDS Coordinator, revealed the most recent comprehensive SC MDS assessment with an ARD of 6/21/19, was not completed within 14 days of determining the status change was significant. On 7/25/19 at 2:44 PM, an interview with the DON revealed she would expect the staff to complete the MDS in a timely manner, to include transmission. A review of the facility's Face Sheet revealed the facility admitted Resident #45 on 11/6/15, with a [DIAGNOSES REDACTED].

Based on observation, record review, staff interview, and facility policy review, the facility failed to implement the comprehensive care plan related to catheter care for one (1) of two (2) care plans reviewed for catheters, for Resident #34. Findings include: A review of the facility's policy titled, Care Plan- Comprehensive, undated, revealed it was the policy of this facility an individual Comprehensive Care Plan included measurable objectives and timetables to meet the elder's (resident) medical, nursing, and mental and psychosocial needs, shall be developed for each elder (resident). The facility policy stated that the facility's care planning team, in coordination with the elder (resident), his/her family or representative develops and maintains a Comprehensive Care Plan for each elder (resident). Review of Resident #34's Comprehensive Care Plan revealed a Problem/Need at risk for Urinary Tract Infection [MEDICAL CONDITION] due to Resident #34 having chronic [MEDICAL CONDITION] and a [DIAGNOSES REDACTED]. The Onset Date was 6/2/2016. The Approaches included the Certified Nursing Assistants (CNAs) was to check the catheter and ensure the catheter was secured to the elder's (resident) thigh with a catheter securement device to prevent excessive movement and minimize accidental removal. Review of the facility's document, Giving Indwelling Catheter Care, no date, revealed the seven (7) Equipment List items to be gathered included tape or a leg strap. This document was provided when a facility policy for catheter care was requested. Review of Resident #34's (MONTH) 2019 physician's orders [REDACTED]. The order stated that the catheter was also ordered due to a [DIAGNOSES REDACTED]. Further review of the (MONTH) 2019 physician's orders [REDACTED].#34's thigh with a catheter securement device to prevent excessive movement and minimize accidental removal. An observation, on 7/24/2019 at 2:21 PM, revealed Certified Nursing Assistant (CNA) #2 provided Resident #34's catheter care. It was observed at that time Resident #34 did not have a catheter strap in place before catheter care began. During the catheter care, CNA #2 put Resident #34 at risk for injury or discomfort, by holding the catheter tubing at the Y connection, instead of close to the meatus. CNA #2 was observed to be cleaning the catheter tubing away from the body in the correct direction. CNA #2 did not provide a catheter strap to Resident #34's thigh/leg to secure the catheter tubing, and prevent tugging or pulling on the tubing. An interview, on 7/24/2019 at 2:28 PM, revealed Certified Nursing Assistant (CNA) #2 confirmed Resident #34 did not have a catheter strap in place. CNA #2 stated, I should have held the catheter tubing close to the body when cleaning the tubing, so that that the tubing won't pull and hurt the resident or come out. CNA #2 stated, It must have come off, cause (sic) she usually has one on. During a follow-up observation on 7/24/2019 at 4:29 PM, with Registered Nurse (RN) #2/Assistant Director of Nursing (ADON), it was revealed there was no catheter strap or securing device in place for Resident #34's catheter tubing, who was lying in bed, in her room. An interview at this time with the Assistant Director of Nursing (ADON) confirmed Resident #34 did not have a securing device for the catheter tubing. The ADON stated that a securing device for the catheter tubing helps to prevent tugging and possible pain and injury, if the catheter came out. The ADON stated that the tubing should be held closer to the body to prevent injury or preventing the dislodgement of the catheter, during care. The ADON stated that the catheter care if not done correctly, could be an infection control problem. During an interview, on 7/25/2019 at 8:56 AM, Registered Nurse (RN) #1/Care Plan and Minimum Data Set (MDS) Coordinator revealed it was her intention that the focused problems have approaches that are to be followed by the staff providing care. RN #1 stated that care is to include the use of a catheter strap. RN #1 stated that securing the catheter tubing close to the body when cleaning, is correct. RN #1 stated, If the CNA failed to clean the catheter tubing properly and failed to provide a securing devise for the tubing, the current care plan was not followed. During an interview, on 7/25/2019 at 11:30 AM, the Director of Nursing (DON revealed it is her expectation that the care plan should reflect the resident's current and complete status. The DON stated that the care plan should be followed as indicated by the problems and interventions that have been assessed by the Interdisciplinary (ID) Team. Review of the Face Sheet revealed Resident #34 was admitted by the facility, on 5/20/2016, with [DIAGNOSES REDACTED].

Based on observation, record review, facility policy review, and staff interview, the facility failed to revise the Comprehensive Care Plans to include updated interventions, and reflect the current resident status related to falls for two (2) of 19 care plans reviewed. Resident #33 and Resident #40. Findings Include: Review of the undated facility policy titled, Care Plan- Comprehensive, revealed it is the policy of this facility that an individual Comprehensive Care Plan that includes measurable objectives and timetables to meet the elder's (resident) medical, nursing, and mental and psychosocial needs, shall be developed for each elder (resident). The facility policy stated that the facility's Care Planning Team, in coordination with the elder (resident), his/ her family or representative develops and maintain a Comprehensive Care Plan for each elder (resident). The facility policy stated that the Comprehensive Care Plan is based on a through (sic) assessment that includes, but is not limited to, the Minimum Data Set (MDS). The facility policy also stated that the assessments of the elders (residents) are ongoing and care plans are revised as information about the elder (resident) and the elder's (resident) conditions change. Review of the facility'd policy titled, Dunbar Village Care Plan Review Policy and Procedure, dated 4/2014, revealed that it is the policy of this facility that the care planning process will be initiated after completion of the MDS assessment to ensure inclusion of the most recent assessment data. The facility policy stated that identified discrepancies will generate additional assessments by the MDS team and the care plan will be modified as necessary to reflect the current needs and capacities of the resident in question. The facility's policy procedure stated that the Care Plan Nurse will compare the completed MDS assessment to identify areas that need to be completed on the Care Plan and identify any discrepancies. The facility's policy procedure stated that the Care Plan calendar will offset the MDS calendar to allow completion of the MDS assessment. The facility's policy procedure also stated that identified discrepancies will generate additional assessment by the MDS team and modification of the care plan as necessary to reflect the current needs and capacities of the resident in question. Resident #33 Review of Resident #33's Care Plan, revealed the Problem/ Need, with an onset date of 7/1/14, for at risk for injury/ falls due to impaired cognition, poor safety awareness, and is legally blind, this puts her at risk for injury/falls. The goal stated Resident #33 will have no falls thru 10/12/2019. The Approaches (interventions) included: A Fall mat is to be placed by the side of Resident #33's bed while she is in bed; Resident #33 is to wear non-skid socks; The nursing department is to notify Resident #33's Medical doctor (MD) and Resident #33's family as needed; The nursing department is to provide any needed medical treatment (TX) for lacerations, hematoma, or other injuries; The nursing department is to perform Neuro checks with falls with head injuries; The nursing department is to perform medication review for potential side effects, and is to check on Resident #33 more frequently when episodes of disorganized thinking occur. During the initial tour of the facility, on 7/23/2019 at 11:05 AM, an observation revealed a four (4) inch fall mat was laying on the floor next to Resident #33's bed. Review of Resident #33's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/7/2018, revealed section C1310C documented no disorganized thinking or behavior was present. The MDS also indicated in the J1800 section, that Resident #33 had no falls since the prior assessment. Review of Resident #33's Quarterly MDS, with an ARD of 3/1/2019, revealed section C1310C documented no disorganized thinking or behavior was present. The MDS also indicated in the J1800 section, Resident #33 had no falls since the prior assessment. Review of Resident #33's Quarterly MDS, with an ARD of 5/22/2019, revealed section C1310C documented no disorganized thinking or behavior was present. The MDS also indicated in the J1800 section, Resident #33 had no falls since the prior assessment. During an interview, on 7/25/2019 at 8:36 AM, Licensed Practical Nurse (LPN) #1/ MDS and Care Plan Coordinator, confirmed Resident #33's care plan does not accurately reflect the resident's current status. LPN #1 stated that based on the past three (3) MDS assessments, the current Problem/Need on Resident #33's care plan, for being at risk for falls, was not accurate. LPN #1 stated that although Resident #33 is still at risk for falls, the current interventions are not appropriate and did not reflect the current status of Resident #33. During an interview, on 7/25/2019 at 11:30 AM, the facility's Director of Nursing (DON) stated it is her expectation that the care plan should reflect the resident's current and complete status. The DON stated the care plan should be followed as indicated by the problems and interventions that have been assessed by the Care Planning Team/ Interdisciplinary (ID) team. The DON stated the care plan should be revised as any status regarding the resident's care changes. Review of the Face Sheet revealed Resident #33 was admitted by the facility, on 8/29/2003 and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/2019, revealed Resident #33 had a Brief Interview of Mental Status (BIMS) score of three (3), indicating severely impaired cognition. Resident #40 Review of Resident #40's Comprehensive Care Plan revealed the Problem/Need, with an onset date of 7/5/18, for potential risk for falls/injury related to impaired cognition, legally blind, weakness, dizziness, and Left Lower Extremity Parestharia (feeling of numbness, tingling, itching, or pins and needles), and History of Falls. The Goal stated the resident would remain free from injuries. Approaches included: Remind several times throughout the day to call for assistance. Keep call light within easy reach. Bed in low position, place fall mat near bed, notify family and physician of fall, provide any needed medical treatment for [REDACTED]. Further review of the Care Plan revealed hand written under the Problem/Need column were Actual Fall dates on 6/10/18, 11/28/18 and 7/7/19. A review of the facility's Accident and Incident Reports revealed, Resident #40 had a fall on the following days: 6/10/18, 11/28/18 (x2), 1/27/19, 4/27/19, and 7/7/19. The comprehensive care plan was not updated to include interventions after a fall on 11/28 (x1) and 4/27/19. On 7/23/19 at 10:10 AM an observation revealed, Resident #40 sitting in her chair in her room talking to her daughter. A review of the most recent Annual MDS assessment, with an ARD of 5/24/19, revealed the MDS was coded to indicate Resident #40 required limited assistance x1 person with transfers, walking in room, walking in corridor, extensive assistance x1 person with locomotion on unit and was coded to include falls since prior assessment. This MDS assessment also indicated Resident #40 had a Brief Interview of Mental Status (BIMS) score of 10 (moderate cognitive impairment). There were no behaviors indicated on the MDS assessment. The Discharge MDS assessment, return not anticipated, with an ARD of 6/22/18, was not coded to include falls, but was prior to the last survey. On 7/25/19 at 9:27 AM, an interview with the Director of Nurses (DON), revealed the staff normally try to figure out the situation when a fall occurs and put interventions in place. She stated the staff try interventions such as floor mats, changing their toileting schedule, looking for patterns to see if the facility could change up anything. She also stated most of the time the staff makes sure they (referring to the residents) have a floor mat and if the resident does not, the staff will place one beside the bed. The DON stated the staff will look at other incidences, such as the time of the fall and have other situational meetings with the team like a huddle and will get the Nurse Practitioner's (NP) input. The DON stated a new intervention is put in place within 24 hours of a fall occurring. She stated the Registered Nurses (RNs) are responsible for making sure the interventions are in place. She also stated falls are an actual problem for this resident. The DON stated she would say the resident would probably not remember education given to her from the staff. She stated the care plan was not updated to include both falls that occurred on 11/28/18, or interventions put in place after the fall that occurred on 4/27/19. She also stated the comprehensive care plan has not been updated enough to accurately reflect this resident and to prevent further falls. On 7/25/19 at 9:36 AM, an interview with RN #1, revealed the comprehensive care plan was updated after each fall. She stated falls was an actual problem for this resident and not a potential for a problem. She also stated educating the resident was not an appropriate intervention because the resident has a moderately impaired cognition. She stated the care plan was not updated to include interventions that the resident had fallen twice on 11/28/18. She stated there were no interventions put in place after the fall on 4/27/19. RN #1 stated the comprehensive care plan does not accurately reflect the resident regarding falls. On 07/25/19 at 11:28 AM, an interview with the DON, revealed she would expect the comprehensive care plan to reflect everything that the staff is currently doing for the resident. A review of the facility's Face Sheet revealed the facility admitted Resident #40, on 5/10/18 and she was readmitted on [DATE], with [DIAGNOSES REDACTED].

Based on observation, record review, facility policy review, and staff interview, the facility failed to provide proper catheter care to prevent the possibility of trauma to the bladder for one (1) of two (2) residents observed for catheter care. (Resident #34) Findings include: Review of the facility's document, Giving Indwelling Catheter Care, no date, revealed the seven (7) Equipment List items to be gathered included tape or a leg strap. This document was provided when a facility policy for catheter care was requested. An observation, on 7/24/2019 at 2:21 PM, revealed Certified Nursing Assistant (CNA) #2 provided Resident #34's catheter care. It was observed at that time Resident #34 did not have a catheter strap in place before catheter care began. During the catheter care, CNA #2 put Resident #34 at risk for injury or discomfort, by holding the catheter tubing at the Y connection, instead of close to the meatus. CNA #2 was observed to be cleaning the catheter tubing away from the body in the correct direction. CNA #2 did not provide a catheter strap to Resident #34's thigh/leg to secure the catheter tubing, and prevent tugging or pulling on the tubing. An interview, on 7/24/2019 at 2:28 PM, revealed Certified Nursing Assistant (CNA) #2 confirmed Resident #34 did not have a catheter strap in place. CNA #2 stated, I should have held the catheter tubing close to the body when cleaning the tubing, so that that the tubing won't pull and hurt the resident or come out. CNA #2 stated, It must have come off, cause (sic) she usually has one on. Review of Resident #34's Comprehensive Care Plan revealed a Problem/Need at risk for Urinary Tract Infection [MEDICAL CONDITION] due to Resident #34 having chronic [MEDICAL CONDITION] and a [DIAGNOSES REDACTED]. The Onset Date was 6/2/2016. The Approaches included the Certified Nursing Assistants (CNAs) was to check the catheter and ensure the catheter was secured to the elder's (resident) thigh with a catheter securement device to prevent excessive movement and minimize accidental removal. Review of Resident #34's (MONTH) 2019 physician's orders [REDACTED]. The order stated that the catheter was also ordered due to a [DIAGNOSES REDACTED]. Further review of the (MONTH) 2019 physician's orders [REDACTED].#34's thigh with a catheter securement device to prevent excessive movement and minimize accidental removal. During a follow-up observation on 7/24/2019 at 4:29 PM, with Registered Nurse (RN) #2/Assistant Director of Nursing (ADON), it was revealed there was no catheter strap or securing device in place for Resident #34's catheter tubing, who was lying in bed, in her room. An interview at this time with the Assistant Director of Nursing (ADON) confirmed Resident #34 did not have a securing device for the catheter tubing. The ADON stated that a securing device for the catheter tubing helps to prevent tugging and possible pain and injury, if the catheter came out. The ADON stated that the tubing should be held closer to the body to prevent injury or preventing the dislodgement of the catheter, during care. During an interview, on 7/25/2019 at 8:56 AM, Registered Nurse (RN) #1/Care Plan and Minimum Data Set (MDS) Coordinator confirmed securing the catheter tubing close to the body when cleaning, is correct. Review of the Face Sheet revealed Resident #34 was admitted by the facility, on 5/20/2016, with [DIAGNOSES REDACTED].

Based on record review, facility policy review and staff interview, the facility failed to ensure the Pre-Admission Screening(PAS) Application for Long Term Care was fully completed prior to admission for one (1) of four (4) records reviewed; Resident #21. Findings Include: A review of the Instruction Manual, provided by the facility, titled Division of Medicaid, Pre-Admission Screening (PAS), Instruction Manual, revised 01/23/2013, revealed under the subtitle, 1.1, When Must a PAS Be Completed?; The PAS must be submitted within 30 days of the physician's certification. All persons requiring nursing facility level of care must have a PAS completed for admission to a Medicaid certified nursing facility or Home and Community Based Services (HCBS) long term care waiver program. Review of document submitted on 08/23/2018 and signed by the Administrator, revealed: Dunbar Village follows the Pre-Admission Screening (PAS) guidelines utilizing the Instruction Manual. Review of the PAS application for Resident #21 revealed: an incomplete application, with unanswered sections related to the physical status for Resident #21. The PAS did not indicate who screened Resident #21 or when it was done. The PAS was signed by the Physician, but was not dated and did not indicate a Primary Diagnosis. An interview on 08/23/2018 at 2:15 PM, with the Administrator (ADM), confirmed the PAS in Resident #21's chart was incomplete. The ADM stated there was no way to determine when and who completed the PAS for Resident #21. An interview on 08/23/2018 at 2:30 PM, with Social Services (SS), revealed the PAS in Resident #21's medical record was not dated and had a lot of blanks that should have been filled out. The SS further revealed she was not employed at the facility when Resident #21's PAS application was completed or when he was admitted . Review of the Face Sheet, revealed the facility initially admitted Resident #21 on 01/03/2014, and readmitted him on 05/04/2016, with [DIAGNOSES REDACTED]. A review of the most current Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/2018, revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of 8, which indicated moderately impaired cognition.

Based on record review, facility policy review and staff interview, the facility failed to ensure that the medical record documentation was complete as evidenced by the Pre-Admission Screening (PAS) application was incomplete for one (1) of four (4) resident records reviewed; Resident # 21. Findings Include: Review of Resident # 21's medical records, revealed the PAS application was incomplete. The PAS application had no completion date or a PAS score for Resident #21. The sections left blank were as follows: Vision, Orientation to Person, Place, and Time Person's Long Term Care Program Choice, Behavior, Selected Active Medical Conditions, the Federal Pre-Admission Screening & Resident Review (PASRR), and the section to be completed by the Physician which included the Primary [DIAGNOSES REDACTED]. Review of the facility's document, revealed a statement dated 08/23/2018 and signed by the facility's Administrator (ADM), which revealed: It is the practice of this Village to ensure medical records are complete and accurate. The letter was provided by the Administrator in regards to not having a written policy pertaining to the completion and accuracy of medical records. During an interview on 08/23/2018 at 2:15 PM, with the ADM, she confirmed the PAS application in Resident #21's chart was an incomplete medical record. The ADM revealed there was no way to determine when and by whom the PAS in Resident #21's medical record had been completed. An interview on 08/23/2018 at 2:30 PM, with Social Services (SS), revealed the PAS in Resident #21's medical record was not dated or marked with a diagnosis. The SS further revealed there was no way to determine when or who completed the PAS for Resident #21. The SS confirmed there were multiple areas left blank on Resident #21's PAS that are required to be filled out. SS stated, she was the person responsible for completing the facility's Pre-Admission Screen for Resident Review (PASRR) assessments. The SS revealed she was not employed with the facility at the time of Resident # 21's admission. A review of the Face Sheet, revealed the facility admitted Resident #21 on 01/03/2014, and readmitted the resident on 05/04/2016, with [DIAGNOSES REDACTED]. A review of the most current Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/2018, revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of 8, which indicated moderately impaired cognition.

Based on observation, record review, policy review and staff interview, the facility failed to provide wound care in a manner to prevent the possible spread of infection, for one (1) of four (4) wound care observations; Resident #69. Findings include: Review of the facility's policy, titled Infection Prevention & Control Program revised (MONTH) (YEAR), revealed, it is the facility's policy to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. The program will include, but not limited to: Precautions to followed to prevent the spread of infection. An observation on 08/22/18 at 11:05 AM, revealed Registered Nurse (RN) #1 provided wound care to Resident #69's feet. RN #1 placed paper towels on the floor as a barrier, and then placed, Puracol, wound cleanser, [MEDICATION NAME] swabs and Q-tips, that were in closed packages, on the paper towels. RN #1 knelt down on the floor to perform the pressure ulcer care. During the observation, RN #1 dropped a Q-tip package on the floor, picked it up and then used it to measure the wound on resident's left heel. RN #1 painted the area to the left heel with [MEDICATION NAME] and then blew on it with her mouth. She also waved her hand to fan the area dry. An interview on 08/22/18 at 4:32 PM, with RN #, revealed she acknowledged that she blew on the heel. RN #1 revealed it was an infection control issue. RN #1 stated she also should have used a table and not placed supplies on the floor, even though she had a barrier. RN #1 revealed she was the Infection Control Nurse and knows better. RN #1 stated she provides the inservices/education to staff and keeps up with all the infections. RN #1 revealed there had not been any inservices provided for infection control related to wound care recently. RN #1 revealed she had been at the facility for three (3) years and had not been to any trainings for Infection Control or Wound Care provided outside of the facility. RN #1 stated, all of her inservices have been provided in-house by the Director of Nursing (DON). RN #1 revealed (Name of Supplier) that provideds the wound care supplies, had come and given a few trainings on wound care supplies. RN #1revealed she did not follow appropriate infection control per policy for wound care. Interview on 08/23/18 at 8:49 AM, with the DON revealed placing supplies on a paper towel on the floor is a breach of infection control. The DON also revealed that blowing on a wound painted with [MEDICATION NAME] is a breach of infection. An interview on 08/23/18 at 11:02 AM, with the DON, revealed she would have expected RN #1 to follow the wound care and infection control policy and procedures, but RN #1 had not followed them. Review of the Face Sheet revealed, the facility admitted Resident #69 on 8/16/17 with [DIAGNOSES REDACTED]. A review of the most recent Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/09/18, revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition.

CI MS # Based on observation, record review, staff interview and policy review, the facility failed maintain comprehensive care plans to meet the current ongoing, individual resident needs for four (4) of four (4) sampled residents (Residents #1 #2, #3 and #4), from a total sample of five (5). This practice resulted in the failure to update comprehensive care plans to reflect current resident safety needs, an ineffective communication tool for staff to convey resident care needs, and the likelihood of inaccurate care with subsequent harm for Residents #1, #2, #3, and #4. Findings include: Review of the facility's policy entitled "Care Plans", undated, read the facility utilized care plans to individualize the care of each resident, provide effective communication between staff, and as a quick reference to individual patient needs. Problems listed on the care plan were to be unique to that individual and updated whenever the resident's needs or status changed. To help resident's achieve their goals, staff needed to document and implement individualized approaches to meet the resident's care needs. Further, "evaluations are done on a continuous basis," with necessary updates made to the care plan. "When needs or problems are met, they are deleted with a date of resolution." Resident #1 Review of the undated face sheet revealed the facility admitted Resident #1 was on 02/02/2012 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had impaired cognition, did not walk, and required a minimum of one staff member to provide extensive assistance with all transfers. Review of the care plan, last review dated 12/30/2013, revealed Resident #1 was at risk for falls with an injury related to his unsteady gait, weakness, impaired mobility, balance problems, visual disturbances, history of falls, and dementia. Staff typed original care plan interventions and added documentation of falls on 07/14/12 and 12/30/13. Staff failed to document a change or update to interventions with each fall. Review of a resident incident report dated 09/08/2013 at 4:00 PM, revealed staff found Resident #1 on a bedroom floor. His wheelchair was nearby. On the incident report, staff documented the resident needed to remain in supervised areas when out of his room. A comprehensive review of the medical record revealed revealed staff failed to care plan any new safety device or supervision to prevent future falls with injury after this fall. Review of a resident incident report dated 09/21/2013 at 11:00 AM, revealed staff found Resident #1 on his bedroom floor, with his pants around his ankles. On a sheet attached to the incident report staff documented the resident needed a wheelchair and bed alarm. Despite this documented recommendation, staff failed to document the need for these devices before 12/30/2013 (three months later), at which time staff implemented a second fall care plan. Review of an incident report dated 01/15/2014, revealed staff responded to a wheelchair alarm and found Resident #1 lying on his bedroom floor. On a sheet attached to the incident report staff documented the resident required a therapy evaluation. The therapy conducted the evaluation on 01/17/2014 and made recommendations for supervision and bed placement while in his room. Despite the documented recommendations for Resident #1, staff failed to care plan any safety interventions to prevent future falls with injury after this incident. Review of an incident report, dated 02/01/2014 at 8:00 AM, revealed Resident #1 fell out of his bed, cut his face, and sustained a skin tear on his right arm. Despite the documented incident, staff failed to care plan any safety interventions to prevent future falls with injury. Interview with Licensed Practical Nurse (LPN) #1 on 03/08/2013 at 12:00 PM, said watching Resident #1 in a supervised area was not always possible, because intermittently he evaded the supervision and returned to his bedroom. Despite the unsafe behaviors she identified, a comprehensive review of the medical record revealed staff failed to care plan any new safety devices or supervision to prevent future falls with injury. Additionally, she had not reviewed the safety care plan for Resident #1 since before 12/2013, because she worked with him five days a week, and knew his needs. The only documented interventions on the safety care plans for Resident #1, that LPN #1 could verbalize, were the need for a wheelchair alarm and bed alarm. She said it was not her job to update care plans, unless related to antibiotic use. An interview with Certified Nursing Assistant (CNA) #1 on 03/18/2014 at 1:00 PM revealed CNA #1 said she witnessed Resident #1 independently transfer to and from his wheelchair and bed at least bi-weekly, with an unsteady gait. Despite these unsafe behaviors, a comprehensive review of the medical record revealed staff failed to care plan any new safety devices or supervision to prevent future falls with injury. Further, she did not feel the need to review Resident #1's safety care plan, because she worked five days a week with him and knew his needs. The only documented interventions on the safety care plans for Resident #1, that CNA #1 could verbalize, were the need for a wheelchair alarm and bed alarm. Interview with Licensed Practical Nurse (LPN) #5 on 03/17/2014 at 3:45 PM, LPN #5 said recently her role had expanded to include the development of care plans, when resident's came due for annual or significant change assessments for the MDS. She implemented the new safety care plan for Resident #1 on 12/30/2013, because his assessment was due. However, she failed to explain, why she did not discontinue or revise the prior safety care plan to meet the individualized approaches staff documented as requirements for Resident #1. Interview with the Director of Nursing (DON) on 03/17/2014 at 4:00 PM, the DON failed to explain why the safety care plan was not updated to reflect the additional safety measures and/or supervision Resident #1 required following each of the aforementioned incidents. Additionally, she failed to explain why the required bed alarm and wheelchair alarm were not care planned until 12/30/2013. Resident #2 Review of an undated face sheet revealed the facility admitted Resident #2 on 04/28/2011 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had severely impaired cognition, did not walk, had a history of [REDACTED]. Review of the fall care plan initiated 04/28/2011, revealed Resident #2 needed anti-skid floor strips, a functional bed alarm, and a wheelchair alarm to ensure her safety. Observations made on 03/17/2014 at 3:30 PM in the presence of DON, revealed Resident #2 was in her wheelchair without her care planned safety alarm. During this observation, the DON suggested the care plan may not be up to date with the resident's current needs, that perhaps the device was no longer necessary. Upon entering the resident's bedroom, the DON could not find the care planned anti-skid floor strips. She said the facility never owned or implemented any anti-skid floor strips, rendering the care plan inaccurate. Resident #3 Review of an undated face sheet revealed the facility admitted Resident #3 on 04/28/2011 with [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], revealed Resident #3 had severely impaired cognition, impaired balance and required minimally one staff member to provide extensive assistance with all bed mobility, transfers, and ambulation. Review of a fall care plan initiated on 10/28/2009, and last updated on 12/23/2013, revealed Resident #3 required non-skid strips on the floor and non-skid footwear to ensure her safety. Review of a "Resident Incident Report" form dated 02/21/2014 at 7:45 PM, revealed staff found Resident #3 on her bedroom floor. A comprehensive review of the medical record failed to identify any updates made to the safety care plan after this fall. During observations made 03/17/2014 at 3:30 PM, the DON reviewed the bedroom assigned to Resident #3, but failed to locate any anti-skid floor strips on the floor. She said the facility never owned or implemented any anti-skid floor strips, which rendered the care plan inaccurate. Interview with the DON on 03/17/2014 at 4:00 PM, reviewed the safety care plan for Resident #3, noted staff had documented the implementation of a wheelchair alarm and bed alarm, twice each, on different dates. The DON said, likely staff implemented the devices, discontinued them, and reinstated them a second time without accurately updating the care plan to reflect these changing approaches. Additionally, she failed to explain why there had been new safety measures and/or increased supervision care planned after Resident #3 fell on [DATE]. Resident #4 Review of an undated face sheet revealed the facility admitted Resident #4 on 09/20/2013 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #4 had impaired cognition, requiring minimally one staff member to provide assist with all transfers and ambulation. Review of the fall care plan dated 09/20/2013 revealed Resident #4 needed a call light within reach, medication assessments, and safety cues/instruction to minimize her fall risk. Review of nursing notes dated 12/04/2014 at 11:30 AM, revealed Resident #4 had a change in condition and now required the extensive assistance of one staff member for all ambulation. Despite this assessment, the medical record failed to provide any documented evidence staff updated the resident's care plans. Review of nursing notes dated 12/04/2014 at 8:00 PM, revealed Resident #4 was "extremely unsteady on (her) feet," requiring minimally two staff members to assist with all ambulation, due to "continuing unsteadiness/stumbling/shambling gait." Despite this assessment, the medical record failed to provide any documented evidence staff updated her care plans. Review of nursing notes dated 12/06/2014 at 11:45 AM, revealed staff permitted Resident #4 to stand and kick a ball with her left foot, causing her to lose balance and fall to the floor. Despite this incident, the medical record failed to provide any documented evidence staff updated her care plans. Review of nursing notes dated 12/07/2014 at 2:00 PM, revealed Resident #4 had an unsteady gait. Despite this assessment, the medical record failed to provide any documented evidence staff updated her care plans. Review of nursing notes dated 12/07/2014 at 9:00 PM, revealed staff placed Resident #4 in a wheelchair due to her ongoing unsteady gait. Despite this intervention, the medical record failed to provide any documented evidence staff updated her care plans. Review of a "Resident Incident Report" form, dated 12/08/13, with the attached written staff statement from LPN #2, revealed between 3:00 PM and 6:00 PM on 12/08/2013 Resident #4 had "escalating behavior" that included packing, ranting, physical threats, verbal threats, and exit seeking behaviors. Despite these symptoms, the medical record failed to provide any documented evidence staff updated her care plans. Review of a "Resident Incident Report" form dated 01/27/2014 at 7:00 PM, revealed Resident #4 fell on the bathroom floor. On the back of the incident report staff documented they applied a chair alarm. Despite this intervention, the medical record failed to provide any documented evidence staff updated her care plans. Review of nursing notes dated 03/16/2014 at 10:05 PM, revealed Resident #4 fell on her bedroom floor. On the back of the incident report staff documented they applied a bed alarm. Despite this intervention, the medical record failed to provide any documented evidence to suggest staff updated her care plans. During an interview with the DON on 03/17/2014 at 3:30 PM, the DON failed to explain why staff did not update the care plan for Resident #4 following any of the aforementioned incidents. The DON said, "I don't understand" the care plan process at this facility, but recommended speaking with the MDS nurse for care plan questions. During an interview with the MDS Nurse on 03/17/2014 at 3:45 PM, the MDS Nurse said care plan updates are not consistently being done, because floor nurses do not know their role in care planning. "I know that's the problem." Despite care plan education provided to the floor nurses, MDS Nurse said the transition from manual care plans, to computer generated care plans, had caused their staff some confusion. She said her duties recently expanded to include care planning for annual and significant change assessments. However, she said floor-nursing staff members are responsible for ongoing care plan updates.

CI MS # Based on observations, interviews, records review and facility policy review, the facility failed to provide the necessary supervision and/or safety devices to prevent falls in four (4) of four (4) sampled residents (Residents #1, #2, #3 and #4), from a total of five (5). This practice resulted in three (3) falls with skin tears and two (2) rib fractures (Resident #1); one (1) fall with skin tears and a pelvic fracture (Resident #4); one (1) fall and a skin tear (Resident #3); and, the likelihood of future falls with injury (Resident #2, Resident #3, and Resident #4). Findings include: Review of the facility's policy entitled "Resident Fall Follow-up", undated, failed to address the implementation of additional safety measures and/or supervision to prevent future falls with injury, after a resident exhibited unsafe behaviors and/or falls. Resident #1 Review of the undated face sheet revealed the facility admitted Resident #1 on 02/02/2012 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had impaired cognition, did not walk, and required minimally one staff member to provide extensive assistance with all transfers. Review of the undated Certified Nursing Assistants care guide (Resident Status Sheet) revealed Resident #1 required the assistance of one person to stand and transfer. Review of a fall assessment dated [DATE] revealed Resident #1 was at "high risk" for falls related to his intermittent confusion, chair bound status, poor vision, unsteady gait, impaired balance, use of prescribed medications, and from predisposing diseases. Review of a resident incident report dated 09/08/2013 at 4:00 PM revealed Resident #1 was unsupervised in a bedroom, when he independently transferred out of his wheelchair to the floor. On the incident report, staff documented the resident needed to remain in supervised areas when out of his room. However, despite this recommendation staff failed to update the fall care plan or certified nursing assistants care guide to reflect his new safety measure. A comprehensive review of the medical record failed to provide any documented evidence staff consistently implemented the recommended supervision. Interview on 03/08/2013 at 12:00 PM with Licensed Practical Nurse (LPN) #1, revealed that watching Resident #1 in a supervised area was not always possible, because intermittently he evaded the supervision and returned to his bedroom. Despite these ongoing behaviors, LPN #1 failed to implement any additional safety measures to prevent future falls with injury. Review of a resident incident report dated 09/21/2013 at 11:00 AM, revealed Resident #1 was unsupervised in his bedroom, when he independently transferred from bed, walked with his pants around his ankles, and fell to the floor sustaining a skin tear on his right elbow and right sided, chest wall pain. On a sheet attached to the incident report staff documented the resident needed a wheelchair and bed alarm. However, despite this recommendation staff failed to update the fall care plan or certified nursing assistants care guide to reflect his new safety measure. A comprehensive review of the medical record revealed Resident #1 had ongoing right sided, chest wall pain that required an X-ray after a fall on 09/21/13. Review of the X-ray report dated 09/23/2013 revealed Resident #1 had fractured his seventh and eighth rib. Interview on 03/18/2014 at 1:30 PM with CNA #1, revealed Resident #1 independently transfer to and from his wheelchair and bed at least bi-weekly, with an unsteady gait. CNA #1 said each fall incurred by Resident #1, happened when staff left him unsupervised. She said Resident #1 was not compliant with his safety devices. Despite these ongoing behaviors, CNA #1 failed to implement any additional safety measures to prevent future falls with injury. Review of an incident report dated 01/15/2014 at 10:00 AM, revealed Resident #1 independently transferred from his wheelchair and fell to his bedroom floor. When staff heard the alarm, they responded and found Resident #1 lying on the floor with a skin tear on his right elbow. Interview on 03/17/2014 at 3:30 PM with the Director of Nursing (DON), revealed rounds were made in the facility and reviewed the aforementioned incident reports. She said, the facility had never owned or implemented any non-skid floor strips for resident safety. Additionally, she failed to explain why the device was care planned to keep Resident #1 safe, if staff never implemented the device. Resident #4 Review of an undated face sheet revealed the facility admitted Resident #4 on 09/20/2013 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed Resident #4 had impaired cognition, requiring minimally one staff member to provide assist with all transfers and ambulation. Review of the undated fall risk assessment revealed Resident #4 was at risk for falls related to her intermittently confusion, prescribed medications, and predisposing diseases. Review of orders dated 12/04/2013 revealed Resident #4 required a psychiatric assessment for "agitation, anxiety/panic, wandering, physical aggression, verbal aggression, and resisting care". Review of nursing notes dated 12/04/2013 at 11:30 AM, revealed Resident #4 had a change in condition and now required the extensive assistance of one staff member for all ambulation. Despite this assessment, a comprehensive review of the medical record and care plan, failed to provide any documented evidence to suggest staff implemented any additional safety measures or supervision, to prevent future falls with injury. Review of nursing notes dated 12/04/2013 at 8:00 PM, revealed Resident #4 was "extremely unsteady on (her) feet," requiring minimally two staff members to assist with all ambulation, due to "continuing unsteadiness/stumbling/shambling gait." Despite this assessment, a comprehensive review of the medical record and care plan, failed to provide any documented evidence to suggest staff implemented any additional safety measures or supervision, to prevent future falls with injury. Review of nursing notes dated 12/06/2013 at 11:45 AM, revealed staff permitted Resident #4 to stand and kick a ball with her left foot, causing her to lose balance and fall to the floor. Nursing documented the activity was not appropriate because she was unsteady at times. Despite this assessment, a comprehensive review of the medical record failed to provide any documented evidence staff implemented any additional safety measures or supervision, to prevent future falls with injury. Review of nursing notes dated 12/07/2013 at 2:00 PM, revealed Resident #4 had an unsteady gait. Despite this assessment, a comprehensive review of the medical record failed to provide any documented evidence staff implemented any additional safety measures or supervision, to prevent future falls with injury. Review of nursing notes dated 12/07/2013 at 9:00 PM, revealed staff placed Resident #4 in a wheelchair due to her ongoing unsteady gait. Review of a "Resident Incident Report" form, dated 12/08/2013, with the attached written staff statement from LPN #2, revealed between 3:00 PM and 6:00 PM on 12/08/2013, Resident #4 had "escalating behavior" that included packing, ranting, physical threats, verbal threats, and exit seeking behaviors. Despite this assessment and knowing the "Elder had been exhibiting (an) increasingly alarming unsteady gait while walking to dining room or anywhere else in facility without staff support." LPN #2 intentionally left Resident #4 unsupervised in her bedroom to deescalate, with the door closed. At 6:10 PM, staff heard Resident #4 calling for help. Upon entering the bedroom, staff observed Resident #4 lying on the floor in "horrible pain." Review of orders dated 12/08/2013 revealed Resident #4 went to the local area hospital for further evaluation and treatment. Review of an x-ray report dated 12/09/2013 revealed Resident #4 had a "moderately comminuted acute fracture of the left parasymphyseal region extending into left superior pubic ramus, with mild fragment separation and some surrounding ill-defined hemorrhage (a pelvic fracture)." A comprehensive review of the medical record failed to provide any documented evidence to suggest staff implemented any additional safety measures or supervision, to prevent future falls with injury. Review of a "Resident Incident Report" form dated 01/27/2014 at 7:00 PM, revealed Resident #4 had no staff supervision when she independently transferred from the wheelchair and fell on the bathroom floor. On the back of the incident report staff documented they applied a chair alarm. Despite the incident reports documentation, a comprehensive review of the medical record failed to provide any documented evidence of the implementation of the device after this fall. Review of nursing notes dated 03/16/2014 at 10:05 PM, revealed Resident #4 was unsupervised when she independently transferred from her bed and fell to the floor. On the back of the incident report staff documented they applied a bed alarm. A comprehensive review of the medical record failed to provide any documented evidence of the implementation of the bed alarm. During dining room observations on 03/17/2014 at 11:30 AM, 12:00 PM, and 12:30 PM, revealed staff provided intermittent supervision for Resident #4, but the required wheelchair alarm necessary to maintain her safety, was not in place. The DON verified these findings during rounds conducted the same day of 03/17/2014 at 3:30 PM. During a transfer observation on 03/17/2014 at 1:15 PM, the surveyor watched as CNA #1 pushed the wheelchair holding Resident #4 in front of the toilet. The room's size did not permit space on either side of the wheelchair. The wheelchair then acted as a barrier between CNA #1 and Resident #4 during the rest of the transfer. While attempting to lock the wheelchairs brakes, Resident #4 stood up despite direction to remain seated. She stood holding the bathrooms wall rails, though her legs trembled with weakness. CNA #1 reached across the wheelchair and pulled down on the resident's pant leg and then brief. As Resident #4 turned toward the toilet, she became more unsteady on her feet. CNA #1 reached across the wheelchair, but was unable to reach any portion of the body required to stabilize the resident. The resident ended up on the toilet seat without injury, despite the transfer technique. When the surveyor left the bathroom, she reviewed the bedroom and the bed alarm. The bed alarms pad sat on top of the mattress. However, the cord that was required to link the sensor alarm to the alarm box was broken with wires exposed on the end but no connector. During an observation on 3/17/14 at 1:45 PM, the surveyor reentered the bedroom and found Resident #4 unsupervised, lying in bed. The bed alarm remained non-functional, without repair or replacement since the prior observation. The DON verified these findings during rounds conducted the same day at 3:30 PM. Resident #3 Review of an undated face sheet revealed the facility admitted Resident #3 on 04/28/11 with [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], revealed Resident #3 had severely impaired cognition, impaired balance and required minimally one staff member to provide extensive assistance with all bed mobility, transfers, and ambulation. Review of the fall risk assessment completed 12/23/2013 revealed Resident #3 was at "high risk" for falls related to her disorientation, history of recent falls, chair bound status, inability to balance while walking, inability to balance while standing, required assistive devices, prescribed medications, and predisposing diseases. Review of a fall care plan initiated on 10/28/2009, and last updated on 12/23/2013, revealed Resident #3 required non-skid strips on the floor and non-skid footwear to ensure her safety. Observations made by the surveyor on 03/17/2014 at 11:30 AM, 12:00 PM, 12:30 PM, and at 3:30 PM in the presence of the DON, revealed Resident #3 did not have a bedside floor mat or anti-skid strips available for use in her bedroom. Additionally, only intermittent staff supervision occurred in the dining room, where Resident #3 sat in her wheelchair, wearing only cotton socks, no tread, on laminate wood flooring. During rounds on 03/17/2014 at 3:30 PM, the DON said Resident #3 had a history of [REDACTED]. She then witnessed the cotton socks on the resident's feet and immediately asked staff to apply footwear that had a tread. Review of a "Resident Incident Report" form dated 02/21/2014 at 7:45 PM, revealed staff found Resident #3 on her bedroom floor, bleeding from a four (4) centimeter (cm) scalp laceration, after an unsupervised independent transfer. Interview on 03/17/2014 at 4:00 PM, the DON said the facility never applied the anti-skid floor strips care planned to keep Resident #3 safe. Review of local hospital records dated 02/21/2014, revealed Resident #3 sustained a scalp laceration and hematoma (localized collection of blood in the tissues), that required staples. A comprehensive review of the medical record revealed Resident #3 returned from the local hospital on [DATE] at 1:50 AM. However, despite the incident report documenting a floor mat was required beginning 02/21/2014, the medical record failed to provide any documented evidence to suggest staff care planned or implemented any safety measures, including a floor mat, after Resident #3 fell . During the same rounds on 03/17/2014 at 3:30 PM, the DON observed the bedroom assigned to Resident #3, but failed to identify the presence of a fall mat and non-skid floor strips required to ensure her safety. Resident #2 Review of an undated face sheet revealed the facility admitted Resident #2 on 04/28/2011 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed Resident #2 had severely impaired cognition, did not walk, had a history of [REDACTED]. Review of the fall risk assessment dated [DATE] revealed Resident #3 was at risk for falls related to her disorientation, chair bound status, inability to walk or balance, and from predisposing diseases. Record review revealed Resident #2 required anti-skid floor strips, with a functional bed alarm and wheelchair alarm for safety. Observations made by the surveyor on 03/17/2014 at 11:30 AM, 12:00 PM, 12:30 PM, and at 3:30 PM in the presence of the DON, revealed staff intermittently supervised Resident #2 in the dining room, yet failed to provide the chair alarm necessary for her safety. During rounds 3/17/14 at 3:30 PM, the DON observed the bedroom assigned to Resident #2 and verified staff failed to implement the required bed alarm and anti-skid floor strips necessary to ensure her safety.

Based on observation, record review, resident interview, family interview, staff interview, Physician interview, Wound Care Clinic Physical Therapist interview, Nurse Practitioner interview, and policy and procedure review, the facility failed to ensure that one (1) of nine (9) Residents reviewed for accidents was supervised and assessed to prevent an avoidable accident. Resident #1 was served a cup of hot coffee in bed by a facility staff member on 4/1/11. The coffee was placed on an over-bed table at Resident #1's bedside. Resident #1 reached for the cup of hot coffee and it turned over causing it to spill on both of his feet. Resident #1 sustained burns to both feet which were first identified by the facility as Second Degree burns. However, the care plan developed on 4/1/11 identified the burns as "3rd degree." The burns were identified as "full thickness" burns when evaluated at the Wound Treatment Center on 4/7/11. Resident #1 required the administration of pain medication for pain management and wound care. Resident #1 developed Methicillin-Resistant Staphyloccus Aureus (MRSA) and Pseudomonas to the burn wounds; and required hospitalization for Intravenous (I.V.) antibiotic therapy for treatment. Resident #1 also was confined to his room for a period of time on isolation. Resident #1 had a previous [DIAGNOSES REDACTED]. The facility did not have a policy and procedure in place prior to the incident on 4/1/11 to test the temperature of the coffee or hot beverages before it was served to the residents. The facility did not have assessments in place prior to the coffee spill for assessing residents with decreased cognitive or decreased motor function as to their ability to drink coffee unassisted. These actions caused Resident #1 harm. Findings include: Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03-02-11, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of "13", which indicated that Resident #1 had no cognitive difficulties with daily decision making. Resident #1 was identified to be totally dependent upon staff for all ambulation. Resident #1 was dependent on one (1) person to physically assist with eating, transfers, bed mobility, dressing, toileting and bathing. The MDS indicated that Resident #1 had impairment on one (1) side of the upper extremities; and both sides of the lower extremities. Resident #1 was incontinent of bowel and required the use of a condom catheter. Interview on 6/27/11 at 2:15 p.m., with Licensed Practical Nurse (LPN) #1, revealed that Resident #1 had a burn on both feet due to a coffee spill. LPN #1 stated that a staff member gave Resident #1 a cup of coffee and he spilled it on his feet causing burns. She stated that the burns became infected with Methicillin-Resistant Staphylococcus Aureus (M.R.S.A.) and he was hospitalized for [REDACTED]. Observation on 6/27/11 at 3:45 p.m., revealed that Resident #1 was lying in bed with the head of the bed elevated and the over bed table was across his body. Resident #1 had a cup of coffee on the overbed table. The coffee was in a clear plastic container that had a lid and a straw in place. Interview on 6/27/11 at 3:45 p.m., with Resident #1 revealed that he had been "grounded" or confined to his bed in a private room due to isolation procedures as result of a "super bug" infection in the burn wounds. Resident #1 stated that he has M.S. (Multiple Sclerosis). Resident #1 stated that he was served hot coffee by the facility staff and he spilled it on both of his feet which caused burns. Resident #1 was not able to recall who the person was that served him his coffee in bed on that day. Resident #1 stated that the hot coffee was brought into his room and placed on his over bed table during the breakfast meal. Resident #1 stated that when he reached to get his hot coffee he knocked it over and it spilled on his feet. Resident #1 stated that he had to go to the hospital to receive Intravenous (I.V.) antibiotics because the facility was not able to administer (I.V.) antibiotics. Resident #1 stated that he was released from isolation on 6/19/11. Review of the "Activities of Daily Living" (ADL) care plan for Resident #1, prior to the incident with the spill, revealed that Resident #1 required extensive assistance of one (1) staff for bed mobility, and turning and repositioning related to "weakness" limited ROM (Range of Motion), and uncontrolled movements." Review of the care plan for Resident #1 dated 4/1/11, also documented that Resident #1 had "Potential for weight loss related to Impaired movement, dexterity Dx (diagnosis) of Multiple Sclerosis - Requires assistance with set up." There was documentation on the care plan dated 4/1/11 that Resident #1 was to have a "cup with a screw/twist on lid." Review of the care plan for Resident #1 dated 4/1/11, documented: "3rd Degree Burn L (left) posterior heel; 3rd Degree Burn R (Right) Lateral Foot; 3rd Degree Burn R (Right) Distal Superior Foot; and 3rd Degree Burn R (Right) proximal Superior Foot. " Review of the care plan dated 6/8/11, documented that Resident #1 had potential for Social Isolation related to"Need for wound isolation." Review of the nursing notes dated 4/1/11, revealed: "10:00 a.m. Res (Resident) spilled coffee off of bed side table onto his feet causing redness and blistering to top and side of Left foot and bottom of heal of Right foot. MD (Medical Doctor) notified and gave instructions to apply ice until area cool and then, apply Silvadene cream to affected area on both feet. Wrap with Kerlex gauze daily til healed. Give Lortab 7.5/500 mg (milligrams) one (1) tab p.o. (by mouth) Q (every) 4 hrs PRN (as needed) for pain. Res (Resident) reported pain meds (medications) effective. Feet floated on pillows and dressings clean and intact. Will continue to monitor. No acute distress at this time." There was no further documentation and/or assessments of Resident #1 documented until seven (7) days later on 4/7/11. The nursing progress note dated 4/7/11, stated; "6 a.m. N.O. (New Order) Whirlpool bilateral feet for burns to feet from spilt coffee per M.D. order." The next documented nursing note was written by the DON on 4/8/11 that stated: " 0900 a.m. Late Entry. On 4/5/11 - Assessed wounds to bilat feet-D/T (due to) coffee burns-blistering and yellow granulation noted to right top and heel of foot. Contacted (Name of Nurse Practitioner) for (Name of Treating Physician). She will come and assess feet on Wednesday a.m. on 4/6/11. New order for whirlpool at the outpatient Rehab. Resident to be seen on 4/7/11." Record review revealed that Resident #1 was not physically examined and evaluated and/or treated by the Attending Physician until 15 days after the coffee spill occurred. The Physician saw the treating Physician made at the facility on 4/15/11. The Physician's progress note does not address the burns. Record review did not reveal an evaluation of Resident #1's burns by the Physician or Nurse Practitioner immediately after the coffee burn occurred. The Nurse Practitioner note was dated 4/6/11. Record review revealed that LPN#1 completed an Incident Report for Resident #1 dated 4/1/11. The Incident report stated: "4/1/11 at 9:30 a.m. CNA (Certified Nurse Assistant) called nurse to room and reported to nurse Residents coffee spilled off of bed side table while he was reaching for it onto his feet causing "redness and blistering". MD notified and first aid applied by nurses. The Incident report had a note written by Registered Nurse (RN) #2 stating: "4/1/11 at 10 a.m. (Name of Attending Physician) notified of incident. New orders noted and implemented. Areas to feet red with blisters. Will cont (continue) to treat & (and) monitor for any S/S (signs and symptoms) of infection until healed." The document revealed that the State was not notified of the incident. Review of a facility "Weekly Skin Report", documented by RN #3 stated: "On 4/1/11 - Stage: 3rd Degree. Location: L (left) posterior Burn Size: (cm. or inch) foot (heel) Length 8 cm, Width 7 cm, Deep 0.2 cm. Open with Intact fluid filled Blisters to edges. Color: pink; Odor: 0; Drainage: (Describe) Small clear. Treatment: Clean with W/C (wound cleaner) pat dry apply Silva cream. Cover with Kling QD (every day) until healed. Progress: Initial Special Device: Elevate Mason Mattress." Review of the "Weekly Skin Report", completed by RN #3 stated:" Date: 4/1/11 - Stage: 3rd Degree Burn R (Right) Location: R (Right) Lateral Foot Size: (cm. or inch) Length 18 cm. Width 11 cm. Deep 0.2 cm open. Color: pink. Odor: 0. Drainage: (Describe) Mod Clear. Treatment: Clean with W/C (wound cleaner) pad dry Silvadene cream cover with Kling QD (every day) until healed. Progress: Initial Special Device: Elevate Mason Mattress." Review of the "Weekly Skin Report" dated 4/7/11, revealed: "Stage: 3rd Degree. Location: L (Left) posterior Burn. Size: (cm. or inch) foot (heel) Length 7 cm, Width 6 cm, Deep 0.2 cm. Seen by wound clinic 4/7/11. Color: 20% yellow 80% pink. Odor: 0. Drainage: (Describe) Small amount lt (light) yellow/clear. Treatment: Clean with w/c (wound cleaner) pat dry Silva cream, ABD pad wrap with Kling QD (every day) until healed. Progress: Decrease size. Special Device: Elevate Mason Matt, Heel Protector." Review of the "Weekly Skin Report", completed by RN #3 dated 4/7/11, revealed: "Stage: 3rd Degree Burn. Location: R (right) Lateral foot. Length: 17.6 cm Width 10.7 cm Deep O.2 cm. Seen by Wound Clinic today on 4/7/11. Color: 60% yellow 40% pink. Odor: 0. Drainage: (Describe) Mod Amount lt(light) yellow /clear. Treatment: Clean with W/C (wound cleaner) pat dry Silva cream ABD, Cover Kling QD (every day) until healed. Progress: Decreased in size. Special Device: Elevate Mason Mattress." Review of the "Weekly Skin Report", completed by RN #3, dated 4/21/11, revealed: "Stage: 3rd Degree. Location: L (left) Posterior Burn Size: (cm. or inch) Heel Length 4.4 cm Width 3.5 cm Deep 0.2 cm. Seen by wound clinic M-W-F (Monday, Wednesday, and Friday). Color: 30% yellow 70% pink. Odor: Faint foul. Drainage: (Describe) Small lt (light) green c/s done 4/20/11. Treatment: Whirlpool, Santyl to yellow, Silva to edges 4x4, ABD, Kerlix, ace wrap M-W-F. Progress: Decreased size Increased drainage. Special Device: Elevate, Heel protector's, Vitamins." Review of the documented verbal physician's orders [REDACTED]. Lortab 7.5/500 mg (milligrams) one (1) tab P.O. (by mouth) Q 4 Hrs PRN (as needed) pain V.O. (verbal order) (Name of Attending Physician) (signed by RN#2)." Review of the verbal orders obtained by the facility Wound Care Nurse (RN #3), on 4/2/11 stated: "4/2/11 - Continue Tx (treatment) to 2nd Degree Burns to R (right) and L (left) foot. Clean with W/C (wound cleaner), pat dry apply Silva cream, cover with ABD pads, wrap with Kling QD (every day) and PRN (as needed) until healed. V.O. (verbal orders) (Name of Attending Physician) (signed by RN#3)." Record review revealed that there were verbal physician's orders [REDACTED]. "Santyl ointment apply to burned areas on feet daily per (Name of Out-Patient Physical Therapy Clinic) rehab to start Monday, 4/11/11. Rehab to do dressing change." Record review revealed that Resident #1 was seen on 4/7/11 by the Family Nurse Practitioner (FNP) and her note stated: "4/6/11 called to evaluate pt (patient) for 2 (degree) burn to R (right) dorsal foot and L (left) heel. Pt (patient) burned self with hot coffee on April 1st feet appear to be worsening . Blistering to R (right foot 18 cm x 10 cm x 0.2 in depth L (left) heel 7 cm x 6 cm fluid filled blisters 15-20 yellowing. " Review of the out-patient wound clinic's Physical Therapy (PT) evaluation and treatment records dated 4/7/11, stated: "4/7/11 - Spilled hot coffee on feet about 2 weeks ago. Sustained full thickness burn to R (right) foot and L (left) heel; Rx tried at (Name of Nursing Home) but more aggressive rx required. Pt. resides at (Name of Nursing Home) Dx (diagnosis) MS (Multiple Sclerosis) that has left him non-ambulatory, requires (assistance) for all transfers." The burns were evaluated by the Physical Therapist at the out-patient wound clinic with the following measurements noted: 4/7/11 - (1) R (Right) foot: 6 cm X 5 cm-dorsum lateral/ prox. 50% adhered eschar in center of wound with 50% granulation tissue. (2) - R (Right) foot: dorsum - distal involving 4 toes 8.0 cm X 5.0 cm plus dorsum of 2nd -5th toes. Abo extends along plantar surface of lateral border of foot 5.0 cm by 3.0 cm, 25% adhered yellow eschar. (3) Lateral R (Right) foot and ankle 16.0 cm X 8.0 cm with blister present 100% adhered yellow eschar tissue periwound swollen and warm distal tibia. (4) L (Left) foot - Heel 6.0 cm X 4.0 cm 100% granulation tissue present." Review of the out-patient wound clinic notes dated 4/18/11, revealed: "Patient appears to have pseudomonas drainage with increased odor with drainage. Staff at (Name of Nursing Home) notified and will get patient on antibiotics ASAP! (as soon as possible)." Review of the lab results dated 4/20/11, revealed that Resident #1 had a positive growth for "Pseudomonas aeruginosa - Heavy Growth." Review of the verbal physician's orders [REDACTED].O. (by mouth) BI D (two times daily) x 7 days. Have therapy wash wounds with acetic acid 0.25% with each dressing change continue Silva and Santyl cream." Review of the a wound culture and sensitivity results on 5/05/11, 5/07/11, and 5/10/11 revealed: "Organism #1 Methicillin Susceptible Staph, aureus (MRSA). Organism #2 Pseudomonas aeruginosa." Resident #1 was admitted to the hospital on [DATE] for antibiotic therapy. Review of the consultant report from the Podiatrist (DPM) on 5/10/11, stated: "This [AGE] year old male patient presents as an admission via (Name of Treating Physician) from nursing home with cellulitis right lower extremity. Patient suffers from multiple sclerosis, states that about 4 weeks ago he spilled hot coffee, knocked off of his tray onto his right foot. He states he burned the area and has been treated by what he relates to be physical therapy in (Name of Town) for the past 4 weeks. Patient has most recently been on Cipro. His most recent culture and sensitivity from the nursing home indicates staph aureus and pseudomonas. Past Medical History: Multiple Sclerosis, [DIAGNOSES REDACTED], Dermatitis. Medications as noted in the chart. allergies [REDACTED]. Hair growth negative bilateral. Skin temperature is warm to warm from the anterior tibia to the distal digits bilateral. Capillary fill time equal to 5 seconds bilateral. Dermatologic - patient has a degloving type burn encompassing the dorsal aspect of the patient's right foot as well as his digits on the right foot. This extends to the lateral aspects of the right foot and above the ankle area. This is a full thickness burn with the extensor tendons being visualized under a layer of fibrous tissue. There's also extensive malodor, obvious signs of pseudomonas infection with a greenish yellow drainage emitting from the area. There's no sign of ulceration of the patient's right heel at this time. Patient does have ulceration on the posterior and plantar aspect of his left heel. These areas do not appear to be currently infected and these ulcerations are present at the time of admission. Musculoskeletal - patient is noted to have flexible contractures of the bilateral lower extremities. Patient is rigid and his lower extremities are able to be manipulated, however this does elicit discomfort. Patient also has discomfort on the dorsal aspect of the right foot where the burn is present as well as infection. No pain is noted upon palpation of the plantar aspect of the left foot where patient has an ulceration uninfected. Neurologic-sharp, dull and vibratory sensations are significantly diminished. Patient does lack some degree of protective sensation, although it is not completely absent on examination today. Patient currently rates his pain at a 3 at time of examination regarding the right foot. Diagnosis: [REDACTED]. HEEL ULCERATION LEFT, UNINFECTED." "PLAN: The patient did have some confusion upon discussion today, was unclear exactly where he was getting treatment for [REDACTED]. Patient was able to give him information regarding the length of time that this injury occurred and how it occurred. Patient is currently on Cipro and Zosyn. I've started acetic acid wet to dry dressings to the dorsal and lateral aspects of the patient's right lower extremity to control the pseudomonas so that the area can begin to heal. Overall the infection appears to be superficial at this time. I'm concerned about the viability of the patient's digits, although they did respond with equal to 5 second capillary fill time on the distal aspects of the digits. Also monitor the web spaces for possible fungal involvement because of the dressings and the wet to dry acetic acid dressings being applied. A well padded dressing was applied to the left heel. Patient does have bilateral heel protectors to prevent further ulceration in these areas. The patient will be followed, monitored and determine whether the patient is responding to the acetic acid wet to dry dressings. Review of the Medication Administration Record (MAR), revealed that Resident #1 required the Lortab 7/500 mg 15 times in April 2011, after he sustained the burns to aid in pain management. Resident #1 also received Lortab as needed for pain in May and June 2011. Observation on 6/28/11 at 9:25 a.m., of the facility coffee in an Air-pump Insulated Urn, revealed a temperature of 160 degrees F (Fahrenheit). Observation on 6/28/11 at 10:15 a.m., of the facility coffee from the Air-pump Insulated Urn, revealed a temperature of 150 degrees F. Observation on 6/28/11 at 11:50 a.m., of the facility coffee from the Air-pump Insulated Urn, revealed a temperature of 150 degrees F. Observation on 6/28/11 at 2:30 p.m., of the facility coffee from the Air-pump Insulated Urn, revealed a temperature of 140 degrees F, which was the same coffee urn and coffee used for all temperatures on 6/28/11 beginning at 9:25 a.m. - 2:30 p.m. Observation on 6/28/11 at 3:30 p.m., of a new urn of coffee was tested at a temperature of 152 degrees F. Observation on 6/29/11 at 10:00 a.m., of the coffee urn located in the dietary department, revealed a temperature of 160 degrees F. Observation on 6/29/11 at 10:15 a.m., of the coffee urn located on Unit 2 in the residents dining area, revealed a temperature of 154 degree F. Observation on 6/29/11 at 10:17 a.m., of the Unit 1 coffee urn, revealed a temperature of 161 degree F. Observations on 6/30/11 and 7/1/11, revealed that there was no brewed coffee in the facility. Interview on 6/28/11 at 9:30 a.m. - 10:10 a.m., with the Director of Nursing (DON), revealed that Resident #1 was served hot coffee in a thermal travel cup on 4/1/11. The DON stated that a CNA served Resident #1 the coffee on his breakfast tray. The DON stated that Resident #1 was in bed and served his breakfast tray on the over bed table. When Resident #1 reached for his coffee, he knocked the coffee on to his feet. The DON stated that a CNA was in the room with Resident #1, when he spilled the hot coffee and that they both yelled out for help. The DON was not able to recall who the CNA was at that time. The DON stated that she and RN #2 responded to the call and that Resident #1 was in bed with the bed covers over him and socks on his feet. The DON stated that Resident #1's socks held the hot coffee next to his skin and was possibly the reason why the burns were severe. The DON stated that she and RN #2 removed the socks and administered first aid per the attending physician's orders [REDACTED]. The DON stated that on Tuesday, April 5, 2011, the facility called the Family Nurse Practitioner (FNP) and asked her to come to the facility and evaluate Resident #1's burns. The DON stated that the (FNP) wrote an order on 4/6/11 to have Resident #1 seen at the out-patient wound care clinic for whirlpool debridement and evaluation. The DON stated that the wound care clinic saw Resident #1 for the first time on Thursday, April 7, 2011. The DON stated that Resident #1 was his own Responsible Party (RP). The DON stated that the facility had no Quality Assurance (QA) minutes and/or projects concerning Resident #1's hot coffee incident. The DON stated that the facility had no records of the coffee temperatures and had no knowledge of any coffee temperatures recorded before the incident occurred. The DON stated that the facility Incident Report was the only documentation that she was aware of following Resident #1's hot coffee burns. The DON stated that there was no investigation conducted in reference to Resident #1's coffee burn. Interview on 6/29/11 at 2:45 p.m., with the facility wound care nurse, RN #3, revealed that she was not working at the facility on 4/1/11, the day Resident #1 was burned. RN #3 stated that she dressed and treated Resident #1's burns on Saturday, April 2, 2011, and on Sunday, April 3, 2011. RN #3 stated that she is the wound care nurse for the facility. RN #3 stated that she wrote the date of 4/1/11 - 3rd Degree Burns for Resident #1 but she did not work that day. RN #3 stated that she wrote the 4/1/11 "Weekly Skin Report", after Resident #1 had seen the Physical Therapist (PT) at the out-patient wound care clinic on 4/7/11. RN #3 stated that she had originally assessed Resident #1 to have 2nd degree burns, but changed it to 3rd Degree burns after the (PT) had written "full thickness burn", which she felt meant 3rd Degree Burns. RN #3 stated that she does not have any documentation and/or assessments for Saturday, April 2, 2011, and Sunday, April 3, 2011, for Resident #1's burns. RN #3 stated that she did not document Resident #1's burns until after 4/7/11. RN #3 stated that she took one (1) picture of Resident #1's healing burns on 6/8/11. RN #3 stated that she took the picture that was dated 6/8/11 after the wounds were healing. Interview on 6/29/11 at 4:30 p.m., with RN #2, revealed that she and the DON were sitting across the hall from Resident #1's room when they heard yells for help. They went into Resident #1's room and found him to have hot coffee soaked socks. RN #2 and the DON took off Resident #1's socks and immediately put cold water on Resident #1's feet per the MD's orders. RN #2 stated that Resident #1 had his own travel cup and it was sent to the dining room for the staff to fill with coffee. The coffee was delivered to Resident #1's room by the facility staff and served to Resident #1 in bed. Resident #1 spilled the hot coffee on his own feet. RN #2 stated that Resident #1 used his own travel cup at times. RN #3 is not 100% sure what cup Resident #1 had used at the time of the burn. Interview on 6/29/11 at 10:00 a.m., with the Dietary Manager (DM) revealed that there were no coffee temperature records prior to Resident #1's coffee burns. The DM stated that there had been no recorded temperatures of the coffee after Resident #1's coffee burns. The DM stated that she was not aware of any assessments of Resident #1's ability to handle hot coffee prior to or after the coffee burn. The DM stated that the coffee was brewed in the dietary department and sent out to the various areas. The DM stated that the nursing staff served and dispensed the coffee. The DM stated that she had no knowledge of any Quality Assurance (QA) projects that were conducted by the facility prior to Resident #1's burns or after Resident #1 was burned regarding serving hot liquids. The DM stated that the facility does have some "sippy cups" available for those residents that ask for them. The DM stated that she had no knowledge of any residents in the facility that have been assessed for safety with hot beverages. Interview on 6/29/11 at 10:45 a.m., with the attending Physician and Medical Director (MD) of the facility, revealed that the (FNP) evaluated Resident #1 on 4/6/11, and wrote an order to have Resident #1 treated at the out-patient wound care clinic. The MD stated that when he was initially called on 4/1/11, it was reported to him that Resident #1 had no blisters, only redness. The MD stated that the blisters appeared later and that was when the FNP was called to evaluate Resident #1. The MD stated that Resident #1 had healed nicely. The MD stated that he was the Chairman of the QA Committee in the facility and was present at the QA meetings. The MD stated that he remembers QA discussing Resident #1's burn. The MD stated that he does not know where the conversations were written and/or documented but he remembers the QA committee discussing hot coffee burns. The MD stated that the dietary department was given the directive to order "sippy cups" (safety cups with screw on lids) for those residents that needed them. Observation on 6/29/11 at 5:30 p.m., of Resident #1, revealed that he was lying in bed with the head of the bed elevated. The overbed table was in front of the resident with his supper tray. Observation and interview on 6/30/11 at 11:00 a.m., with Resident #1, revealed that he was sitting in a geri-chair in the front lobby. Resident #1 stated that he was going on a van ride because he had not been able to get out and do anything because he had been confined to his room in isolation for an infection to his burned feet. Interview on 6/29/11 at 2:45 p.m., with the out-patient wound care clinic Physical Therapist (PT), revealed that the clinic does not have a Physician on staff there. The PT stated that no Physician saw Resident #1 at the out-patient wound care clinic. PT stated that she received an order from the (FNP) to treat Resident #1's wounds. The PT stated that the clinic does not stage wounds and does not [DIAGNOSES REDACTED].#1's feet were full thickness burns and the treatments were faxed to the MD after each treatment, and he signed the evaluations that she faxed. The PT stated that Resident #1's first visit was on 4/7/11, and that the burns were severe and looked bad. PT stated that the wounds had to be debrided via the whirlpool and via sharps debridement with a scalpel. PT stated that Resident #1 had an infection to his feet several weeks after the burn. PT stated that it was within the scope of practice for PT to use sharps debridement of wounds without additional orders from the MD. (PT) stated that the initial (FNP) order to treat and debride wounds were all the orders needed for the treatment and evaluation. Interview on 6/29/11 at 3:10 p.m., with LPN #1, revealed that she was the nurse assigned for care on 4/1/11 for Resident #1. LPN #1 stated that she was across the hall from Resident #1 when she heard Resident #1 yell out for help. LPN #1 stated that she was alone in Resident #1's room when she discovered a "sippy cup" of coffee had spilled on the resident's feet. LPN #1 stated that she was upset that the "sippy cup" did not have the lid on securely. LPN #1 stated, "I got upset with my CNA about the lid." LPN #1 stated that Resident #1 did not have on socks to his feet. LPN #1 stated that she ran and got the DON and RN #2 to come help her with Resident #1's burns. LPN #1 stated that she does not remember which CNA was assigned to Resident #1 on 4/1/11. LPN #1 stated that the CNA assigned to Resident #1 on 4/1/11 was responsible for the cup of coffee that was served to Resident #1. LPN #1 stated that she completed the Incident Report and called the Physician for first aid orders to treat Resident #1. Interview on 6/30/11 at 7:23 a.m., with the Family Nurse Practitioner (FNP), revealed that she was called on Tuesday and was asked to come on 4/6/11 and write orders for out-patient wound care whirlpool debridement for Resident #1, due to a hot coffee burn to his feet. FNP stated that she saw Resident #1's burns and looked at the burns. FNP stated that the burns looked bad and that the nurses stated that the burns had worsened over the weekend and they wanted him referred to the wound care clinic for debridement. FNP stated that she was not a specialist in burns and did not know how to evaluate the degree of burns. The FNP stated that she knew that an expert needed to see to the burns. The FNP stated that she did not measure or stage the burns, she relied on the evaluations of the facility nurses. FNP stated that the MD had been notified and was aware of the burns. The FNP stated that she has never seen Resident #1 prior to this visit on 4/6/11, and had not seen him since that day. The FNP does not have any knowledge when a Physician saw Resident #1's burns. The FNP stated that she never discussed Resident #1 with the MD. Interview on 6/30/11 at 9:30 a.m., with RN #2, revealed that Resident #1 had declined in his Activities of Daily Living (ADL's) prior to the burn and required assistance with all of his (ADL's). RN #2 stated that Resident #1 was unable to operate his motorized wheel chair and was confined primarily to a geri-chair prior to the burn. RN #2 stated that she had no knowledge of a Physician seeing Resident #1's burns and no knowledge of Resident #1 being evaluated by a Physician until the MD made rounds on 4/15/11. RN #2 stated that she made rounds with the MD on 4/15/11. RN#2 reported that the MD did not look at Resident #1's burns. RN #2 stated that the MD looked at the bandages and saw that they were dry and intact and that he did not want her to remove the bandages. RN #2 stated that Resident #1 was seen at the out-patient wound care clinic. RN #2 stated that Resident #1 had to be hospitalized twice for antibiotics to be given by IV due to infections in the burns. RN #2 stated that Resident #1 first went to the hospital in May 2011, and then again later. Interview on 6/30/11 at 9:50 a.m. with Certified Nurse Assistant (CNA #1), revealed that she was working on 4/1/11 and had no knowledge of the burn. CNA #1 stated that she did not serve any coffee to Resident #1 on 4/1/11. CNA #1 stated that CNA #3 was assigned to Resident #1 on 4/1/11. CNA #1 stated that all she knew about the burn was that she was asked to bring ice to the room for the nurses to put on Resident #1's feet after the burn. Interview on 6/30/11 at 12:20 p.m., with the (Name of Company) representative revealed that he was informed not to give any written information to the facility or to any one. The representative stated that they were notified on 6/29/11 about someone being burned by hot coffee. The representative stated that was the first date anyone from the facility had called. The representative stated that the machines were installed in the facility in February 2011 and no concerns had been reported until 6/29/11. The machines were installed to have a high temperature of 186 degrees F. and a low of 150 degree F. The representative stated that In-services were conducted by the sales representative to the facility staff in February 2011. Interview on 6/30/11 at 2:30 p.m., with the family of Resident #1, revealed that she was in the facility to see Resident #1 at least one (1) to two (2) times each week. The family member stated that she does not have much recall concerning the chain of events surround