Every finding on record at Focused Care at Hogan Park

Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for 5 of 5 residents (Residents #1, #3, #4, #5 and #6) reviewed for wheelchair cleanliness; Resident wheelchairs were dirty and in poor repair. (Residents #1, #3, #4, #5, and #6) This failure could place residents at risk for injury or decreased quality of health related to poor maintenance of resident care equipment. Findings included:Resident #1Review of Resident #1's admission Record, dated 7/22/26, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral ischemia (a blood clot blocks a specific blood vessel to the brain, a type of mini-stroke), lack of coordination, and muscle weakness. Review of Resident #1's Initial MDS assessment dated [DATE] revealedHe had a BIMS score of 15 of 15 (indicating he was cognitively intact)He used a wheelchair. Review of Resident #1's Care Plan, dated 7/3/26, on ADL self-care performance did not address mobility or use of a wheelchair. Resident #3Review of Resident #3's admission Record, dated 7/22/26, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness on one side of the body), muscle wasting and atrophy, history of transient ischemic attacks (mini-stroke). Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed:He had a BIMS Score of 10 of 15 (indicating moderate cognitive impairment)He had upper and lower extremity impairment on one side and used a wheelchair. Resident #4 Review of Resident #4's Quarterly MDS Assessment, dated 4/23/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia.He had a BIMS score of 13 of 15 (indicating he was cognitively intact).The 4/23/26 MDS indicated he used a walker. Resident #5Review of Resident #5's admission Record, dated 7/27/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hemiplegia (one-sided paralysis) following a stroke. Resident #5 was still in her MDS Assessment window and one had not been completed yet. Review of Resident #5's initial care plan, dated 7/17/26, revealed she used a wheelchair. Review of Resident #5's emergency visit, dated 7/17/26 documented Resident #5's cognition was severely impaired. Resident #6Review of Resident #6's admission Record, dated 7/24/26, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (any condition causing difficulty breathing). Review of Resident #6's admission Screener, dated 7/18/26 revealed no ambulatory devices used. Interview on 7/27/26 at 1:50 p.m. a confidential group of 4 residents, the residents stated wheelchairs were not cleaned. Observation and interview on 7/27/26 beginning at 3:06 p.m. showed:Resident #5's wheelchair seat had a brown substance ground into the wheelchair seat, and the brake had a build-up of grime on it.Resident #6 stated the facility did not wash his wheelchair.Resident #1 stated hell no they don't clean my wheelchair.Resident #4's wheelchair had an accumulation of food particles in the seat, and the back grommet was detached from the frame.Resident #3's wheelchair had a buildup of grime on it. Interview on 7/28/26 at 11:00 a.m. the DON stated the wheelchairs were supposed to be cleaned by the night shift. The DON said 'they were thinking about having the wheelchairs cleaned opposite of the residents' shower day. The DON stated the night charge nurses were responsible for monitoring that the wheelchairs were cleaned. The DON stated currently there was no schedule for the wheelchairs to be washed, and it was brought to her attention last week. The DON said she had not checked wheelchairs for cleanliness. The DON said previous places she worked at had a schedule for cleaning wheelchairs. The DON said it was not done and she was not going to make excuses why it was not done. The DON said it needed to be done. The DON said the Administrator gave the nightshift brushes. She checked the shower room and verified there were no scrub brushes in the shower room. Observation and interview on 7/28/26 beginning at 1:22 p.m. revealedResident #5's wheelchair seat was brown. The DON stated she would not want to sit on that.Resident #4's wheelchair had the accumulation of food debris and grime. The DON said she would not want to sit in the wheelchair and the back grommet coming off the frame was unsafe. Review of the facility's policy and procedure on Maintenance Services, dated 2/1/27, revealed: It addressed the grounds and building, but not wheelchairs or other resident equipment.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 3 of 5 carts (MA Cart Station 1, MA Cart Station 2, Treatment Cart) reviewed for labeling and storage. The facility failed to ensure the MA Medication Carts and the Treatment Cart were locked and secured when staff were not present. This failure could place the residents at risk of gaining access to unlocked medications which were not prescribed to them. The findings included:Observation on 7/22/26 beginning at 9:59 a.m. revealed:The MA Medication Cart Station 1 was unlocked and unattended.The MA Medication Cart Station 2 was unlocked and unattended.The Treatment Cart was in a hallway unlocked and unattended, the Treatment Nurse was not in the room the cart was parked by. Observation on 7/22/26 at 11:15 a.m. revealed the MA taking vital signs for the resident, she left the medication cart station 1 unlocked and unattended with residents walking past. The MA left the medication cart unlocked and unattended for 5 minutes. Observation on 7/27/26 at 10:48 a.m. revealed the treatment cart unlocked and unattended in the hallway. Observation and interview on 7/27/26 at 12:00 p.m. revealed the treatment cart was left unlocked and unattended. The DON stated the carts were not supposed to be left unlocked and unattended as she locked the cart. Interview on 7/27/26 at 1:22 p.m. the DON stated the ADONs did rounds every 2 hours and were supposed to check that medication carts were locked while they were unattended. A policy for medication carts was requested. No policy on locked medication carts was provided.

Based on interview and record review, the facility failed to ensure residents were provided with reasonable access to receive their mail in a timely manner for 1 of 3 residents (Resident #2) reviewed for resident rights. The facility failed to respect residents' right to privacy and opened their personal mail. (Resident #2) The facility failed to deliver financial mail to residents. (Resident #2) This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials. The findings included:Based on interview and record review, the facility failed to ensure residents were provided with reasonable access to receive their mail in a timely manner for 1 of 3 residents (Resident #2) reviewed for resident rights. The facility failed to respect residents' right to privacy and opened their personal mail. (Resident #2) The facility failed to deliver financial mail to residents. (Resident #2) This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials. The findings included: Review of Resident #2's admission Record, dated 7/28/26, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: quadriplegia (unable to use all extremities), reduced mobility, and pressure sore to the sacral area (lowest part of the back). Review of Resident #2's quarterly MDS Assessment, dated 5/21/26, revealed:She had a BIMS score of 15 of 15 with no signs or symptoms of delirium (indicating she was cognitively intact).She had range of motion impairment on all extremities and used a wheelchair.She was dependent on staff for all ADLs There was no care plan related to Resident #2's desire to get mail unopened. Review of Resident #2's admission packet revealed nothing about permission for the facility to open her mail. Interview on 7/24/26 at 3:45 p.m. Resident #2 stated the staff opened her mail from Medicaid, scanned it into the computer and then put it in a file. Resident #2 said the staff did not deliver the mail to her, so she was not notified of an increase in services and now she has a back bill she did not know how she was going to pay for her back bill. Resident #2 said she was very upset about it. Interview on 7/27/26 at 10:00 a.m. the BOM and receptionist stated the regional BOM trained the receptionist to open mail. Interview on 7/27/26 at 10:02 p.m. the Receptionist stated the Regional Accounts Manager trained her to open Medicaid/Medicare and Social Security mail and upload it to the electronic record. The Receptionist said the residents were not given their letters, it was put into a file or a binder. The Receptionist stated the rest of the mail was delivered by the Activity Director unopened. The Receptionist said she was trained from the very beginning of her employment to open the Medicaid/Medicare/Social Security mail. The Receptionist said she was never told she could not open residents mail. During an interview on 7/27/26 at 10:14 a.m. the Administrator stated they had a new Director of Records and she did not know how to distinguish facility mail and resident mail from Medicaid/Medicare and Social Security. The Administrator stated that it was duplicated information since the facility got the same letter as the residents and the addresses at the top was hard to read. The Administrator stated Resident #2 complained every time Social Security increased their money, but she did not get more than $75 for her Personal Needs Allowance. Interview on 7/27/26 at 1:50 p.m. a confidential group of 4 residents, one of the residents stated they did have their financial mail opened. The residents felt the Receptionist got it mixed up with facility mail because the building got so much mail and she did not look at it. Follow up interview on 7/28/26 at 3:35 p.m. Resident #2 stated she was still angry the facility opened her mail no and did not her of the bill increase. Resident #2 asked how was she supposed to know what was going on in her life if she did not get her mail. Resident #2 stated she was in her right mind and there was no reason she should not get her mail. Resident #2 stated she felt powerless over her life because she could not even control her finances. Review of the facility's policy and procedure on Resident Rights, revised 12/2016, revealed:Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:Manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes)Access to a telephone, mail, and email; Review of the Rights and Protections as Nursing Home Resident, undated, documented:Get proper privacy, property, and living rights. You have the following rights: to have privacy in sending and getting mail and email.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored foods were properly stored, labeled, and dated. The facility failed to ensure prepared food was discarded after 7 days per facility policy. The facility failed to ensure personal food items were not stored in the kitchen refrigerators. The facility failed to ensure Dietary Staff wore hair nets and beard guards properly when entering the kitchen.The facility failed to protect clean silverware and dishes from contamination. These failures could place residents at risk of food-borne illnesses. The findings included:During the initial tour of the kitchen on 4/13/2026 at 9:35 AM, the following was observed: Dietary Staff-Director of Food Services wore a hairnet that partially covered her hair.-Food Service Manager #B wore a hairnet that partially covered her hair. Freezer #1-a bag of French fries was opened and not sealed. Freezer #2-a box of smoked sausage was opened and not sealed-a box of cheese omelets was opened and not sealed Dry storage-a plastic bin of rice was not labeled with an open date or a use by date.-a plastic bin of flour was not labeled with an open date or a use by date.-a plastic bin of sugar was not labeled with an open date or a use by date.-a box of cream of wheat was opened and not sealed. -a package of brown sugar was opened and not sealed.-the floor underneath, between, and behind shelves was littered with trash, dust, and a sticky black substance. Food Prep Area-a loaf of bread was opened and not sealed.-a bag of hamburger buns was opened and not sealed.-plastic drawers containing cooking and serving utensils had dirt and crumbs in the bottom.-serving utensils and colanders were hanging on hooks and not covered.-baking pans on a shelf were facing up and not covered. Refrigerator #1-a bag of ham was opened, not sealed, did not have an open date, and had a use by date of 4/7.-a bag of sliced turkey was opened, not sealed, did not have an open date, and had a use by date of 4/7.-a bag of boiled eggs was opened, not sealed, and did not have an open date.-a bag of an unknown breaded item was not labeled with item name, open date, and use by date.-a bag of parmesan cheese had an open date of 04/08/2026 and did not have a use by date.-a bag of shredded cheese was opened, not sealed, had an open date of 04/06/2026 and did not have a use by date.-a pitcher labeled ketchup had an open date of 03/31/2026 and a use by date of 04/05/2026.-a carton of nutritional drink was opened and did not have an open date and use by date.-a carton of nutritional drink was opened, had an open date of 3/23 and did not have a use by date.-a metal storage container labeled sliced strawberries with sugar had an open date of 10/04/2024 and did not have a use by date.-a bag of an unknown yellow item was not labeled with item name, open date, and use by date. Spice shelf #1-a bottle of parsley was opened and did not have an open date.-a bottle of season salt had an open date of 3/12 and a use by date of 4/3. Spice shelf #3-a bottle of salt was opened and not sealed.-a bottle of creole seasoning was opened and not sealed. Milk Refrigerator-an open bottle of soda.-a bottle of water. Dish Area-clean silverware was not covered.-clean dessert plates were facing up and not covered.-clean bowls were facing up and not covered. Kitchen Floor-the floor underneath, between, and behind shelves, oven, steam table, and prep table was littered with trash, dust, and a sticky black substance. During a follow-up visit to the kitchen on 4/15/2026 at 11:15 AM, the following was observed: Dietary Staff-Food Service Assistant #F wore a hairnet that partially covered his hair and did not have a beard cover on. During a follow-up visit to the kitchen on 4/16/2026 at 11:25 AM, the following was observed: Dietary Staff-Food Service Assistant #F wore a hairnet that partially covered his hair and did not have a beard cover on. In an interview on 4/16/26 at 1:00 PM with the Director of Food Services, she said she was aware of multiple items not being sealed properly and not being labeled properly. She said she had reminded dietary staff several times previously and both the sealing and labeling were still not done correctly. The Director of Food Services said the soda and water bottle in the Milk Refrigerator were staff items and they should not have been in the Milk Refrigerator. She said the hairnets supplied by the facility were not large enough to cover all a person's hair. She said beard covers were provided by the facility and Food Service Assistant #F should wear one. The Director of Food Services said Dietary Staff was responsible for cleaning the floors in all areas of the kitchen. She said they should not just clean around items; they should clean under and behind them as well. The Director of Food Services said her expectations were for these things to be performed correctly and the Dietary Staff know her expectations. She said she was responsible for ensuring these items were conducted correctly and policies were followed. She said these failures can cause foodborne illnesses and cross contamination. Record review of the facility policy Personnel Hygiene revised 10/2023, revealed in part: Food and Nutrition Services staff will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. All staff who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Staff will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Hair nets or other hair restraint to be worn by employees at all times in the kitchen. Facial hair must be covered with a facial hair restraint.Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Record review of the facility policy Food Storage revised 04/11/2022, revealed in part: Stock will be rotated first-in, first-out. Food removed from its original packaging will be labeled with the following-receive date, open date, and contents in the package. Opened package or leftover food is to be tightly wrapped or covered in airtight, clean containers. It should be labeled, dated with the opened or use by date. Do not keep leftovers in the refrigerator for more than 7 days. All refrigerators and freezers have thermometers that are monitored daily. Employee beverages and food will be in a closed container stored in designated employee area away from food area. Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 06/19/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observations and interviews the facility failed to dispose of garbage and refuse properly for 2 of 4 dumpsters reviewed for food safety requirements. Two dumpsters were observed uncovered with garbage inside. This failure could affect residents by placing them at risk of foodborne illness, illnesses, and rodents or be provided an unsafe, unsanitary and uncomfortable environment. Findings:Observation on 04/15/2026 at 11:20 AM, of the outside dumpsters outside, revealed:One dumpster was missing 1 of 2 lids. The dumpster had trash in it.One dumpster had 1 of 2 lids with a broken hinge and hanging off the side of the dumpster. The dumpster had trash in it.Interview on 04/16/2026 at 1:00 PM, with the Director of Food Services, revealed she said she was aware of the 2 dumpsters not functioning correctly and had not reported them to the administrator. She said she did not know she needed to report it. The Director of Food Services said the two dumpsters not closing was a concern because it can attract pests and may not contain trash when the wind blows. Interview on 04/16/2026 at 1:15 PM, with the Administrator, revealed she said she was not aware of the two dumpsters not closing. She said the Dietary Services Manage should have reported it to her. She said that was not acceptable and she will take care of it immediately. The Administrator said this would attract insects, mice, and cats. No policy on garbage and refuse disposal was provided by time of exit on 04/16/2026 at 2:15 PM.

Based on observations, interviews and record review it was determined the facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 2 nurse medication carts (hall C and D) observed for expired medications. The C and D nurse medication cart had one insulin pen that was found expired. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.Findings included: Record review of Resident #36's admission record dated 04/15/2026 revealed he was admitted to the facility on [DATE] with diagnosis of diabetes type 2. He was [AGE] years of age. Record review of the current care plan for Resident #36, last reviewed/revised: 12/16/2025, revealed in part: The resident will have no complications related to diabetes. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #36's physician orders dated 04/15/2026. Humalog injection insulin. Inject as per sliding scale: subcutaneously before meals and at bedtime diabetes type 2. Observation and interview on 04/13/2026 at 9:40 AM the nurse medication cart for halls C and D was inspected with the DON present. Inside the cart were a total of 2 separate insulin pens that had expired or had no open dates written on them. An insulin pen that belonged to Resident #36 had a date of 02/28/2026 inscribed on it. The DON said the insulin pens were supposed to be dated when opened and disposed of when expired. The DON said after an insulin pen was opened it was good for like 30 days. The DON said it was expected for the nurses to date the insulin pens when they were opened and to dispose of them when they had expired. The DON said normally the insulin was good for 30 days after it was opened. The DON said if the insulin pens were not dated then staff would be unable to tell when the medication was expired, then it was possible for the expired medication to be administered. The DON said if the staff administered an expired insulin medication it could have negative effects on the resident such as not lowering their blood sugar. Interview on 04/16/2026 at 01:14 PM the Administrator said the expired insulin pens should have not been in the nurse medication cart. The Administrator said if an insulin pen was not dated then how would staff know when it was expired. The Administrator said if an expired medication was administered to a resident there was a possibility of them having a bad reaction to the medication. Record review of the facility's policy titled Vials and ampules of injectable medications and dated 08/2020 indicated in part: Vials and ampules of injectable medications are used in accordance with the manufacture's recommendations or the provider pharmacy's directions for storage, use and disposal. Medication in multi-dose vials may be used until the manufacturer's recommended expiration date if inspection reveals no problems during that time. USP guidelines recommend discarding multi-dose vials at 28 days after opening. The date opened and the triggered expiration date should be recorded on a label for such purpose affixed to the vial. (USP = United States Pharmacopeia).

Based on observations, interviews and record review it was determined the facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals administering of drugs for 1 of 2 nurse medication carts (hall C and D) observed for medications storage.The C and D nurse medication cart had one insulin pen that had been opened but had no open date was found on it.This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.Findings included:Record review of Resident #39's admission record dated [DATE] revealed she was admitted to the facility on [DATE] with diagnosis of diabetes type 2 . She was [AGE] years of age.Record review of the current care plan for Resident #39, last reviewed/revised: [DATE], revealed in part: The resident will have no complications related to diabetes. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Record review of Resident #39's physician orders dated [DATE]. Lantus subcutaneous (under the skin) Solution Pen-injector 100 UNIT/ML Inject 10 unit subcutaneously one time a day for diabetes type 2.Record review of Resident #36's admission record dated [DATE] revealed he was admitted to the facility on [DATE] with diagnosis of diabetes type 2. He was [AGE] years of age.Record review of the current care plan for Resident #36, last reviewed/revised: [DATE], revealed in part: The resident will have no complications related to diabetes. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Observation and interview on [DATE] at 9:40 AM the nurse medication cart for halls C and D was inspected with the DON present. Inside the cart were a total of 1 insulin pens that had no open dates written on it. An insulin pen that belonged to Resident #39 that had been opened had no open date inscribed on it. The DON said the insulin pen was supposed to be dated when opened. The DON said after an insulin pen was opened it was good for like 30 days. The DON said it was expected for the nurses to date the insulin pens when they were opened. The DON said if the insulin pen was not dated then staff would be unable to tell when the medication was expired, then it was possible for the expired medication to be administered. The DON said if the staff administered an expired insulin medication it could have negative effects on the resident such as not lowering their blood sugar.Interview on [DATE] at 01:14 PM the Administrator said an undated insulin pen should have not been in the nurse medication cart. The Administrator said if an insulin pen was not dated then how would staff know when it was expired. The Administrator said if an expired medication was administered to a resident there was a possibility of them having a bad reaction to the medication. Record review of the facility's policy titled Vials and ampules of injectable medications and dated 08/2020 indicated in part: Vials and ampules of injectable medications are used in accordance with the manufacture's recommendations or the provider pharmacy's directions for storage, use and disposal. Medication in multi-dose vials may be used until the manufacturer's recommended expiration date if inspection reveals no problems during that time. USP guidelines recommend discarding multi-dose vials at 28 days after opening. The date opened and the triggered expiration date should be recorded on a label for such purpose affixed to the vial. (USP = United States Pharmacopeia).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #70) reviewed for infection control in that; CNA C failed to change her gloves after they became contaminated during incontinent care while assisting Resident #70. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Record review of Resident 70's electronic admission record dated 04/14/2026 indicated she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. She was [AGE] years of age. Review of Resident #70's care plan revised on 01/10/2026 indicated in part: I am incontinent of bowel/bladder and I am at risk for skin breakdown. I will remain clean, dry, and odor free with no occurrence of skin breakdown over the next 90 days. Monitor for incontinence Q2H/PRN, change promptly and apply protective skin barrier. Record review of Resident #70's quarterly MDS assessment dated [DATE] indicated in part: Bladder and bowel: Urinary continence = Always incontinent. Bowel continence = Always incontinent. Observation on 04/14/2026 at 9:12 AM CNA C performed incontinent care for Resident#70. The CNA entered the resident's room, washed her hands and then put some gloves on. CNA C then undid Resident #70's brief and turned the resident on her left side. The CNA then took some wet wipes and wiped the resident's rectal area. While still wearing the same gloves, CNA C turned the resident on her back and took some wet wipes and cleaned the resident's vaginal area. While wearing the same gloves the CNA took a clean brief and fastened it to the resident. While wearing the same gloves CNA C took the bed sheets and covered the resident then she removed her gloves. Interview on 04/14/2026 at 4:48 PM CNA C said she should have changed her gloves before she wiped Resident #70's vaginal area and fastened the resident's brief on her. The CNA said she should have changed her gloves before she covered the resident with the covers. CNA [NAME] said that not having changed her gloves could have led to possible cross contamination and infections. The CNA said she had forgotten to change her gloves at the appropriate times. Interview on 04/16/2026 at 10:56 AM the DON said the staff was expected to change their gloves before going from dirty to clean. The DON said if staff did not change their gloves then that could lead to cross contamination and possible urinary tract infections. The DON said they staff will be monitored by her and the RN supervisors who will also be conducting more training on incontinent care. Interview on 04/16/2026 at 01:12 PM the Administrator said it was her expectation for the staff to change their gloves after they became contaminated. The Administrator said that if staff did not change their gloves then it could possibly lead to infections. Record review of the facility policy titled Perineal Care dated 10/01/2021 indicated in part: To provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. Steps in the Procedure - Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Put on gloves. Wash perineal area, wiping from front to back Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of the facility's policy titled Infection Control and dated 10/25/2022 indicated in part: This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. This communities' infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteers, works and the public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status or payor source. The objective of our infection control policies and practices are to: prevent, detect, investigate and control infections in the community. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors and the public. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for residents in one bathroom (Sink 1 and Sink 2) of 5 sinks reviewed for environment.The facility failed to maintain 2-bathroom sinks shared by rooms [ROOM NUMBERS], effecting 6 Residents.This failure could affect all residents that share bathroom sinks and place them at risk for diminished quality of life due to the lack of a well-kept environment. Record review of Resident 22's electronic admission record dated 04/14/2026 indicated he was admitted to the facility on [DATE] with diagnoses of Seizures and Heart Failure. He was [AGE] years of age.Record review of Resident 37's electronic admission record dated 04/14/2026 indicated he was admitted to the facility on [DATE] with diagnoses of Acute kidney failure and type 2 diabetes. He was [AGE] years of age.During an interview on 4.13.26 at 2:05 pm Resident #22 stated that there was no running water in his bathroom. He stated that he let maintenance know a couple of days ago, but nothing had changed. He stated he would like at least one of the two sinks to work so he could shave and wash his hands after using the restroom.During an interview on 4.13.26 at 4:15 pm Resident #37 stated that he could not remember exactly how many days there had been no running water in the bathroom sinks. He stated that he knew Resident #22 let the Maintenance Director know because he was in the room when Resident #22 told the MD. He stated he does not use that restroom very often but it would be nice to have running water in it so when he did use the restroom he could wash his hands.During an observation on 4.13.26 at 2:15 pm both sinks in the restroom shared by rooms [ROOM NUMBERS] had no pressure, which resulted in no running water. rooms [ROOM NUMBERS] were shared by Residents #22 and #37.During an interview on 4.14.26 at 2:45 pm the CMD stated that the process for any issue in the building that was associated to maintenance should be put in the maintenance log book which was at each nursing station. He stated that he did not know that there was no running water for the residents in rooms [ROOM NUMBERS]. He said he would get with the maintenance director immediately to get this fixed.Record review on 4.14.26 of the maintenance request log book dated April 2026 indicated: no request had been made for the sinks to be fixed for rooms [ROOM NUMBERS].During an interview on 4.14.26 at 3:45 pm the maintenance director stated he does not remember any resident or employees letting him know that the sinks shared by rooms [ROOM NUMBERS] were not working. He stated that this will be fixed immdiately because it was not healthy for the residents to not have running water in their bathroom. He stated this could put the residents at risk of getting sick and not having a homelike environment. He stated that he did round on the facility and that no other Resident's bathroom sinks were not working.During an interview on 4.15.26 at 2:45pm the DON stated she did not know the residents did not have running water in their bathroom sinks that was shared between rooms [ROOM NUMBERS]. She stated this needed to be fixed immidiately. She stated this puts the residents at risk of getting sick by not washing their hands and not a homelike environment for them in their rooms.Record review of facility policy titled, Maintenance Service, dated 2.1.17, indicated:The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.Functions of maintenance personnel include, but are not limited to:Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.Maintaining the building in good repair and free from hazards.Maintaining the fire alarm system and emergency generator system in good working order.Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.Maintaining lighting levels that are comfortable and assuring that exit lights are in good working order.Establishing priorities in providing repair service.Maintaining the paging system in good working order.Maintaining the grounds, sidewalks, parking lots, etc., in good order.Providing routinely scheduled maintenance service to all areas.Others that may become necessary or appropriate.

Based on interview and record review the facility failed to promptly notify the physician or physician's representative when laboratory results fell outside of the clinical reference range in accordance with facility policies and procedures for 1 (Resident #1) of 6 residents reviewed for lab services. The facility failure to relay the test results from Resident #1 to the physician as per facility Lab Monitoring & Lab Orders Policies and Procedures. The failure placed residents at risk of delays in receiving the necessary interventions to treat their medical condition. Findings included: Record review of Resident #1's admission record, dated 02/10/2026, revealed admission on [DATE], to the facility. Record review of Resident #1's history and physical dated 01/29/26, revealed a [AGE] year-old male with a diagnosis of Schizoaffective Disorder, Bipolar Type, Post-Traumatic Stress Disorder, and Constipation. There was no indication of Diabetes Mellitus noted. Record review of Resident #1's quarterly MDS assessment, dated 01/14/2026, revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #1 did not have a diagnosed of diabetes nor was he coded under Section N - Medications for Insulin Injections under part A or B. Record review of Resident #1's care plan, dated 02/10/26 revealed that Resident #1 did not have focus area for Diabetes nor interventions for diabetes. Record review of Resident #1's Order Summary Report reviewed on 02/10/26, revealed Resident #1 did not have any orders for insulin or blood glucose monitoring. Risperdal Oral Tablet 2 MG (Risperidone) Give 2 mgby mouth two times a day (Anti-psychotic medication). Start 08/14/2024 Record review of Resident #1's Progress Notes dated 01/28/26, revealed Resident #1 ambulating pushing his wife who was pushing a full grocery cart from the local store full of snacks (chips, drinks, and other items.). Resident #1 informed the nurse that he was having stomach aches and had been taking a lot of stuff to make him poop and he had pooped. Resident #1 took prune juice, enema, and Lactulose. Resident #1 informed that Since he has so much bowel prep that even though he had a BM he might have stomachache from that. Progress Note dated: 01/29/26 - Revealed in 10:47 a.m., ambulating about the facility, no c/o spasms or pain. NP here. Negative KUB and Resident #1 notified. Revealed at 8:26 p.m., complained of foul bowel odor, smelling breath, and feeling nausea. New orders give for CBC, CMP, and Colace BID. Progress Note dated: 01/30/26 - Revealed at 4:10 p.m., Resident #1 was alert and oriented enjoying foods related to activities. Progress Note dated: 02/02/2026, 1:20 p.m. revealed, Called EMS 911, resident alert and oriented x3 (Resident was alert, knew who he was, where he was), clean and dry, transferred to hospital per request. Report given to ER nurse. Record review of the 24-Hour Report dated 01/29/26, revealed Resident #1 - negative on KUB. Fleets of enema given. Colace BID (Given twice a day), Labs reviewed negative outcome. CBC and CMP were done. - 01/30/26, revealed CBC drawn in the am (morning). Record review of Resident #1's laboratory results dated , Friday 01/30/2026, revealed his blood glucose level was 934 (Reference/normal range 74-109). It also indicated, Critical results called to (Resident #1's doctor) at 12:23 p.m. central time by lab tech. Read back and verified? Y). (Note: The lab directly called the doctor and not the facility. Record review of Resident #1's hospital records, dated 02/02/2026, revealed in part: Chief complaint via EMS from facility c/o abdominal pain x 3 days, acid reflux. Pt has been having high glucose readings x1 week reading high. Kussmaul respirations (an abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace. It's a sign of a medical emergency - usually diabetes-related ketoacidosis (DKA), which can affect people with diabetes and people with undiagnosed Type 1 diabetes). [AGE] year-old male, bilateral blindness, chest burning since last three days. He was also complaining of polyuria (Urinating a lot) and poor appetite and glucometer reading as high since last one week. He was never diagnosed with diabetes in the past. Blood work showed glucose 743. Diabetic [NAME] Acidosis (a serious health condition that could happen as a result of diabetes. It could be life-threatening). Assessment/Plan of Lactic Acidosis, Diabetic Ketoacidosis, and newly diagnosed diabetes mellitus on 02/02/26. Plan - s/p 2 L NS in ER, Will give 2 more liters of LR fluid boluses start DKA protocol insulin and IV fluids. NPO for now ok meds and ice chips. Routine chemistry: Glucose levels 2/3/26 = 195, 2/4/2026 = 297, 2/5/2026 = 155. Start statin once tolerating diet transfer to PCU (Progressive Care Unit).02/04/2026 Seen and examined no acute distress patient states overall feeling slightly better, blood sugars back in the 400s though this morning augmented insulin basal, continue to monitor likely discharge tomorrow if glucose much more controlled. Continue IV fluids, increase Lantus insulin to 40 units with 10 units preprandial continue sliding scale, will give additional bolus today. 02/05/2026 discharge recommendations: return to long term, care planned treatmentd discharge/discontinue OT treatment evalution complete: Yes. During an interview on 02/06/2026 at 1:25 p.m., the Treatment Nurse said on Thursday, 01/29/2026, Resident #1 told the doctor he was not feeling well. The Treatment Nurse said Resident #1 told the doctor he felt nauseous and his poop smelled bad and asked the doctor if he wanted to test his stool and the doctor said no but ordered some labs. The Treatment Nurse said she filled out the lab sheet and placed it on the lab book, she said the lab usually arrived the next day. The Treatment Nurse said Resident #1 did not request to go to the hospital at that time nor did he appear in distress. The Treatment Nurse said the following day (01/30/2026) after the labs were drawn that the lab normally calls the facility but for some reason they contacted the doctor. The Treatment Nurse stated the physician did not contact the facility. The Treatment Nurse said that on Saturday 01/31/2026 at about 9:30 a.m. Resident #1 asked her about his lab results but told him to ask LVN B because she was his nurse at that time. The Treatment Nurse said she had not witnessed if Resident #1 had asked LVN B about his lab results. During an interview on 02/06/2026 at 2:00 p.m., LVN C said she worked on Monday (02/02/2026) at 6:00 a.m. to 2:00 p.m. shift. LVN C stated she checked on Resident #1 and he was pale and talking differently. LVN C said the resident was awake and alert, so she checked his vital signs, and his blood pressure was high, and Resident #1 asked about his lab results. LVN C said she recalled that Resident #1 had had some labs done so she went to check to see if the results were back. LVN C said she looked at the Ring App and Resident #1's blood sugar was at 945 on his lab results which was at a high critical level. LVN C said she checked Resident #1's blood sugar with their glucometer and it was 478. LVN C said Resident #1 was sent to the hospital. LVN C said she did not understand why the laboratory had not called because whenever there were critical value results, they called to make them aware ASAP. LVN C said she worked on Friday 01/30/2026 when the lab results were done but no one from the laboratory or doctor's office called with the critical values since the doctor was contacted about the critical values around noon. LVN C said, at shift change, she discussed with the night shift what was on the 24-hour report and there was nothing about Resident #1's lab results. (Note: the ring app is an app that is located on the nurse's computer, and they can view lab results when they login to the app). During a telephone interview on 02/06/2026 at 3:30 p.m., the NP said if a resident had a critical lab result, it was expected for the facility to contact them. The NP said it also depended on what lab it was because at times it could be treated at the facility. The NP said the blood glucose of 934 was high but, if reported to Resident #1's doctor and not her, she would not know what Resident #1's doctor would do. The NP said Resident #1's doctor needed to be interviewed as to why he had not called the facility to report the high blood sugar result. During an interview on 02/06/2026 at 4:47 p.m., ADON F said efax would send the labs directly to the Ring App and then staff would print them off and fax them to the doctor and called them if there was a critical value. ADON F said any nurse could monitor the app and print the labs from there. ADON F said all the nurses should know about that app and they recently did an in-service to make sure all nurses knew about it. ADON F said they also placed the orders on the 24-hour report. ADON F said they started doing the daily lab tracking log which was also initiated. ADON F said a negative outcome from a person going without treatment for high blood sugar could be a diabetic coma or pass out. During a telephone interview on 02/06/2026 at 5:12 p.m., LVN B said she worked at the facility on the weekend of 31st of January through the 1st of February 2026. She said Resident #1, on Saturday 01/31/2026, complained of feeling nauseous and issues with going to the restroom. LVN B said she gave Resident #1 a fleets enema and medication for nausea. LVN B said Resident #1 was able to go to the restroom and the medication had made him feel better and there had been no problems after that. LVN B said Resident #1 after the treatment had felt better. LVN B said ADON D gave her Resident #1's lab results on 01/31/2026 and told her to fax them to the doctor. LVN B said she did not pay attention to the lab results since it indicated the doctor was already aware. During a telephone interview on 02/10/2026 at 8:48 a.m., the Laboratory Technician said, in case of critical value results, it was their protocol to call the location or doctor who ordered the lab test. The Laboratory Technician said they would fax the orders if they were requested from the facility or doctor's office but did not know about an app that the facility could submit the labs electronically. The Laboratory Technician said she was not sure why the doctor had been contacted about the critical results instead of the facility. The Laboratory Technician said it could have occurred because whatever label was on the test tube would have been the person they notified. During a telephone interview on 02/11/2026 at 1:52 p.m., LVN B said on 01/31/2026 ADON D brought her the lab result from Resident #1 and told her to fax them to the doctor. LVN B said ADON D did not mention anything else besides faxing them to the doctor. LVN B said that she had not reviewed them and only faxed them as she assumed that ADON D had viewed them already and had done something about it. LVN B said she had reviewed the 24-hour report and had not noticed any pending lab orders. LVN B said again that she had not actually viewed the labs that she saw the MD was aware and there were no new orders. LVN B said she assumed ADON D viewed them before he handed them to her and he did not say anything about critical value on the lab sheet. LVN B said a negative outcome to a resident with high blood sugar could be them feeling horrible and going into diabetic ketoacidosis. During a telephone interview on 02/11/2026 at 2:48 p.m., ADON D said that he had worked on Saturday 01/31/2026 and saw on the Ring App there were labs pending and printed them out. ADON D said he printed them out and handed them to LVN B to include in Resident #1's records. ADON D said he told LVN B to either call or contact Resident #1's doctor with the lab results. ADON D said he had not seen the results and had just printed the results out and handed them to each of the nurses. ADON D said if he had seen the critical lab values he would have contacted the doctor himself. ADON D said a negative outcome could have occurred from a critical level of high blood sugar could be that the resident could have passed away. During a telephone interview on 02/10/2026 at 10:05 a.m., The Medical Director said he did not recall if he got a call from the laboratory on Friday 01/30/2026 regarding Resident #1. The Medical Director said normally the facility called him with critical values and they were good at doing that. The Medical Director said he did recall if they sent Resident #1 to the hospital. The Medical Director asked what the critical lab was and was told the glucose of 934 and said he would have sent Resident #1 to the hospital. The Medical Director said the negative outcome could have been several things such as diabetic ketoacidosis. During an interview on 02/12/2026 at 10:56 a.m., the Administrator said she was monitoring the lab reports by looking at them on the TEAMS (A messaging app to communicate with other people). The Administrator said that the ADON or DON would monitor the labs that were coming in from the lab and then they would fill out the lab tracking form on TEAMS. The Administrator said that on 01/30/2026 she was out of the country so the previous DON and ADON were the ones monitoring that. The Administrator said the nurses should have reported the high blood sugar to the doctor and not just assumed the doctor knew about it. The Administrator said if a resident with a critical level of high blood sugar was not treated timely, they could go into a diabetic coma or die. During a telephone interview on 02/27/26 at 9:55 AM, the Medical Director stated that it would be hard to determine if Resident #1 had not gone to the hospital would have resulted in in death. The Medical Director stated he was not sure if sending Resident #1 sooner to the hospital would have prevented harm. The Medical Director stated the nurse should have called him instead of assuming that he was notified and followed the facility policy of notifying him. The Medical Director stated he did not recall getting called by the Laboratory Technician on the critical lab value. The Medical Director stated if he would have recalled or received the call from the Laboratory Technician he would have sent the resident to the hospital and the same if the facility had called him, he would have done the same thing which was send Resident#1 to the hospital. During an interview on 02/27/26 at 4:22 PM, ADON F said it was expected for ADON D to have reviewed the lab report before ADON D handed it to LVN B. ADON F said LVN B should have reviewed the lab report(s) before she faxed or sent the results to the doctor as per facility policy. During a telephone interview on 02/27/26 at 4:42 PM, LVN B said she had sent the lab results to the Medical Director on 01/31/2026. LVN B said she had not received confirmation that the results had gone through. LVN B said she only worked at the facility PRN and was not too familiar with how the facility's process/policy was done regarding faxing/notification of the lab results. LVN B again denied she had reviewed the lab results and denied Resident #1 had ever asked her to read him the lab results. During a telephone interview on 02/27/26 at 5:10 PM, the Medical Director stated that if LVN B had faxed him the results or texted the results it would be impossible for him to remember that. The Medical Director said that there was no way to see if he had received the text back on 01/31/2026 or the fax at his office. The Medical Director stated the facility should have followed there policies. Record review of the facility policy titled, Lab monitoring, dated 05/2021 revealed, in part It is the policy of this community that physician ordered laboratory services will be provided and monitored. All lab results will be reviewed by a nurse. The nurse will date and document the time the result was reviewed. Critical lab results will be called to physician or on-call physician immediately. Initially, date and time of the lab result. Inform the DCO regarding the abnormal lab values. If a reply is needed and there is no reply within 24 hours, you must call the physician's office and notify them of the abnormal value. The physician's office is to be notified daily until there is a response. Record review of the facility policy titled, Lab orders, dated 08/2021, revealed in part, It is the policy of this community to provide or obtain laboratory services to meet the needs of its residents. The community is responsible for the timeliness of the services. The community must notify the attending physician of the lab results. The DCO/designee will be responsible for monitoring lab orders to ensure that all ordered labs have been drawn as ordered by the physician. Lab tracking is to be documented daily on the Daily Lab Tracking Form. Ensure that all labs ordered have been collected with results communicated to MD/family in a timely manner. Proof of notification to be included on lab report sheet and/or in the nurse's notes. The EDO must periodically check the lab tracking book on a random basis to ensure DCO/designee is complaint with the process. The attending physician will be notified promptly of lab results.

Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 6 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's Safe Smoking Assessment record did not accurately document the resident's smoking status. This failure could place residents at risk of inaccurate records with the potential for inadequate care and treatment. Record review of Resident #3's admission Record dated 11/06/25, revealed admission to the facility on [DATE]. Resident #3 was a [AGE] year-old female with diagnoses of acute respiratory failure and Type 2 Diabetes Mellitus (a disease in which the body does not control the amount of sugar in the blood and kidneys).Record review of Resident #3's MDS dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment.Record review of Resident #3's care plan dated 10/09/25, revealed: Focus- Resident is a smoker; Goal-The resident will not smoke without supervision through the review date; and Intervention-The resident requires supervision while smoking.Record Review of Resident #3's Safe Smoking Assessment completed by RN B, dated 08/09/25, revealed Section B Summary, the following items were check-marked:The resident is safe to smoke unsupervised, at this time.The resident requires direct supervision while smoking.The resident requires a fire-resistant smoking apron while smoking.All smoking materials will be kept at the nurse's station.Care plan is up to date or dated.The evaluation has been discussed with the resident.An interview with Resident #3 on 11/10/25 at 12:19 PM, revealed, Resident #3 said she has been able to smoke unattended since she was admitted and she does not have to wear a smoking apron. Resident #3 said staff hold her supplies and light cigarettes for her.An interview with RN B on 11/12/25 at 10:32 AM, revealed, RN #B said the error on the Safe Smoking Assessment for Resident #3 must have been a typo and she was not sure what she meant to check because it had been 3 months, and she has worked at different facilities.

Based on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the residents' status for 2 of 6 residents (Resident #3 and Resident #4) whose assessments were reviewed:Resident #4's quarterly MDS did not accurately reflect the resident's level of consciousness.This failure could place residents at risk for inadequate care due to inaccurate assessments. Findings included:Resident #4Record review of Resident #4's admission Record dated 11/06/25, revealed admission on [DATE] and a readmission on [DATE]. Resident #4 was a [AGE] year-old male with diagnoses of heart failure and Type 2 Diabetes Mellitus.Record review of Resident #4's MDS dated [DATE], revealed: Section B-Hearing, Speech, and Vision; and B0100 Comatose, Persistent vegetative state with a code of 1. Yes-Skip to GG0100. This error resulted in sections C. Cognitive Patterns (BIMS), D. Mood, and E. Behavior to be skipped. Observation on 10/29/25 at 1:25 PM, revealed Resident #4 in his wheelchair, conscious, conversing, and following instructions provided by staff. Interview with Resident #4 on 11/10/25 at 12:37 PM, revealed Resident #4 said he has not been in a comatose state while in the facility.Interview with the MDS Coordinator on 11/10/25 at 3:00 PM, revealed the MDS Coordinator said she was not aware of the error, it was a typo, and Resident #4 had not been in a comatose state while at the facility. The MDS Coordinator said she was responsible for generating the MDS's. The MDS Coordinator said the risk of inaccurate MDS's is inappropriate care.Interview with the DON on 11/12/25 at 12:00 PM, revealed the DON said she performs random reviews of MDS's, and she was not aware of the error on Resident #4's MDS. The DON said the MDS Coordinator was responsible for completing the MDS's for each resident. The DON said whichever nurse is working at the time the Safe Smoking Assessment is due, is responsible for completing it. The DON said she started reviewing all Safe Smoking Assessments about 1 month ago, but she had not reviewed Resident #3's Safe Smoking Assessment.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #6) of 3 residents reviewed for infection control. 1. The facility failed to ensure CNA A, and the Treatment Nurse turned the water faucets off with a paper towel after washing hands while providing wound care to Resident #6.2. The facility failed to ensure the Treatment Nurse used each 4X4 gauze once while performing wound care to Resident #6. These failures could place residents at risk for cross contamination and the spread of infection. Findings include:Record review of Resident #6's admission record dated 10/29/25, indicated a [AGE] year-old male admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses included Type 2 Diabetes Mellitis (a disease in which the body does not control the amount of sugar in the blood and kidneys), metabolic encephalopathy (a change in how your brain works due to an underlying condition), and chronic heart failure. Record review of Resident #6's MDS dated [DATE], indicated: BIMS of 00, meaning the resident was severely cognitively impaired and never/rarely made decisions. Section M - Skin Conditions = Resident had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.Record review of Resident #6's care plan, dated 10/27/25, indicated: Focus- The resident has DTI (deep tissue injury) right great toe; Goal- The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date; Interventions/Tasks- The resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate.Focus- The resident has stage 4 pressure injury to left heel, history of ulcers; Goal- The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date; Interventions/Tasks- Administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning.Record review of Resident #6's Order Summary Report dated 10/29/25 revealed: Right great toe DTI Dressing Change Frequency: Daily, Clean Wound With: Wound Cleanser Primary, Treatment: Betadine open to air every day shift for wound healing, effective 10/07/25; Left heel stage 4 Dressing Change Frequency: Daily, Clean Wound With: Wound Cleanser Primary, Treatment: Betadine Other Dressings: Gauze, Wrap with Kerlix, wear heel protectors every day shift for wound healing, effective 10/07/25.Observation of wound care on Resident #6's right big toe on 10/29/25 starting at 10:50 AM revealed: the Treatment Nurse used one 4x4 gauze, wet with wound cleanser, and wiped the wound three times; and the Treatment Nurse used one 4x4 gauze, wet with Betadine, and wiped the wound four times. Observation of wound care on Resident #6's left heel on 10/29/25 starting at 11:15 AM revealed: CNA A turned the faucet on with contaminated hands, performed handwashing, and turned the water faucet off with bare hands; the Treatment Nurse turned the faucet on with contaminated hands, performed handwashing and turned the faucet off with bare hands; the Treatment Nurse removed the dressing on Resident #6's heel, performed hand hygiene; the Treatment Nurse used one 4x4 gauze, wet with wound cleanser, and wiped the wound four times; the Treatment Nurse used one 4x4 gauze, wet with Betadine, and wiped the wound four times; and dressed the wound with gauze and Kerlix. Interview on 11/12/2025 at 12:00 PM, the DON said her expectations after performing hand washing is for all staff to use a paper towel to turn the faucet off. The DON said gauzes, wipes, etc. should never be used more than 1 swipe/wipe due to possibility of cross contamination and infections. The DON said the Treatment Nurse has been trained in wound care and preventing infections, and all CNAs have been trained on hand washing.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. - The facility failed to ensure that prepared food stored in the refrigerator was labeled and dated. - The facility failed to ensure that lids were sealed on spices kept in the dry storage room. - The facility failed to ensure that food stored in the refrigerator and dry storage room was in sealed containers. - The facility failed to ensure the overall cleanliness and sanitation of the kitchen and its storage areas. The findings included: Observation of the kitchen on 01/14/25 from 9:28 AM -10:32 AM revealed the following: - juice machine spigot/holder with red liquid collecting in bottom of holder and red buildup at mouth of holder that was sticky to touch - floors visibly dirty throughout kitchen and dry storage area (food and other debris noted on the floor in all areas); - one large metal bowl with clear plastic wrap cover containing yellow food noted in refrigerator with no label or date; - one package of pre-sliced yellow cheese noted in refrigerator; plastic package was torn open and discoloration and hardening of the edges of the 7 slices of cheese in package; - five 16-ounce bottles of spices (nutmeg received 1/18/24, ground oregano received 2/19/24, ground oregano received 11/20/24, ground allspice received 2/6/23, poultry seasoning received 2/6/23) noted on metal shelf in dry storage with lids open; - large clear plastic storage container labeled flour noted on shelf in dry storage with flour covering the lid of the container and surrounding storage containers; - large clear plastic storage container labeled pasta noted on shelf in dry storage with loose pasta noted in the bottom of the container; the container did not have a lid; - white tile on wall to either side of stove with visible brown droplet stains that were greasy to touch; - food debris, greasy/gritty stains, and dust build-up noted under the stove which was being held level by wooden shims under the front feet; wooden shims were heavily stained; - 3 basin sink area noted to have mildew odor coming from under the sink where chemical/soap container the fed the sinks was stored; - mildew odor noted in area under dishwasher; - black fuzzy debris noted to wall behind dish drying racks; - ceiling mounted outlet next to steam table and plate rack with build-up of black/dark brown substance and visible dust and dirt on top; substance was gritty and greasy to touch. In an interview on 01/14/25 at 10:35 AM, the Dietary Manager stated that the kitchen was only allowed one cook and one dietary aid per shift to cook, clean, serve, and wash dishes and they had trouble keeping up with deep cleaning. He stated that the kitchen could only be spot cleaned (cleaning up spills or washing dishes) while food was being prepared and served so the staff had to wait until after the evening meal or come in overnight to deep clean. He stated that he did not have staff to work overnight and that he had come in himself to clean on several occasions. He stated that he had requested additional staff and was told no by the corporate office. He stated that all the dietary staff had been trained on labeling/dating/storing food by him when he started in the position of Dietary Manager, and he had no explanation for the unlabeled and open items in the refrigerator or the open lids on containers in the dry storage. In an interview on 01/16/25 at 4:29 PM, the Interim Administrator stated he was aware of the issues in the kitchen regarding sanitation. He stated that the kitchen was not clean. He stated that all facility staffing was done per the corporate staffing formula, and it was not likely to be changed to allow for cleaning staff. He stated that due to his being interim, he would bring it up with the regular Administrator when she returned. In an interview on 01/16/25 at 4:57 PM, Maintenance Director stated that cleaning was the responsibility of the food services staff, but he was aware that the kitchen needed to be deep cleaned per the facility schedule. He stated he was not aware of the mildew smell coming from the 3 basin sink and dishwasher areas. In an interview on 01/16/25 at 5:11 PM, the DON stated she was aware that the kitchen was not clean or sanitary. She stated that the facility's kitchen was not under her oversight but there were ongoing issues since before she started as DON in October of 2024. Review of facility policy titled Food Safety in Receiving and Storage, dated 04/2022, revealed, in part: Food is stored in its original packaging as long as the packaging is clean, dry, and intact.Food that is repackaged is placed in a leak-proof, pest-proof, non-absorbant, sanitary container with a tight-fitting lid. The container/lid is labeled with the name of contents and dated with the date it was transferred to the container. Dry bulk foods (i.e. flour, sugar) are stored in seamless metal or plastic containers with tight covers, or bins that are easily sanitized.Containers are cleaned regularly. Storeroom floors will be swept and mopped daily. Review of facility policy titled Kitchen Cleaning Schedule, revised 11/2023, revealed, in part: Food and Nutrition Services Personnel will be responsible for maintaining the cleanliness and sanitation of kitchen.The Director of Food & Nutrition Services is responsible for utilizing the kitchen cleaning schedule template and assigning tasks to staff on a daily, monthly, and annual basis. Review of Food Code 2022 Recommendations of the United States Public Health Service Food and Drug Administration revision date 01/18/2023 revealed, in part: 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination

Based on observation, interview, and record review, the facility failed to ensure residents maintained the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility reviewed for resident rights. The facility failed to ensure all residents had the right to receive visitors between 9:00 PM and 9:00 AM. This deficient practice placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life. The findings included: Observation on 01/14/2025 at 9:00 am revealed a sign on the front door entrance that read Resident visiting hours: 9:00 AM to 9:00 PM. For the safety of our residents and in order for the staff to take care of the residents and the residents to have a quiet time of rest, visiting hours are from 9:00 AM to 9:00 PM During a confidential resident council meeting on 01/15/2025 at 1:45 PM Ombudsman stated that the administrator had been informed multiple times that the visiting hours posting was not within regulation standards. Ombudsman stated that the administrator was aware of the regulation and refused to take down the sign. During an interview with Administrator interim and DON on 1/16/2025 at 12:47 pm DON stated that prior to being hired in September 2024 the administrator had placed visiting hours on the door. DON stated that she was told this was done because there were vagrants and drug dealers coming into the facility and the administrator wanted to try to prevent this from happening. Stated that they do not enforce the visiting hours but keep the sign as a deterrent. The interim administrator did not have anything to add as he was not the acting administrator. 01/16/25 6:00 PM No policy available for visitation hours according to interim Admin.

Based on observation and interview, the facility failed to provide reasonable access to the use of a telephone for residents to have private conversations for 1 of 1 facility reviewed for resident rights. The facility failed to provide the residents a telephone where they could talk without being overheard. This deficient practice placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life. Findings included: In a confidential group interview with 6 residents on 01/15/2025 at 1:30 pm, it was revealed that resident's conversations can be overheard. During the interview it was revealed resident's do not have a dedicated phone for them to make phone calls. They are allowed to use the phones at the nurse's station and at the front reception area. The resident's stated they do not like to use these telephones because they are located in an area that is not private and their conversations can be overheard. In an interview on 01/16/2025 at 12:47 pm the DON stated that there had not been a designated phone for resident's since she was hired in September 2024. DON stated that the reason she was told that there was a resident that would call 911 six plus times a day. This resident was very confused. The residents are now allowed to use the phones that are located at the nurse's station and at the front reception desk. DON stated there was no telephone where the residents are able to have a private phone call. Interim administrator did not have anything to add as he was covering for administrator while she was on vacation. 01/16/25 6:00 PM No policy available for Telephone privacy per interim Admin.

51011 Based on observation, interview, and record review, the facility failed to ensure personal privacy was provided for 2 (#23 and #37) of 3 residents reviewed for dignity. The facility failed to ensure staff treated Resident #23 with respect and dignity while performing wound care ensuring the door was closed and without the privacy curtain being closed all the way on 01/15/2025. CNA A did not close the window blind while providing incontinent care for Resident #37 on 01/16/2025. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: Record Review of Resident #23's face sheet revealed a [AGE] year-old male, who was admitted to the facility on [DATE] with a pertinent diagnoses of spinal stenosis-cervical region (narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs), functional quadriplegia (a condition that causes a person to be completely unable to move due to a severe disability or frailty), Diabetes Mellitus (chronic condition that occurs when the body does not produce enough insulin or cells do not respond to insulin properly), muscle wasting and atrophy [shrinking of muscle or nerve tissue], major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), neuromuscular dysfunction of bladder (a condition that causes bladder control problems due to nerve damage) and neurogenic bowel (a condition that causes bowel control problems due to nerve damage). Record Review of Resident #23's MDS dated [DATE] revealed Resident #23 with the BIMS of 00 indicating severe cognitive impairment). Record review of Resident #23's care plan revised 12/09/24 reflected the resident has stage 3 pressure injuries to left lateral ankle, coccyx, stage 4 pressure injury to right hip, and potential/actual impairment to skin integrity of the right outer ankle related to trauma. Record Review of Resident #23's physician orders dated 01/16/2025 revealed: Stage 3 pressure area to coccyx: cleanse with wound cleanser and 4x4 gauze, pat dry with 4x4 gauze, apply calcium alginate with honey (or equivalent to) to wound bed then secure with foam dressing every day shift every other day for Wound Healing. Stage 3 pressure area to left lateral ankle: cleanse with wound cleanser and 4x4 gauze, pat dry with 4x4 gauze, apply BETADINE to wound honey strip cut to wound size then secure with foam or dry dressing every day shift every other day for Wound Healing. Stage 3 pressure area to right outer ankle: cleanse with wound cleanser and 4x4 gauze, pat dry with 4x4 gauze, apply betadine to wound honey strip cut to wound size then secure with foam or dry dressing every day shift every other day for Wound Healing. STAGE 4 pressure injury to the right hip: cleanse with wound cleanser and 4x4s, pat dry with 4x4s, apply calcium alginate with honey (or equivalent to) to wound bed then secure with silicone super absorbent dressing every day shift every other day for Wound Healing Observation on 01/15/25 at 9:21 a.m. revealed the Wound Care nurse was unable to close the privacy curtain while providing wound care for Resident #23. Resident #23 was in the bed closest to the door. Resident #23's privacy curtain was not long enough to provide privacy from his roommate and the door to the hall (in case it was opened). The Wound Care nurse pulled the curtain as far as she could to allow privacy for Resident #23 from his roommate. The curtain ended at the foot of Resident #23's bed. Observation on 01/15/2025 at 10:08 a.m. revealed the Wound Care nurse opened the door half-way, took her gown off, went to a cart outside the door, retrieved gloves from the cart, put the gloves on, gathered the trash in the room, rolled Resident #23 to his right side, placed a pillow behind Resident #23's back and under his legs, and adjusted the pillows under Resident #23's head. These actions were performed by the Wound Care nurse while the door is half-way open and Resident #23 was lying in bed with only a shirt and brief on, legs bare. Then, the Wound Care Nurse covered Resident #23 with his blankets. During an interview with the Wound Care nurse on 01/15/2025 at 10:15 a.m. she stated the privacy curtain was not acceptable and she will report it. During an interview with Resident #23 on 01/16/2025 at 03:56 p.m. Resident #23 answered sometimes when asked if it bothers him when his brief and legs are showing with the door open. Resident #23 again answered sometimes when asked if it bothers him that the curtain does not close all the way to provide privacy from the door if opened, during care. Record review of Resident #37's admission record dated 01/16/25 indicated she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. She was [AGE] years of age. Record review of Resident #37's care plan dated 08/15/2024 indicated in part: Focus: Resident has an ADL self-care performance deficit related to disease processes. Disease Process. Goal: The resident will maintain current level of function through the review date. Interventions/Tasks: Personal hygiene: The resident requires extensive assistance by 1 staff with personal hygiene and oral care. Toilet use: The resident is not toileted. Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated in part: BIMS = 13 indicating the resident's mental status was cognitively intact. Bladder and Bowel was: Urinary Continence Always incontinent (no episodes of continent voiding). Bowel Continence - Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). During an observation on 01/16/25 at 4:08 PM CNA A performed incontinent care for Resident #37. CNA A entered the resident's room and explained to the resident what she was going to do and then closed the door and pulled the privacy curtain. CNA A then performed the incontinent care by uncovering Resident #37 and cleansed her vaginal and rectal area. During the personal care the window blind was not closed. The window faced an area where people would walk by as there was a convenience store next to the facility and the resident's bed was by the window. During an interview on 01/16/25 at 4:13 PM Resident #37 said the staff usually closed the window blinds to provide privacy but did not know why the staff had not this time. The resident said she would not like to be seen by people passing by while her private parts were exposed as that would be embarrassing to her. During an interview on 01/16/25 at 4:14 PM CNA A acknowledged that she should have closed the window blinds but had not thought about that. CNA A said she closed the privacy curtain and closed the door, but she probably got nervous and forgot to close the blind. The CNA said not closing the window blind could expose the resident to passersby and embarrass Resident #37 and violate her privacy rights. During an interview on 01/16/25 at 4:26 PM the DON said her expectations was for staff to provide privacy for residents when providing some type of personal care to prevent exposure of the resident. The DON was made aware of the observation of the wound care and incontinent care and how the staff did not fully provide privacy during the care for Residents #23 and #37. The DON acknowledged that the staff should have provided full privacy to prevent violation of the privacy and dignity rights. During an interview on 01/16/25 at 4:38 PM the Administrator was made aware of the observations listed above. The Administrator said he acknowledged that the nursing staff should have provided privacy during the patient care and would provide a policy of privacy. Record review of the facility's document titled Nursing services-competency evaluation dated 06/13 indicated in part: Prepare work area. Provide privacy (Pull curtain, close door/blinds).

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 6 dumpsters reviewed for food and nutrition services. - The facility failed to ensure that 2 of 6 dumpsters were placed on a concrete slab. - The facility failed to ensure that the area surrounding the dumpsters was free of garbage and other debris. - The facility failed to ensure dumpster doors for 3 of 6 dumpsters were when no staff were disposing of garbage . These failures could lead to an unsanitary environment and encourage the presence of pests. The findings included: Observation on 01/15/25 at 12:53 PM revealed a row of six commercial size dumpsters at the rear of the facility. Dumpster #1 was placed on dirt and a puddle was noted under the back corner with mud, loose garbage, and an odor coming from the water. Dumpster #1 did not sit flat and even - the rear, left corner of the dumpster was angled into the puddle. It could not be determined if the puddle had developed from the drain in the dumpster or recent snow. Dumpster #6 was placed on dirt and rocks. Dumpster #6 did not sit flat and even due to the rocks underneath. Three of six dumpsters (dumpsters #1, #2, and #6) had open lids at the time of the observation and no staff were observed in the area. In an interview on 01/16/25 at 4:29 PM, the Interim Administrator stated that he was not aware of the dumpsters not being on a slab since he was not the regular administrator. He stated he would need to look into what could be done with the city to fix the issue. In an interview on 01/16/25 at 4:57 PM, Maintenance Director stated he was not aware that two of the facility's six dumpsters were not placed on the proper surface and he would have to speak to the city's waste removal department about the slab under the dumpsters and their placement. He stated that the facility frequently had all 6 dumpsters full, and they could not be removed. Interview on 01/16/25 at 5:09 PM, the Interim Administrator stated that there was no facility policy or procedure regarding the proper placement of the dumpsters.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#21) of 2 residents reviewed for infection control. The facility failed to ensure the Wound Care nurse used PPE during wound care for Residents #21 as the resident was on EBP precautions. These failures could place resident's risk for cross contamination and the spread of infection. Findings included: Record review of Resident #21's admission record dated 01/16/2025 indicated she was admitted to the facility on [DATE]. Diagnoses included dementia, muscle wasting and atrophy, and heart failure. She was [AGE] years of age. Record review of Resident #21's MDS dated [DATE] indicated in part: BIMS = 5 indicating resident had severe impairment. Section M - Skin conditions = Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Record review of Resident #21's care plan dated 10/30/2024 indicated in part: Problem: The resident has unstageable ulcer to coccyx r/t disease process, history of ulcers, immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Record review of Resident #21's Order Summary Report dated 01/16/2025 revealed in part: Cleanse with wound cleanser and 4x4s.Pat wound dry with 4x4s. Apply calcium alginate to the wound. Cover wound with dry dressing. Change daily and every 4 hours as needed if dressing comes off or becomes soiled. Effective 01/12/2025. During an observation on 01/14/2025 at 10:18 a.m. the Wound Care Nurse performed wound care. The Wound Care nurse entered the resident's room, washed her hands, and put gloves on. The Wound Care nurse performed the wound care as ordered. The Wound Care nurse did not put on any type of PPE except gloves during the process. There was an EBP posting above the bed of Resident #21. During an interview on 01/15/2025 at 9:08 a.m. the Wound Care nurse stated she forgot to put a gown on. The Wound Care nurse stated she is aware of the requirement and the facility's policy. During an interview on 01/16/2025 at 6:40 p.m. the DON/Infection Preventionist (IP) said EBP was to be used for any resident with any MDRO (Multi-Drug Resistant Organisms), residents with chronic indwelling devices, and residents with pressure ulcers. The DON/IP said if the staff were going to be performing high-contact care, such as wound care, then they should use the PPE. The DON/IP said if the staff did not wear the correct PPE such as the gown and gloves that could lead to possible cross contamination for resident #21 and other residents. Record Review of the facility's policy and procedure titled Enhanced Barrier Precautions (EBP) dated 04/01/2024 indicated in part: EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted multi-drug resistant organism (MDRO), or who have open wound or indwelling medical device. Wounds generally include chronic wounds. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. High contact resident care activities include .wound care.

Based on observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 of 11 (Resident #1) residents reviewed for resident call system. The facility failed to provide a working communication system on 10/23/2024 that was easily at reach and that would allow Resident #1 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living. The findings included: Record review of Resident #1's admission record dated 10/23/24 revealed Resident #1 was a [AGE] year-old male with an admitted [DATE]. Medical diagnosis that included spinal stenosis (the narrowing of the space around your spinal cord or nerves), muscle weakness, muscle wasting, and quadriplegia (paralysis of both arms and legs). Record review of Resident #1's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 indicating a moderately impaired cognition. under Section GG - Functional Abilities and Goals revealed the resident requires Substantial/maximal assistance for oral hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene . Record review of Resident #1's care plan dated 09/25/24 revealed Focus - The resident is at risk for falls and fractures as evidence by: residents diagnosis of quadriplegia. Goal - The resident will be free of falls through the review date. Interventions/ Task - Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. And Focus - Resident has an ADL self-care performance deficit r/t disease processes. Resident has a diagnosis of quadriplegia. Goal - Will maintain ability to participate with self care at current level QD through review date. Interventions/ Tasks - Keep call light within reach and encourage resident to use it for assistance. Respond promptly to all requests for assistance. (resident uses specialized call light). Observation on 10/ 23 / 2024 at 11:50 a.m., revealed Resident #1 lying in bed asking for help. Resident #1 asked if surveyor would be able to get his call light to call staff into his room. Resident #1 stated he is able to use his call light as long as the staff give it to him and place it over his chest. Resident #1 stated the staff will clip it to his pillow, but they do not always ensure it is over his chest. Surveyor pressed the call light that was observed hanging off the side of the bed out of reach of Resident #1. An unknown staff entered the room, asked what was needed, turned off call light, and left. The staff did not give the resident the call light. Observation on 10/ 23 / 2024 at 1:11 p.m revealed Resident #1 lying in bed with the call light out of reach. Resident #1 stated that staff had come in to adjust him but did not give his call light to him before leaving. Observation on 10/ 23 / 2024 at 4:03 p.m., revealed Resident #1 lying in bed with the call light out of reach. Resident #1 stated one staff member, did not remember who, had come into the room because his roommate pressed the call light for him. Resident stated the staff member went to get help to place the resident in his wheelchair. Resident #1 did not have his call light in his reach . During an interview on 10/23/24 at 1:45 p.m., the DON stated it is expected of staff to answer the call light within 5 minutes, to do what is being asked of the resident, if need to come back actually come back to resident promptly, keep call light within reach. The DON stated she was not aware that Resident #1 was not being given his call light routinely. The DON stated she would ensure staff are in-serviced on importance of keeping call light within reach. No policy available for call lights .

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent leaving the facility unsupervised for 1 (Resident #1) of 4 residents reviewed for supervision. The facility failed to ensure Resident #1 was adequately monitored and she eloped on 01/08/23 with Resident #2. Resident #2 had discharged from the facility on 01/06/23 and was at the facility collecting his personal belongings on 01/08/23 and had the door code to go in and out of the facility. Resident #2 had Resident #1 leave with him. The facility failed to ensure that Resident #1, who had an order for a wander guard, was wearing it on 01/08/2023 when she eloped with Resident #2. An Immediate Jeopardy (IJ) was identified on 02/15/2023. The IJ template was provided to the facility on [DATE] at 4:26 PM. While the IJ was removed on 02/16/2023, the facility remained out of compliance at a scope of potential for more than harm that is not immediate jeopardy and a severity level of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect residents that were identified as an elopement risks and placed them at risk of serious bodily harm, physical impairment, or death. Findings included: Record review of Resident #1's admission record, dated 02/06/2023, indicated she was admitted to the facility on [DATE] with diagnoses of dementia and cognitive communication deficit. She was [AGE] years of age. Family member A was responsible party only; there were no POA or guardian listed. Record review of Resident #1's quarterly MDS assessment, dated 12/20/2022, indicated in part: BIMS = 06 indicating the resident had severe cognitive impairment. The MDS reflected her Functional status - Walking - resident required Supervision - oversight, encouragement, or cueing. Record review of Resident #1's care plan, dated 04/04/2022, indicated in part: Focus: Resident has impaired cognitive function or impaired thought processes r/t Res has cognitive loss (loss of memory, time sense and requires assistance with decision making) and Impaired decision making abilities, is not always understood or able to understand verbal and non-verbal expression Dementia: Goal: The resident will be able to communicate basic needs on a daily basis through the review date. Interventions/Tasks: Cue, reorient and supervise as needed. Ask yes/no questions to determine the resident's needs. Focus: Resident is an elopement risk/wanderer and is at risk for possible injury r/t impaired, safety awareness and diagnosis of dementia. Resident does attempt to remove wander guard bracelet. Goal: Resident's safety will be maintained throughout the review date. Interventions/Tasks: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Wander guard placed for resident's safety, bracelet will alert staff when resident attempts to exit doors of facility. Staff to monitor daily. Record review of Resident #1's physician's active orders as of 01/01/2023 indicated in part: Order status = active, check wander guard placement every shift related to unspecified dementia without behavioral disturbance. Start date 01/29/2020. Record review of Resident #1's TAR for the month of December 2022 indicated in part: Resident to have wander guard to right leg and was documented as NO (resident was not wearing her Wander Guard bracelet) for day shift from 12/01/2022 through 12/31/2022. Record review of Resident #1's electronic licensed nurse TAR for the month of January 2023 indicated in part: Resident to have wander guard to right leg. 01/01/2023 through 01/08/2023 indicated that the resident did not have the wander guard on as staff documented NO (resident was not wearing her Wander Guard bracelet) for Days, Evening and Night as indicated on the document. Record review of Resident #1's electronic nurses notes, completed by the SW and dated 01/03/2023, indicated in part: Family member A of Resident #1 called and stated she did not want Resident #1 to go anywhere with Resident #2, stating he would like to take her out for a few days and she just worried that he might take her out of the facility. Resident #1 was on a bracelet monitor and the SW advised Family Member A that the facility would make sure she did not leave with him. Record review of Resident #2's admission record, dated 02/02/2023, indicated he was admitted to the facility on [DATE] with diagnoses of anxiety disorder and high blood pressure. He was [AGE] years of age. Record review of Resident #2's admission MDS assessment, dated 12/19/2022, indicated in part: BIMS = 10 indicating the resident was moderately cognitively impaired. Record review of Resident #2's care plan, dated 01/03/2023, indicated in part: Focus: The resident is/has potential to be physically aggressive related to poor impulse control. Goal: The resident will demonstrate effective coping skills through the review date. Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Record review of Resident #2's electronic nurses notes dated 01/06/2023 7:33 PM completed by RN C indicated Resident called from home states that he does not intend to return to facility instead he will be living with his family member. He adds that he was grateful for being here and his needs were met then. He plans on stopping by the facility 1/7/23 to pick up his clothing but advised to call management on Monday during working hours to finalize the discharge process. Verbalizes understanding in an enthusiastic voice. On call person informed, as well as information written on the 24-hour communication report. Record review of Resident #2's electronic nurses notes dated 01/08/2023 10:08 AM completed by LVN A indicated Resident came to facility to get personal property. Resident stated he was moving home. Resident stated he was going to go to his car to put his things in and return to pick up his meds. Resident was made aware of care needs still needed, resident stated he would be ok with his [family member]. During an interview on 02/02/2023 at 11:12 AM the DON said she was called by facility staff on Sunday 01/08/2023 to make her aware that Resident #1 was missing. The DON said she asked other staff to call local hotels and such to see if they could find Resident #1. The DON said Resident #2 had come to the facility to pick up his personal belongings on 01/08/2023 at approximately 10:30 AM, as he had discharged himself from the facility on 01/06/2023. The DON said she came to the facility to help search for Resident #1, she said Resident #2's Family Member called the facility and told the staff that Resident #2 had Resident #1 with him but was not sure where they were at. The DON said she believed the facility staff called Resident #2's Family Member and then the family member apparently called the resident to see if he had her. The DON said the police arrived at the facility and they were in the process of putting out a silver alert when the police were notified that EMS had Resident #1 because Resident #2 had called 911 due to Resident #1 having an anxiety attack or something. The DON said when Resident #1 arrived at the facility with EMS the resident was very upset because she felt she had been taken away from her husband referring to Resident #2 and she wanted to stay with him. The DON said Resident #1 was assessed at the facility an no injuries were noted. The DON said Resident #1 was not wearing her wander guard when she arrived back at the facility and probably did not have it on before she went missing since she would not keep it on. The DON said Resident #1 was placed on 1 on 1 supervision until they transferred her to another facility that had a secure unit on 01/09/2023. The DON said she drove Resident #1 to the other facility and the resident was okay as she did not recall what had occurred the day before. The DON said Resident #2 had been at the facility for about 1 month and had gone out on pass one day and did not come back to the facility. The DON said Resident #2 was his own responsible party, could sign himself out and had the door code to go out the front door. The DON said they had other residents that also knew the door code as they were considered independent and were allowed to have the code to go out the front door unsupervised. The DON said after the elopement happened, they had the door code changed the next day, 01/09/2023, and said there was no code required to enter the facility from outside, but the code was needed to exit through the front door. The DON said the police did not arrest Resident #2 because they said the resident was not of sound mind and had a dementia. The DON said the police told them that if Resident #2 came to the facility again they could arrest him for trespassing. During an interview on 02/01/2023 at 2:52 PM the SW said she was called in to the facility on [DATE] due to Resident #1 missing. The SW said by the time she arrived at the facility the police were already at the facility. She said she gave the police a photo of Resident #1 and they sent out a silver alert. The SW said about 25 minutes later the police located Resident #1 because a previous facility resident (Resident #2) had called 911 from a local motel due to Resident #1 complaining of chest pain so EMS and the police went to the hotel. The SW said EMS then brought Resident #1 back to the facility and the police had refused to arrest Resident #2 because the resident had dementia according to the police. The SW said the resident was assessed by the facility nurse and no injuries were noted. The SW said Resident #2 had taken Resident #1 from the facility to a local hotel. The SW said Resident #2 was familiar with the facility since he lived there and knew how to go in and out of the facility plus, he knew the door code to the front door. The SW said on 01/03/2023 Resident #1's Family Member A told her that Resident #2 had asked her if he could take Resident #1 out of the facility to which she told him no and that she did not want him around her. The SW said when Family Member A told her about this, Resident #2 was still a current resident at the facility. The SW said she told the other staff at the facility about Resident #2 asking to take Resident #1 out of the facility but did not recall who she reported it to, and she also said that she had discussed it during the morning meeting the next day, 01/04/2023. The SW said she had not talked to Resident #2 about what Family Member A told her. During an interview on 02/03/2023 at 3:45 PM the DON said Resident #1 was not an elopement risk and had never attempted to leave the facility. The DON said the only reason Resident #1 had the wander guard was because the initial elopement assessment indicated she was a risk for elopement. The DON said the most recent elopement assessment was done on 10/24/2022 and she scored a 5 or medium risk and that did not necessarily require a wander guard plus she had never attempted to elope. The DON said Resident #1 had a history of removing the wander guard bracelet, would not keep it on and that it was care planned. The DON said Resident #1 had a physician's order for a wander guard and they should have discontinued that order a long time ago and updated the care plan. During a telephone interview on 02/03/2023 at 4:15 PM LVN A said on 01/08/2023 she was at the nurse's station when Resident #2 just showed up and told her that he was there to pick up his belongings. LVN A said she went with the resident to his room and observed him get his belongings. LVN A said she saw Resident #2 go out the front door and get into a white car driven by someone else. LVN A said the resident then came back inside and she gave him his medications and signed the AMA form and then he left in the white car. LVN A said after Resident #2 left the facility she saw Resident #1 sitting in the common area which was located by the front door. During an interview on 02/06/2023 at 9:46 AM the Treatment Nurse said one day Resident #1's Family Member A asked her about the moving boxes that were in the resident's room. The Treatment Nurse said Resident #2 had brought the boxes into Resident #1's room and had told her to put items in the boxes. The Treatment Nurse said she told Family Member A that her boyfriend (referring to Resident #2) had brought the boxes for Resident #1. The Treatment Nurse said she did not recall telling the DON or Administrator about the boxes or that Resident #2 had told Resident #1 to place her items in them. The Treatment Nurse said this had occurred around 01/03/2023. During a telephone interview on 02/06/2023 at 12:04 PM Resident #1's physician said if the resident no longer required a wander guard since she was not considered an elopement risk then they should have called him to have the order discontinued. During an interview on 02/06/2023 at 2:04 PM the DON said they had not done any training for the resident's that had the door code and allowed to go out the front door alone. The DON said the way it was determined as to which residents could be given the code was based if they were able to sign themselves out and had a high cognitive status. The DON said when Resident #2 was at the facility he was one of the residents that knew the code. During an interview on 02/06/2023 at 2:15 PM the Administrator said she was not sure how or which residents were allowed to have the front door code as she was still new at the facility. The Administrator said the DON would know more about how it was determined which residents were considered safe to go out of the facility unsupervised. The Administrator said she was aware there were some residents that knew the code and would go to the store next door. The Administrator said she had not been informed that Resident #2 had asked Resident #1's family member A if he could take her out or about the boxes seen in Resident #1's room. She said this was the first time she had heard about it. During a telephone interview on 02/06/2023 at 3:20 PM Resident #1's Family Member A said she was the resident's responsible party. She said she had visited the resident at the facility one day and Resident #2 approached her and asked if he could take Resident #1 out of the facility. Family Member A said she told him that he certainly could not, and Resident #1 became upset and told her that she could go out with Resident #2 if she wanted to and did not need her permission. Family Member A said she did not trust Resident #2 as Resident #1 was confused at times and had dementia. Family Member A said she told the SW that she did not want Resident #2 around Resident #1 because he had asked to take her out of the facility. Family Member A then said they could be friends but that he could not take Resident #1 out of the facility. During an interview on 02/07/2023 at 10:42 AM LVN B said she was going home for the day and as she went past Resident #1's room she observed some moving boxes in her room and that Resident #2 was standing outside in the hallway. LVN B said she reported it to the Administrator right away and the Administrator went and spoke to Resident #1 and told Resident #2 that he could not bring the boxes into Resident #1's room. LVN B said she was not aware that Resident #2 had asked Resident #1's Family Member A if he could take her out for a few days. LVN B said Resident #1 had never tried to elope or exit the facility. LVN B said she had not seen Resident #1 wearing the wander guard bracelet at all since she would not keep it on. LVN B said she had documented NO on Resident #1's treatment administration records because she did not have the wander guard on. During an interview on 02/07/2023 at 11:58 AM the DON said the day Resident #1 went missing someone at the facility said that maybe Resident #2 had taken her because he had brought Resident #1 some moving boxes. The DON said that on 01/08/2023 was the first time she had heard about the moving boxes and the first time she had heard that Resident #2 had asked Resident #1's family member A if he could take her out. The DON said they had not had their morning meetings that week of 01/03/2023 and could have been the reason the department heads had not discussed those issues. During an interview on 02/07/2023 at 5:22 PM the DON said she believed Resident #1 was able to be taken out of the facility due to Resident #2 knowing the code to the front door. The DON said the code had been changed since the day the incident occurred. The DON said Resident #1 did not know the door code and even if she was given the code, she could not recall the number or how to press the buttons. The DON said Resident #1 was very confused, knew where her room was, knew what her name was and knew who her family member A was but that was it. During a telephone interview on 02/14/2023 at 10:25 AM Resident #1 said she was doing okay at the facility she was currently at. Resident #1 said she did not recall living at another facility prior to being at the one she was at right now. Resident #1 said she did not recall Resident #2 and that she did not recall being married or wanting to get married with a gentleman that went by Resident #2's name. Resident #1 said she did not recall leaving a facility or going to a hotel with a man. During an interview on 02/14/2023 at 12:12 PM the SW said on 01/08/2023 when Resident #1 went missing and she came to the facility the police told her they called Resident #2's family member because when the facility staff tried to call Resident #2's family member, he would not answer the phone but did answer the police when they called Resident #2's family member. The SW said the family member told them that Resident #2 did have Resident #1 with him at a hotel, but that Resident #2 did not want to tell him what hotel they were at, and that Resident #2 told him that he would be bringing Resident #1 back to the facility in a couple of hours. The SW said she was not sure how Resident #2 took Resident #1 out of the facility, but that Resident #2 did know the door code to exit through the front door. The SW said she told staff about Resident #1's Family Member A request to monitor interactions between Resident #1 and Resident #2 and Family Members concerns about Resident #2 taking Resident #1 out of the facility (phone conversation on 01/03/2023). The SW said she had discussed it in their morning meeting the next day which was 01/04/2023, and she did not recall who was in the morning meeting but for sure the Administrator was since she called the meetings. The SW said she did not recall seeing any moving boxes in Resident #1's room before she eloped and that she did see some boxes in her room after Resident #1 was brought back to the facility after she eloped on 01/08/2023. The SW said Resident #1 was forgetful and did not believe Resident #1 had the capacity to plan to leave the facility with Resident #2. The SW said Resident #2 had the mental capacity to plan an escape. During an interview on 02/14/2023 at 1:26 PM the Treatment Nurse said the boxes had been in Resident #1's room for a while because they were full of items but that her clothes were still in her closet. The Treatment Nurse said she did not think to say anything to the DON and Administrator about it and since she did not feel like Resident #1 was packing to move out. The Treatment Nurse said one day (unable to voice the date) when she was leaving work for the day, she saw Resident #2 brining in some moving boxes that he got off a pickup which was driven by someone else. The Treatment Nurse said Resident #2 would take Uber and whatever else rides he could get and that he came and went from the facility as he chose since he was his own RP. The Treatment Nurse said a few days later she observed some of those boxes in Resident #1's room and the boxes had items in them. The Treatment Nurse said that she had not observed Resident #2 bringing the boxes into Resident #1's room herself but had later heard someone saying Resident #2 asking Resident #1 to put her stuff in the boxes. The Treatment Nurse said she believed it was CNA D that had witnessed Resident #2 bringing the moving boxes into Resident #1's room. The Treatment Nurse said she had not reported to anyone that she witnessed Resident #2 brining the moving boxes into the facility because it did not seem suspicious to her at that time. During an interview on 02/14/2023 at 1:42 PM CNA D said she had seen some boxes in Resident #1's room on 01/02/2023 and heard Resident #2 telling Resident #1 to pack her stuff and that she was leaving with him the following day. CNA D said she asked Resident #2 to leave the room and he told her that he did not have to. CNA D said she reported this to LVN B and that LVN B went and talked to Resident #1. CNA D said LVN B told Resident #1 that she could not leave the facility with Resident #2 because there was no indication from Family Member A that she was leaving. CNA D said Resident #1 told LVN B that Resident #2 had told her that they were leaving and getting married and to pack her stuff. CNA D said LVN B was the only person she recalled reporting this information to. CNA D said they kept an eye on Resident #1 because Resident #2 would leave the facility frequently as he was his own RP and could sign himself out. CNA D said she was working on 01/08/2023, the day Resident #1 went missing. CNA D said she was passing supper hall trays at approximately 5:00 PM when she did not see Resident #1 in the lobby area (where Resident #1 usually sat) so she told her co-worker that she could not find Resident #1. CNA D said they looked for Resident #1 and could not find her, so she told the LVN B about it and they contacted the DON and the Administrator. CNA D said she last remembered seeing Resident #1 sitting in the front lobby at approximately 4:00 PM. CNA D said she recalled seeing Resident #2 that morning on 01/08/2023 since he came to the facility to sign the paperwork to discharge himself. CNA D said at that time Resident #2 did not take anything and he wanted to stay at the facility until he could get a ride because apparently Uber only dropped him off. CNA D said Resident #2 was not allowed to stay in the facility because he was no longer a resident and he had to leave so the Resident #2 left. CNA D said Resident #2 came back later in the afternoon to pick up his belongings and she witnessed him going out the front door. CNA D said as Resident #2 was leaving Resident #1 was sitting at the front lobby and asked him when they were leaving and getting married. CNA D said Resident #2 told Resident #1 that they would talk about it later and then he left. CNA D said when she noticed Resident #1 was not walking around the facility as usual and was not in the front lobby where she usually was, and she thought that maybe Resident #2 had taken her. CNA D said Resident #1 could be very confused and wander around the facility and ask where she was or have incontinent accidents in her brief and when she was not as confused, she could toilet herself, so she had days of being more confused than others. CNA D said she believed Resident #1 did not really comprehend what it would mean to have a relationship with another resident because some days she was very confused and forgetful. An Immediate Jeopardy was identified on 02/15/2023 at 4:26 p.m. due to the above failures. The Administrator and the DON were informed of the IJ. The Administrator was provided with the IJ template on 02/15/2023 at 4:26 p.m. The Plan of Removal was accepted on 02/16/2023 at 1:28 PM and reflected the following: Interventions: Plan of Action Door codes changed on 1/9/23 and 2/9/23. Residents no longer have access to door codes; staff will open for residents and visitors as needed. Resident at immediate risk was transferred to sister facility on 1-9-23. All residents will have a current Elopement Assessment done by DCO/ADCO/charge nurse to be completed by 2/15/23. Residents have updated Kardex (desktop file system that gives a brief overview of each resident and is updated every shift) for those identified at high risk for elopement based on updated elopement assessments, by the DCO or regional DCO on 2-15-23. New admissions will be evaluated upon admission identified as at risk for elopement will have identification form added to elopement binder. Care plans updated to reflect any changes in elopement status based on new assessments conducted by DCO. In-service initiated on 1/8/23 and ongoing on Elopement policy and procedure by DCO/EDO and Staff in-serviced on the policy. 1 to 1 in-service with EDO/DCO by RVP regarding Elopement policy and interventions to reduce risk of elopement with residents who are at risk or exit seeking. In-service provided by RVP and RDCO on 2/15/23 to the Social Worker regarding elopement policy and grievance policy with special focus on communication to EDO/DCO. In-service completed 2/15/23 on all staff reporting suspicious/unusual activity to DCO or Administrator. All residents with orders for wander guards were checked 2/7/23 and 2/15/23 to check for functioning of wander guards. LTAR was reviewed 2/16/23 to ensure that staff is checking and documenting daily. In-service completed 2/16/23 that all staff must notify DON, ADON, or Administrator immediately and not to just document no. Physician's orders will be reviewed daily at clinical meeting. RDCO will spot check to ensure this is being completed. In- service completed 2/16/23 on identifying changes of condition and notification to physician and responsible party. In-service completed 2/16/23 on what to do if wander guard is not in place. Staff is required to notify DON, ADON, or Administrator. One on one supervision with resident should occur until wander guard replaced or resident moved to secure unit. ADCO will monitor LTAR to ensure that documentation is accurate. In-service completed 2/16/23 on communicating pertinent information and changes in condition and documenting it as well on the 24-hour report sheet. Department heads will relay information to all departments at daily stand up unless information is urgent or needs immediate attention. New staff will be trained on information during orientation by ADON. An agency education binder will be placed at nurses' station for all agency staff to review when working at the facility. All agencies will be notified of location of binder and responsible for reading information in binder. Monitoring of the facility Plan to address the immediacy through interviews and record reviews on 02/16/2023 revealed: During an interview on 02/16/2023 at 1:32 PM the Housekeeping Supervisor as well as other facility staff stated they were no longer allowed to give the front door code to the residents even if they had been deemed safe to have the code before. They said they were no longer allowed to give visitors the code such as family members. They said they could open the door for the residents and visitors to allow them out of the facility but just not give them the code. Review of the facility's in-service Staff to not Provide Door Code to Residents or Visitors, indicated the same as told by the staff and indicated signatures from nursing staff, housekeeping staff, office staff and dietary staff. The list of included nursing staff from the 3 shifts which were 6 AM-2 PM, 2 PM-10 PM and 10 PM-6 AM. Record review of Resident #1's closed records revealed Resident #1 had been transferred to another facility on 01/09/2023 and was currently still at the other facility. Record review of current residents at the facility revealed they had a current elopement assessment done as well as the Kardex on their electronic records. Record review of current resident care-plans were conducted for any changes due to their current elopement assessments. During an interview on 02/16/2023 at 1:36 PM the DON and Administrator stated they had received an in-service by the RVP regarding elopement and prevention of elopements. Record reviewed of in-service Elopement and Prevention of Elopements revealed the DON and Administrator had signed the in-service dated 02/15/2023 6:30pm. During an interview on 02/16/2023 at 1:55 PM the SW said she had received training regarding reporting and communication about any concerns voiced to her. She said she was made aware to report any grievances immediately to the DON and o Administrator. She said she was to immediately report anything suspicious to the Administrator and or DON. The SW said they were no longer supposed to give out the door code to any residents and visitors. The SW said they were share any important information during their morning meetings. During an interview on 02/16/2023 at 2:38 PM the Rehab Director said she had been in-serviced on no longer giving out the door code to residents or visitors. The Rehab Director said that if a resident asked for the code, she is to first check with nursing to see if the resident could go out but to never give residents the code, not even to visitors such as family members. The Rehab Director said she was also told to immediately report to the DON and or Administrator anything odd or any suspicious activity going at the facility. During an interview on 02/16/2023 at 3:04 PM MA J said she worked doubles on the weekend. MA J said she had been in-serviced on what to do if a resident went missing such as to report it to the charge immediately and start searching for the resident, she said that if witnessed anything suspicious going on to report it immediately to the DON and or Administrator and not assume some had already reported it. She said they were no longer allowed to give out the door code to resident's or any visitors. During an interview on 02/16/2023 at 3:14 PM the Dietary Manager said she had attended the in-service training and they were trained to no longer give out the door code to residents or any visitors. Dietary Manager said staff could let the visitors out but not give them the code. Dietary Manager said she was also told to report anything suspicious right away to the DON and or Administrator. Dietary Manager said training was received of what to do in case of a missing resident such as to report it right away and search everywhere in the facility. During an interview on 02/16/2023 at 3:38 PM LVN's E and F said they had received training on what to do regarding TAR documentation such as to not just document NO if the resident had no wander guard and to report it to the DON. They said to monitor the wander guard on the residents that wore them and if the resident did not have the wander guard on them to report it immediately. Both staff said they received training to no longer give out the door code to residents or visitors. They said they could open the door for them but to make sure they were not given the code. During an interview on 02/16/2023 at 4:22 PM MA I said she worked 6 AM-2 PM and the 2 PM-10 PM shifts regularly. MA I said she had been in-serviced to report any suspicious activities to the Charge Nurse, DON and Administrator as soon as possible and to not put it off or assume someone knew about it. MA I said she was told to not give out the front door code to anybody and if someone wanted to go out to let them out but not give them the code. MA I said she had also been in-serviced on what to do if a resident went missing such as to report it to the nurse right away, start searching for the resident and continue to search until the resident was found. MA I said they had

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice, based on the resident assessment and physician orders, to prevent development and worsening of pressure injuries for 1 (Resident #52) of 4 residents reviewed for pressure injuries. The facility failed to: a) ensure staff notified treatment nurse, charge nurse and/or DON of a pressure ulcer on Resident #52's right buttock per facility protocol; b) ensure treatment nurse provided timely wound care to prevent worsening of the pressure ulcer on Resident #52's right buttock. Findings included: Review of Resident #52's clinical record indicated she was [AGE] years old and admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's MDS assessment dated [DATE] indicated she had a BIMS of 11/15 meaning she had moderate cognitive impairment. Review of the comprehensive care plan dated 07/19/21 included she was at high risk for pressure ulcers. (Resident #52 was not interviewable) During observation of incontinent care on Tuesday 08/03/21 at 11:20 AM for Resident #52, Surveyor noted a stage II pressure ulcer on resident's right buttock approximately 1 cm in diameter with partial thickness of skin loss, presenting a shallow open ulcer. The wound bed was pink with no drainage. Adipose (fat) is not visible and deeper tissue is not visible. CNA D said she didn't know if it was new or if the treatment nurse knew about it. She said she usually works the other side. CNA D transferred the resident from her bed to her chair. During observation of wound care on Tuesday 08/03/21 at 11:40 AM the treatment nurse provided wound care for Resident #52's left lateral ankle (which was present at time of admission). After the treatment nurse had completed the ankle dressing, she returned to the treatment cart outside resident's door. When asked if CNA D had reported the PU on the resident's right buttock, she said no, but she would look at it whenever the resident was put back in bed. In an interview on Wednesday 08/04/21 at 11:20 AM the treatment nurse said she had not had a chance to look at Resident # 52's bottom. Review of facility Skin assessment dated Wednesday 08/04/21 by the treatment nurse documented Resident #52 as having a stage II pressure ulcer on the left gluteal and doctor notified 08/04/2 at 10:30 AM. In an interview on Thursday 08/05/21 at 2:50 PM the treatment nurse said she did not look at Resident #52's new PU on Tuesday 08/03 because it honestly just slipped my mind. She said she put a dressing on it yesterday (Wednesday 08/04/21). Review of Resident #52's clinical record on 08/05/21 there was no skin assessment, progress note, or physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on Thursday 08/05/21 at 3:50 PM, the treatment nurse provided wound care for Resident #52's right buttock pressure ulcer. Today the wound bed was yellow. The treatment nurse cleaned the wound with wound cleanser and the yellow remained. She applied a border dressing. In an interview with the DON on 08/05/21 at 4:38 PM, she stated she was not aware of Resident #52 having a new pressure ulcer. She said when a new wound is discovered it is documented, care planned, and orders are received from the physician. The DON was informed of Surveyor identifying a pressure ulcer on Resident #52's right buttock on Tuesday 08/03/21 during observation of incontinent care by CNA D. CNA D said she did not know if it was new or not as she usually works on the other side. The CNA placed a clean brief and pants on the resident and transferred her to her wheelchair. Surveyor informed the DON of the Surveyor's conversation on Tuesday 08/03/21 with the treatment nurse notifying her of the open area and the treatment nurse said no one had told her about it. The treatment nurse told the surveyor she would look at it when the resident was put back in bed. The treatment nurse told the Surveyor she forgot about it on Tuesday 08/03 but put a dressing on it Wednesday morning 08/04/21. Surveyor informed the DON there were no orders, and no assessment or documentation in the clinical record regarding the new pressure ulcer even though pressure ulcer care was care planned. Surveyor informed the DON that the wound had a pink wound bed on Tuesday 08/03/21, and today, Thursday 08/05, the wound bed was yellow that did not come off after cleaning. The DON asked, slough? and surveyor answered, yes, it did appear to be and the DON said that would be unstageable. Review of Resident #52's clinical record included the following order: Effective Date: 8/5/2021 16:38:00 Department: Nursing Position: LPN Created By: (treatment nurse) Created Date: 8/5/2021 17:41:10 Note Text: Resident noted to have stage II to left gluteal. Left message for guardian to return call. Order to cleanse LT gluteal with NS/wound cleanser, pat(sic) dry with 4x4x's, apply collagen, followed by calcium ag (sic) & secure with bordered dressing. Daily & PRN drainage. Informed resident with understanding of resident. In an interview on 08/06/21 at 2:30 PM with the DON and treatment nurse, the treatment nurse stated she looked at Resident #52's wound on Tuesday afternoon 08/03/21 after peri-care was done. The treatment nurse stated she didn't put a dressing on it at that time because the resident wanted to get up to eat. She said she did a skin assessment on the morning of Wednesday 08/04/21 and cleaned the wound with Theraworks and applied a border dressing based on standing orders. The treatment nurse stated she notified the doctor on 08/04/21 at 10:30 AM. She said she got an order from the NP the afternoon of 08/04/21 to clean with Theraworks and apply a border dressing. She said the yellow in the wound bed was the medication. The treatment nurse was reminded by the Surveyor that the yellow did not come off with cleaning. The treatment nurse did not say what medication was on the wound. The DON said she did not think it was a pressure ulcer because of where it was located and because the resident had 2 episodes of diarrhea. The treatment nurse stated she and the ADON assessed/observed Resident #52 wound to left gluteal this a.m. then she and the corporate nurse looked at it again and they thought it looked like a sheer, not a pressure ulcer. The DON stated it was excoriated today due to the diarrhea. The DON stated it should have been reported regardless of whether it was a sheer or a pressure ulcer. The DON stated she expected to be notified of skin issues immediately because she has to stage the wound since the treatment nurse cannot and she (the DON) has to do wound care report 08/03 /21 the treatment nurse shouldn't be doing an initial assessment unless I tell her it is what it is. In an interview on 08/06/21 at 02:45 PM, the treatment nurse acknowledged that the facility did not have standing orders for wound care. She said they had standing orders at a sister facility where she used to work. She said, I looked at it Tuesday night (08/03/21). I helped an aide, I don't remember who, put her to bed. I didn't put a dressing on it because the resident wanted to eat. It looked like a shear, like the first skin was back a little bit, not even 1/2 cm was back. The treatment nurse said' I normally do the initial assessment and the RN/DON does the staging (of the wound). She said the RN has to do the wound staging. The DON said the treatment nurse can do an initial assessment and the RN does the staging. The treatment nurse said she documented a stage II pressure ulcer because that's what the Surveyor said and she (the Surveyor) is an RN. The DON acknowledged that facility nursing staff are responsible for identifying and assessing wounds. Review of undated facility policy, Skin Management System, included the following in part: 4. CNAs will note any alteration in skin integrity during care in PCC and reported (sic) to the charge nurse. Review of Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated October 2010, included the following, in part: Assessment and Recognition 4. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration. Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments .

Based on interview and record review the facility failed to provide basic life support, including CPR, prior to the arrival of emergency medical personnel for 1 (Resident #1) of 1 resident who required emergency care. On the morning of [DATE] Resident #1 was found to be unresponsive. RN A initiated Cardiopulmonary Resuscitation (CPR) on Resident #1, but ceased CPR prior to the arrival of Emergency Medical Services (EMS) when LVN A incorrectly identified Resident #1 as a resident with a completed Out of Hospital Do Not Resuscitate (OOHDNR). Resident #1 was declared deceased by RN A on [DATE] at 8:12 AM at the facility. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could affect the 44 residents in the facility who were as identified as a full code, placing them at risk of not having their code status correctly identified and followed, resulting in possible unintended death. The findings included: Closed record review of Resident #1's Face Sheet, undated, revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #1's Face Sheet did not identify her Code Status. The Face Sheet revealed There are no Advanced Directives selected for this resident and that Physician A was identified as her attending physician. Record review of Resident #1's facility record revealed there was not a completed OOHDNR or a physician's orders [REDACTED].#1's code status was Do Not Resuscitation. Record review of Resident #1's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed she was unable to complete the Brief Interview for Mental Status due to rarely/never being understood. The MDS indicated Resident #1 had short and long term memory issues, and displayed inattention and disorganized thinking. The MDS revealed Resident #1 required the physical assistance of staff with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Record review of Resident #1's Care Plan, undated, revealed the following: Problem: Resident/or family member has requested Full Code status. Start Date: [DATE], Edited [DATE] Long Term Goal: Full code status will be honored through next review date. Target Date: [DATE], Edited: [DATE]. Approaches: Notify MD (medical doctor)/ family of any change in condition (Edited [DATE]) . Staff will be aware of where to locate Code status information (Edited [DATE]) . Staff will initiate CPR and notify EMS for transport to a hospital. (Edited: [DATE]) Record review of the Provider Investigation Report, signed by the Administrator on [DATE], revealed the following description on the incident: On [DATE] at approximately 08:00 am the resident was sitting in the dining room when she became unresponsive, the resident was immediately escorted to her room, transferred to her bed, and CPR was initiated by (RN A). During this time (LVN A) went to locate and verify the code status of the resident. (LVN A) was unable to locate the code status in the residents' chart, (LVN A) then pulled up the resident's electronic medical record; (LVN A) noted next to the living will section it stated DNR. This information was read aloud by the (LVN A), and the staff went to the residents' room and informed the (RN A) of the DNR status. CPR proceedings were stopped, patient was noted to have no apical pulse; resident expired at 08:12am, Physician Administrator, DON and family notified. While investigating the incident it was later noted that the resident DNR (OOHDNR paperwork) had not been initiated. The information give to the (RN A) had been misread by the LVN on duty (LVN A). Therefore, the information of the resident being a DNR that was relayed to (RN A) was incorrect. Record review of Resident #1's Nurses Notes revealed the following: [DATE] 11:34 AM At approximately (8:00 AM) resident (Resident #1) was in dining hall sitting in her wheelchair this nurse was called over . to asses (sp) the resident. Upon assessment resident was unresponsive, appeared to be gasping for air, capillary refill and radial pulse were not present. Resident was unresponsive to chest sternal rub. Resident was immediately escorted to her room laid on her bed and this nurse began chest compressions at (8:04 AM). Chest compressions were stopped when I (RN A) was notified by staff members the resident was a DNR status. No apical pulse was auscultated by stethoscope at (8:12 AM). DON notified. Left message for (Physician A) at (8:24 AM). Administrator notified. Family was called at (8:25 AM) spoke with . the residents niece. Signed by RN A [DATE] 12:14 Order obtained for RN to pronounce and discharge body to funeral home of family's choice. Family aware. Signed by RN A Record review of Resident #1's Record of Death and Mortician's Receipt, signed by RN A on [DATE], revealed Resident #1's date of death was [DATE] at 8:12 AM. RN A was identified as the nurse present at the time of death. Record review of a written statement signed by LVN A, dated [DATE], revealed the following in relation to the incident involving Resident #1: On [DATE]-around 800 AM I (LVN A) was called . to dinning (sp) room states its an emergency this writer ran to dinning (sp) room (at) this time (RN A) was already with resident, pushing resident to room in a hurried pace. Resident was transferred to bed by staff x (times) 4 and chest compression began! This writer pulled chart and found no Advance Directives-looked through the chart repeatedly w/ (with) help . still no advance directives were found (.) Logged into computer and looked under Advance Directives and first line read Living Will-DNR. I read it out loud and staff went to room (with) RN and Resident and told RN resident was DNR-chest compression were stopped. Record review of a written statement signed by RN A, dated [DATE], revealed the following in relation to the incident involving Resident #1: I (RN A) was in the dining room checking a resident's vital signs when I heard my name being called over by (CNA C) who was standing in front of (Resident # 1). Upon assessment of the resident she was unresponsive, appeared to be gasping for air, capillary refill and radial pulse were not present. Resident was unresponsive to sternum rub. I quickly decided to (sic) it would be best to remove the resident from the dining hall. I delegated to (Medication Aide (MA) A) to call 911. As we were escorting the resident to her room (LVN A) met us in the hallway, looked at our current situation and I told her I was going to start chest compressions. (LVN A) asked if the patient was a full code or DNR. I realized at that moment I did not know, and stated I do not know can you go check for me. (LVN A) headed to the nurses station asking (CNA D) to grab the crash cart. We arrived in the resident room quickly placing the resident on her bed and I began chest compressions. I was notified the patient was a DNR status. (LVN A) walked into the room and said the patient is a DNR. Chest compressions were dc'd (discontinued). I heard the sirens from the ambulance . I checked the residents pulse one more time it was not palpable . I auscultated the patient's chest for an apical pulse for one full minute and pronounce resident expired at (8:12 AM). After spending a few more minutes in the room with the resident I left to follow protocol and notify the family. After notifying the DON and leaving a message for (Physician A) I pulled up the residents computer chart to begin charting the sequence of events and the chart was incomplete. There was no where in the electronic chart or the residents paper chart that stated the patient had a DNR status. There was also no where (sic) in either of the charts indicating the resident was a full code status. Quickly realizing there may have been a mistake I called (ADON B) asking her if she could come to the facility to verify the resident status. (ADON B) told me I needed to call . the DON to explain the situation. I notified the DON and in the administrator of the situation. Record review of the facility's CPR Plan of Correction, undated, developed after the incident involving Resident #1 revealed the following: INTERVENTIONS-(Social Worker/DON) 1. Prepare a list of the most up-to-date code status information. a. Code Status will be verified on all resident (complete chart audit). If the Code Status cannot be verified, the resident/patient will be considered a full code. b. All information will be placed into the Advance Directive Section of the Matrix EMR (Electronic Medical Record). 2. Red Dot/Green Dot System implementation a. The resident/patent (sp) name will be placed near the door of the room upon admission. b. If the resident/patient is a DNR (Do not Resuscitate) there will be a red dot next to the name. c. If the resident is a full code, there will be a green dot next to the name. IN-SERVICES 1. In-service and Training will be provided to Medical Records Clerk on procedure for printing Code Status Report and how to verify integrity of the Red Dot/Green Dot System 2. In-service and Training will be provided to all Nursing Staff on a. Obtaining Advance Directive information upon admission. MONITORING 1. Code Status updates will be verified during nursing Start-up meeting the following date. If the a. Any Code Status that cannot be verified will be considered a full code. Record review of the facility's CPR Plan of Correction, undated, revealed no in-services related to identifying what constituted a completed OOHDNR, were an OOHDNR can be located in a resident's chart, or when it was appropriate to stop CPR after it had been initiated. According to the American Heart Association's 2010 Guidelines Emergency Cardiovascular Care, updated in 2015, trained rescuers should provide rescue breaths in addition to chest compressions . All lay rescuers should, at a minimum, provide chest compressions for victims of [MEDICAL CONDITION]. (Class I, LOE C-LD) In addition, if the trained lay rescuer is able to perform rescue breaths, he or she should add rescue breaths in a ratio of 30 compressions to 2 breaths.The rescuer should continue CPR until an AED arrives and is ready for use or EMS providers take over care of the victim. https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/?strue=1&id=,[DATE] (accessed on [DATE]) In an interview on [DATE] at 3:46 PM the DON stated staff called her and told her they had to do CPR on Resident #1 because she wasn't breathing well. The DON stated the nurse originally doing the code (RN A) asked another nurse (LVN A) to check the resident's chart, and the second nurse (LVN A) looked at the wrong document in the chart and said Resident #1 was a DNR. The DON stated the first nurse (RN A) stopped CPR, but when she reviewed Resident #1's chart she realized the resident's DNR paperwork was not completed. The DON stated after the incident they immediately put a system into effect where each resident has a colored dot by their name which was located outside of their room. A green dot was residents who are a full code and red dot was used for residents who have executed a DNR. The DON stated her understanding was that once CPR was started you shouldn't stop unless too exhausted or EMS relieved you. DON stated at this time the social worker was responsible for obtaining the OOHDNR if that was what the resident and/or family choose. The social worker was also the person responsible for sending the document to the physician for it to be signed. The DON stated in her personal opinion a completed DNR form was signed by the family or resident, the required witnesses, and the physician signature. The DON stated the facility's expectation was that once the family and/or the resident had signed the OOHDNR then it was complete and did not require a physician's signature. The DON stated she had not seen the facility's policy, but that was what she was told by corporate staff. The DON stated corporate staff told her the facility had to respect the resident's wishes. The DON stated she had never instructed her staff to honor an OOHDNR that was not signed by a physician. The DON stated she believed the social worker had the same belief that an OOHDNR was not completed without a physician's signature, but was not certain. In an interview on [DATE] at 4:04 PM the MDS Coordinator stated what constituted a completed OOHDNR could change based on the situation. The MDS Coordinator stated her understanding was an OOHDNR would be valid as long as there was a verbal physician's orders [REDACTED]. The MDS Coordinator stated the system is broken and there were too many people involved in the system. In an interview on [DATE] at 4:04 PM the Administrator stated his expectation was that if a resident expressed a desire to have their code status be DNR the staff should honor the resident's wishes. The Administrator stated when a family member and/or resident had signed an OOHDNR then their code status should be DNR. The Administrator stated he did not believe a physician's signature should be required on an OOHDNR for the resident's code status to be changed to a DNR. The Administrator stated if a family member wanted a resident to be a DNR and CPR was done then the facility was at risk of getting sued. The Administrator stated technically a DNR was not valid until signed by the physician, but the family would be upset if they signed a document and their wishes were not followed due to waiting on a physician's signature. In an interview on [DATE] at 4:29 PM RN B stated the facility recently implemented a green dot (full code), red dot (DNR) system for code statuses. RN B stated initially the DON was responsible for the dots and the social worker had also been involved. RN B stated prior to the incident in November that involved Resident #1 the facility used the color coded sheets in front of the resident's chart. She stated she could rely on the dot on the door to determine a resident's code status, but she could also check in the computer on the resident's electronic face sheet. RN B stated for an OOHDNR to be valid she believed the doctor, a witness, and the family and/or patient had to sign. RN B stated several people work on code status system, but she personally had not had to handle DNR paperwork. RN B stated recently the social worker asked her to put a red dot on a resident's door but there was not a doctor's order for the resident to be a DNR. She stated she did not put the dot on the door, but she saw it a couple of shifts after she was asked to put it on there, and figured it was resolved. RN B stated if she received a completed OOHDNR while working she would notify the social worker and the ADON and/or the DON. RN B stated she was not certain if a verbal order was sufficient to make an OOHDNR valid, and that she would have to ask the DON. In an interview on [DATE] at 5:18 PM the Social Worker stated she was responsible for the residents' code statuses. The Social Worker stated for an OOHDNR to be valid it had to be witnessed and have the physician's signature. The Social Worker stated she explained to the family and resident that just because they have signed the OOHDNR their code status would not be changed to DNR until the OOHDNR had been signed by a physician. The Social Worker stated the facility's corporate staff indicated to her that a DNR can be based on a resident's and/or family wishes, and did not require a physician's signature to be valid. The Social Worker stated nurses can change a resident's code status if they received a completed OOHDNR when she was not there. The Social Worker stated she was not aware of any specific in-services regarding what was required for a valid OOHDNR. The Social Worker stated prior to the incident involving Resident #1 the dot system was not in place prior. In an interview on [DATE] at 10:58 AM LVN C stated a resident's code status could be found by checking their chart, checking the computer, the colored dot next to their name, or the list on the crash cart. He stated this information could also be found on the resident's face sheet. LVN C stated whatever code status the resident was admitted with was what he goes with, and he lets the social worker handle the rest of it. LVN C stated for an OOHDNR to be valid it had to be signed by the physician, and there had to have a written order in the resident's chart. LVN C stated the in-service he received after the incident that involved Resident #1 was them just reviewing what was written on the paper, and was not an extended in-service. LVN C stated he did not receive an in-service about what is necessary for an OOHDNR to be valid. LVN C stated if he began CPR on a resident, and was then told the resident was a DNR he would stop CPR. LVN C stated he would not feel comfortable withholding CPR unless an OOHDNR had a physician's signature. In an interview on [DATE] at 11:28 AM LVN B stated she was the treatment nurse, but that she also worked as a charge nurse. LVN B stated she would not consider an OOHDNR valid unless it was signed by the physician. LVN B stated if she started CPR on a resident and then was informed the resident had a valid OOHDNR she would stop CPR. LVN B stated she had not received in-services since the incident about what was required for a valid OOHDNR or when it was appropriate to stop CPR. In an interview on [DATE] at 1:10 PM RN A (nurse who performed CPR on Resident #1) stated on the day of the incident involving Resident #1 she was in the dining room assisting residents with breakfast. RN A stated one of the aides called her over to Resident #1, and the resident seemed like she was in distress and non-responsive. RN A stated she had the aides assist her in taking Resident #1 to her room, and then asked the aide to get the other nurse. RN A stated the other nurse (LVN A) asked if Resident #1 was DNR. RN A stated she informed LVN A that she was not sure of the resident's code status. RN A stated at that point she began chest compressions, and asked the aide to get the crash cart. RN A stated one of the aides informed her LVN A had said Resident #1 was a DNR. RN A stated once she was informed Resident #1 was a DNR she stopped chest compression prior to the arrival of EMS. RN A stated after the incident she stayed with the resident for several minutes, and then went to the resident's chart to document the incident. RN A stated after she reviewed Resident #1's physical and electronic medical record she determined the other nurse had misinterpreted Resident #1's code status. RN A stated she immediately reported to the DON and the Administrator. RN A stated Resident #1's physical chart did not have a red or green paper in the front, which was how code status was determined prior to the incident. RN A stated after the incident she received an in-service about the new red dot/green dot system. RN A stated she was in-serviced yesterday ([DATE]) via the phone by the DON related to what makes an OOHDNR valid and that once CPR was started it was not to be stopped until EMS arrived. In an interview on [DATE] at 11:45 AM the DON stated prior to the incident a resident's code status could be determined by the red or green sheet in front of the resident's chart. The DON stated prior to the incident she was not aware Resident #1's chart did not have a green sheet. In an interview on [DATE] at 12:42 PM LVN A stated she was at her station and the RN supervisor (RN A) had sent an aide to ask for assistance. LVN A stated when she got to the other side of the building RN A and the aides were wheeling Resident #1 into her room. LVN A stated RN A began CPR. LVN A stated she did not assist with CPR, but went to the resident's chart to determine her code status. LVA A stated when she checked Resident #1's physical chart there was not a red sheet or green sheet in the front. LVN A stated she continued to look through Resident #1's chart, but did not find anything related to her code status. LVN A stated she thought she saw something that indicated the family wanted to make Resident #1 a DNR. LVN A stated she couldn't find anything in the physical chart so she looked in Resident #1's EMR. LVN A stated in the EMR, under the resident's name, it will usually say full code or DNR, but Resident #1's EMR did not have this. LVN A stated she saw at the bottom of the screen in the EMR something that said Do Not Resuscitate/Do Not Intubate. LVN A stated she called out that Resident #1 was a DNR, and another staff member told the nurse (RN A) who then stopped CPR. LVN A stated she had not had anything like this happen before, and that where there was always a red or green sheet in the resident's chart that indicated their code status. LVN A stated the dot system was not in place at that time, but now everybody had a red or green dot. LVN A stated she currently works at the facility on weekends. LVN A stated she received an in-service the day of the incident about the new dot system. LVN A did not recall an in-service at that time about what constituted a valid DNR or about CPR. On [DATE] at 6:05 PM the Administrator and DON were informed an Immediate Jeopardy (IJ) was identified. Record review of the facility's in-services revealed the following in-services were the only two in-services identified related to CPR and Code Status prior to [DATE]: In-Service Title: Code Status Date: [DATE] Objectives of the In-Service: Check code status on all new admissions and re-admissions . Make sure green or red dot goes with the res name on door, if they change room. every chart must have a green sheet (with) full code or red sheet (with) DNR, if not notify DON, SS (social services), or ADON . See CPR guidelines attached (no documents attached) . Crash cart-know where its kept . Code status cannot be obtained the resident/patient will be considered a full code. In-Service Title: Monitoring Code Status Date: [DATE] Medical Records will print a copy of the Advanced Directives orders from the EMR and verify the accuracy of the Red/Green sticker every week. DON will sign the printed form to verify completion. Record review of the facility's CPR Plan of Correction, undated, revealed their CPR guidelines (reference in the in-service on [DATE]) were: When a resident/patient is found to be [MEDICAL CONDITION], DO NOT Leave Unattended. Turn on call light and go to the door to call for help. If it is a nurse in the room, begin chest compressions immediately after checking code status at the door . Code Blue Room/Area will be called. The Crash Cart & defibrillator will be brought to the room. 911 will be called . When the defibrillator arrives, deflate mattress if necessary and place cardiac board between shoulder blades . Place leads on resident/patient and follow the instructions given on the defibrillator. The CPR guidelines provided by the facility did not address when it was appropriate for staff to cease performing CPR. Record review of the facility's policy entitled Advance Directives, revised ,[DATE], revealed: . 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical records . 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The following Plan of Removal was submitted by the facility on [DATE]: Areas of Concern: Status Codes of Residents Intervention for prevention of Code Status Conflict-Identification/Interventions ensure correct Code Status Nurses re-educated on the importance of obtaining accurate Code Status information upon admission. In-service ongoing Started [DATE] In-service Ongoing 1. Prepare a list of the most up-to-date code status information. a. Code Status will be verified on all residents (complete chart audit). If the Code Status cannot be verified, the resident/patient will be considered a full code. b. All information will be placed into the Advance Directive Section of the Matrix EMR and a copy of the OOH DNR form is in the resident's chart. i. An OOH DNR becomes effective immediately once the form has been completed and executed appropriately. 2. Red Dot/Green Dot System a. The resident name will be placed near the door of the room upon admission by DON/designee. b. If the resident is a DNR (DO Not Resuscitate) there will be a red dot next to the name. c. If the resident is a full code, there will be a green dot next to the name. 3. DON/designee will be primarily responsible for placing the appropriate corresponding red/green dot. Resident's with a completed OOH DNR form will receive a Red Dot next to their name otherwise the resident is a Full Code and will receive a Green Dot next to their name. 4. After hours and on weekends, new admissions or return admissions with completed OOH DNR form, the Admitting Nurse will be responsible for ensuring the red dot next to resident's name by the door and the OOH DNR document placed in the chart. Otherwise the resident is a Full Code and will have a Green Dot placed next to their name. 5. SS/designee will initiate within 14 days of admission the Out of Hospital DNR form based on resident's wishes. Staff education related to Code Status 1. In-service and Training will be provided to Medical Records Clerk on procedure for printing Code Status Report and how to verify integrity of the Red Dot/Green Dot System. In-service ongoing Started [DATE] 2. In-service and Training will be provided to all Nursing Staff on a. Red Dot/Green Dot System and who's responsibility it will be to initiate and maintain the Red Dot/Green Dot system including after hours and on weekends. In-service ongoing Started [DATE] 3. In-service and Training will be provided to all Nursing Staff on a. Instruction for residents who code i. When a resident is found to be [MEDICAL CONDITION], DO NOT Leave Unattended. Turn on call light and go to the door to call for help. If it is a nurse in the room and the resident is determined to be Full Code begin chest compressions immediately. ii. Code Blue Room/Area will be called. The Crash Cart & defibrillator will be brought to the room. 911 will be called. iii. When the defibrillator arrives, deflate mattress if necessary and place cardiac board between shoulder blades. iv. Place leads on resident/patient and follow the instructions given on the defibrillator. v. If resident is found without life and CPR is initiated and/or code status is unknown, CPR will be continued until EMS arrives regardless if resident is a DNR. In-service ongoing Started [DATE] 4. After hours and on weekends new admissions or return admissions with completed OOH DNR form, the Admitting Nurse will be responsible for ensuring the red dot next to resident's name by the door and the OOH DNR document placed in the chart. Otherwise the resident is a Full Code and will have a Green Dot placed next to their name. In-service ongoing Started [DATE] Monitoring of Code Status Started [DATE] Ongoing 1. Code Status updates will be verified during by Nursing Management Monday thru Friday: a. Any Code Status that cannot be verified will be considered a full code. b. Verify appropriate Red/Green Dot placement next to resident's name. 2. Medical Records will print a copy of the Advanced Directive orders from the EMR and verify the accuracy of the Red/Green Sticker every week. Don will sign the printed form to verify completion. 3. Social worker will verify weekly that all new admissions have a code status selected. She will ensure a copy of the DNR is placed in the chart as applicable. Social worker will also ensure that Code status is updated weekly to reflect the most up-to-date information. 4. Facility will ensure all licensed nurse on duty maintain current CPR certifications. 5. Mock Codes will be held monthly on varying shifts. On-Going Code Status System Monitoring 1. Results of the audits will be brought to the QAPI meeting for review for minimum 3 months and until the satisfaction of the QAPI Committee is achieved thereafter. On-going Starting [DATE] Interviews conducted on [DATE] and [DATE] with 7 LVN's and 2 RN's that represented all three shifts, including weekends revealed staff had been in-serviced on the areas of concerns identified in the plan of removal. All indicated that they had been in serviced in regards to how to determine a resident's code status, what was required for an OOHDNR to be valid, and when CPR should be stopped. In an interview on [DATE] at 11:45 AM the DON stated she believed the Immediate Jeopardy (IJ) occurred because the incident that involved Resident #1 was mishandled and the nurse stopped CPR after starting it. The DON stated she also believed the IJ was related to Resident #1's code status not being clear in the chart. In an interview on [DATE] at 12:00 PM the Administrator stated he believed the Immediate Jeopardy occurred because the nurse started and then stopped CPR on Resident #1 and the facility was not completing all the necessary parts of the OOHDNR before a resident was identified as a DNR. The Administrator stated the staff's confusion on what was considered a valid OOHDNR also contributed to the situation. The Administrator stated prior to the incident the ADON and DON had expressed concerns about not requiring a physician's signature on an OOHDNR, but he thought they were okay with corporate's policy. The Administrator stated he was not initially aware that it was a problem for the nurse to have stopped CPR once it was initiated. He stated his DON informed him of the concern during the investigation. The Administrator was informed the Immediate Jeopardy was lifted on [DATE] at 12:44 PM. The facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Record review of the facility's Advanced Directives and Code Status Report, dated [DATE], revealed 44 residents were identified as having a code status of full code.

Based on observation, interview, and record review the facility failed to ensure the environment remained free from accident hazards to prevent accidents for one (Residents #2) of 8 residents reviewed for accident hazards. On 12/07/17 Resident #2 sustained a second degree burn during a shower from high water temperatures. Water temperatures in that shower continued to measure above 120 degrees for over a month after the incident. This facility failure could affect the 22 residents identified by the facility as receiving showers on that hall, and could place them at risk of injury, skin breakdown, and burns. Findings included: Record review of Resident #2's Face Sheet, dated 01/11/18, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated mild cognitive impairment. The MDS revealed Resident #2 required the physical assistance of staff with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The MDS also revealed Resident #2 had a stage four pressure ulcer, but indicated Resident #2 did not have any other skin issues, including burns. Record review of Resident #2's Care Plan, undated, revealed the following: Problem: Resident is at risk for pressure ulcer due to impaired sensory perception. Problem Start Date: 11/01/17 (Edited: 01/03/18) Goal: Intact skin without evidence of redness, irritation, maceration, or open areas. Target Date: 01/02/18 (Edited 01/03/18) Approach: . Skin assessment and inspection every shift with close attention to heels Start Date: 01/02/18 Problem: Limited physical mobility R/T (related to) total dependent on staff for ADL's (activities of daily living)/care D/T (due to) [DIAGNOSES REDACTED]. Goal: Will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through next review date. Target Date: 01/02/18 (Edited: 01/03/18) Approach: . Observe, document, report to MD (medical doctor) prn (as needed) s/sx (sign/symptoms) of immobility (contractures forming or worsening, thrombus formation, skin breakdown, fall related injury) Record review of the facility's Incident/Investigation Summary for (Resident #2), undated, revealed the following: . on 12/07/17 the treatment nurse (LVN B( was notified by (CNA A) that the resident had a small red area on her back. When the treatment nurse assessed the residents' skin, she noted a large red area and referred to the DON for further assessment. Upon further assessment with the DON it was noted that the resident had a large reddened area that appeared to be in the shape of the shower head beginning at the residents' lower back and extending to her upper buttock, measuring (11x4 cm); (Physician A) was notified and treatment orders were obtained. The Administrator, DON, MD (Medical Doctor), Family and THHS (Texas Health and Human Services) were notified, and investigation proceedings began. During the investigation the shower temperatures was found to be 132 degrees Fahrenheit, the showers were immediately shut down and a plumber was called to assess, identify and repair the problem. Upon interviewing (CNA A) told the resident the water was too hot, and the resident insisted that the water temperature was fine, the CNA then continued to give the shower to the resident; this resulted in the affected area and upon completion of investigation, the employee (CNA A) was terminated from the facility. Record review of Resident #2's nurses' notes revealed the following notes related to the burn that occurred on 12/07/17: 12/07/17 4:30 PM This nurse was notified by CNA when you do res. (resident) tx (treatment) she has a small red area on her back. When tx nurse entered res. room to do tx. Res. Positioned on (L) (left) side. Explanation of tx given to pt (patient) . Noted a large reddened area to lower center of back extending outwards with several small fluid filled blisters and peeling skin. DON was immediately notified and came to room. Resident unable to say what happened. Area measured 11cm x (by) 4cm (4.3 x 1.6 inches). Paddle shaped with narrow end across lower back and wider end towards outer side of back. Area was gently cleansed with NS (normal saline) and pat dry. Thin layer of silver [MEDICATION NAME] to area and covered with protective dressing. Signed by LVN B 12/07/17 6:30 PM MD notified related to area to rsd (resident) back, MD stated to continue with tx notify of any changes or s/s (signs/symptoms) of infection to area Signed by ADON A 12/07/17 6:30 PM DON spoke to resident about going to hospital for eval (evaluation) and tx. Resident declined going to hospital and stated she would stay at facility for tx. Signed by DON 12/14/17 11:06 AM Continue with wound care as ordered to burn to lower back, noted skin color red with white patches in middle resembling wound healing. Signed by LVN C 12/15/17 3:35 PM Reddened area to lower back improving. Decreasing in size. Will cont (continue) tx 2 x (times) daily with close monitoring. Signed by LVN B 12/22/17 5:00 PM Area to lower back showing increase in healing. Center of wound showing new granulation in scattered large amts. There is no drainage. Light to dark pink in color. Edges are smooth, pink in color. Size of area decreasing 9 in x 3.5 in (inches). Denies pain or feeling to area. Signed by LVN B 12/29/17 4:23 PM Wound to back showing large improvement and healing. Area to middle of back 3.5 in area healed with pink healthy tissue. Large area in center of wound on (Right) side of back has 2 in x 1.5 in healing with pink healing tissue. Signed by LVN B 01/05/18 4:24 PM Tissue injury to back cont to show improvement. Large areas of healing tissue. Pink in color. Skin intact. Cont with smaller area of tissue with tiny hair follicles coming in. Slight red in color. Signed by LVN B (No further Nurses' Notes containing assessments of the wound or treatments of the wound) Record review of Resident #2's Weekly Skin Integrity Review form revealed there was a section entitled Skin Condition to allow for staff completing the assessment to document the condition of the skin. Below that section were the following check boxes: Skin Intact, Dry, Bruises, Rash, Redness, Skin Tears, Blisters, Other, Open Area, New, and Old. The form also included instructions that if there was an Open Area staff should Proceed to appropriate skin condition record. The form also included a diagram of the human body to illustrate the physical location of the wound on the body. The following entries were documented on Resident #2's Weekly Skin Integrity Review sheets: 12/08/17 There was no documentation related to Resident #2's back wound. On the body diagram the wound was not noted. The entry was signed by LVN B 12/14/17 Written under Skin Condition was Back 9x4 in. There was no further information related to the wound on Resident #2's back was provided. None of the provided boxes were checked. The area was identified on the body diagram. The entry was signed by LVN B 12/21/17 Written under Skin Condition was back 9x3.5 There was no further information related to the wound on Resident #2's back was provided. None of the provided boxes were checked. The area was identified on the body diagram. The entry was signed by LVN B 12/29/17 The Other box was checked and written next to it was back-mid back. There was no further description of or documentation related to the wound on Resident #2's back. No other boxes were checked. The back area was marked on the body diagram. The entry was signed by LVN B 01/05/18 The Other box was checked and written next to it was mid bk (back) 6in x 6in. There was no further description of or documentation related to the wound on Resident #2's back. No other boxes were checked. The back area was not marked on the body diagram. The entry was signed by LVN B 01/11/18 The Other box was checked and written next to it was mid bk (back) 4in x 6in (10cm x 15 cm). There was no further description of or documentation related to the wound on Resident #2's back. No other boxes were checked. The back area was not marked on the body diagram. The entry was signed by LVN B Record review of Resident #2's Physician's Telephone Orders revealed the following orders: 12/07/17 1) Cleanse area to back (lower (with) NS (normal saline) pat dry, apply thin layer of silver sulfadizine to area et (and) cover (with) protective drsg (dressing). 12/11/17 Cleanse area to lower back (with) NS pad dry, apply thin layer of silver [MEDICATION NAME] to area et cover (with) protective drsg. BID (twice a day) until resolved. According to the U.S. National Library of Medicine [MEDICATION NAME] (generic name: Silver [MEDICATION NAME]) is used to prevent and treat infections of second- and third-degree burns. It kills a wide variety of bacteria. https://medlineplus.gov/druginfo/meds/a 8.html (accessed on 01/26/17) Record review of Resident #2 records from the local wound care center revealed the following documents: Multi Wound Chart Details Date of Service: 12/19/17 Wound Location: Right Back-Medial (middle of the back) Wounding Event: Thermal Burn Primary Etiology: 2nd degree Burn Measurements in centimeters (Length x Width x Depth): 11.5 x 24.5 x .1 (4.5in x 9.6in x .04in) Physician order [REDACTED].>Date of Service: 12/19/17 Primary Wound Dressing . Right, Medial Back . [MEDICATION NAME] apply a thin layer to wound bed. Cover with [MEDICATION NAME].-ABD (abdominal) or pad dressing tape x 7 days, the d/c [MEDICATION NAME]. (No wound care visits between 12/19/17 and 01/09/18) Multi Wound Chart Details Date of Services: 01/09/18 Wound Location: Right Back-Medial Wounding Event: Thermal Burn Primary Etiology: 2nd degree Burn Measurements L x W x D (cm): 8 x 12.5 x .1 (3.1in x 4.9in x .04in) Discharge Instructions Details Date of Services 01/09/18 Dressing Change Frequency . Medial Back . Change dressing every day and as needed for excessive drainage or soiled dressing . Cleanse the wound with wound cleanser or normal saline using gauze sponges . clean well and apply [MEDICATION NAME]/vasaline gauze, ABD and secure with medispore tape. According to the U.S. National Library of Medicine second-[MEDICAL CONDITION] both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial thickness burns. https://medlineplus.gov/ency/article/ 0.htm (accessed on 01/26/17) In an interview on 01/10/18 at 5:24 PM LVN B, the treatment nurse, stated she was called in to work as a charge nurse on the day of the incident involving Resident #2 (12/07/17). LVN B stated around lunch time a CNA approached her and told her there was a little red spot on Resident #2's back and if she could please check it when she was doing resident's treatment. LVN B stated the CNA held up her hand and indicated a spot the size of a penny, so she did not think it was an emergency. LVN B stated she finished her shift as a charge nurse, and began doing her treatment. LVN B stated she did not begin doing treatment until after 2:00 PM. LVN B stated she was shocked by the size of the area on Resident #2's back, and immediately notified the DON. LVN B described the wound as being, at that time, in a paddle shape, skinny on one side and a larger rounded area on the opposite side of her lower back. LVN B stated the wound was bright red with multiple fluid filled blister. LVN B stated initially it was unknown what caused the injury. LVN B stated she had provided treatment to Resident #2 the day before for a different wound and there had not been any injuries to Resident #2's back. LVN B stated she contacted the doctor and got the order to treat the burn with normal saline and [MEDICATION NAME]. LVN B stated the burn started peeling within a couple of days and has been healing. In interview on 1/10/18 at 5:10 PM the Maintenance Assistant stated they were checking the hot water temperature in the morning and around 3:00 PM since the incident on 12/7/17. He stated they turn the hot water on at the sink and shower, let it accumulate in a cup, insert a thermometer into the cup and let the water run. Observation on 01/10/18 at 4:29 PM revealed the water temperature in the second stall shower staff (furthest from the door) of the D Hall shower room was 120 degrees Fahrenheit. The temperature was taken by a surveyor after allowing the shower to run for approximately 2 to 3 minutes and then collecting water in a cup, and using a digital thermometer. In an interview on 1/11/18 at 2:07 PM the Maintenance Assistant stated he was the person who took water temperature readings on 12/7/17. He was not able to recall what time that day he obtained the temperatures. The Maintenance Assistant stated he considered a temperature over 110 degrees to be too hot and 92-95 degrees as too cold. He stated when the new maintenance director began working at the facility two weeks ago, they started doing things by the book. He would not explain what was meant of things by the book. The Maintenance Assistant stated when the water temperatures are too cold or too hot, he tells the administrator and the plumbers come out to adjust the mix of hot/cold water. He stated he was not a plumber and does not touch the mixer valve that controls the mix of hot and cold water. In an interview on 01/11/18 at 4:00 PM Resident #2 stated she received a shower about a month and half ago from CNA A. Resident #2 stated that she liked warm showers and that she did ask CNA A to turn the water up warmer. Resident #2 stated after the shower was finished CNA A informed her there was an area on her back that hadn't been there before. Resident #2 stated CNA A went and reported the incident to the treatment nurse (LVN B) who was working as a floor nurse that day. Resident #2 stated once the treatment nurse finished her shift, a couple of hours after the shower, she came and checked her back. Resident #2 stated then she was asked by the DON if she wanted to go to the hospital, but she declined. Resident #2 stated she did not feel like CNA A intentionally let the water get too hot or burn her on purpose. Resident #2 stated often times the water temperature will fluctuate without ever adjusting the nob. Resident #2 confirmed she did have decreased sensation in that area due to her injury. In a later interview on 01/12/17, Resident #2 stated the incident occurred in the shower room on Hall D, in the shower stall furthest from the door. In an interview on 01/12/18 at 8:59 AM CNA A confirmed she was the CNA who showered Resident #2 on the day Resident #2's back injury occurred. CNA A stated she showered Resident #2 around lunch time in the D Hall shower in the stall the furthest from the door. CNA A stated that she tried to tell Resident #2 the water was too hot, but Resident #2 stated the water felt comfortable. CNA A stated the water was warm, but not uncomfortable to the touch. CNA A stated after the shower she noticed a spot on Resident #2's back that was peeling and looked like a bruise. CNA A stated that she had not seen that on Resident #2's skin before so she reported it to the treatment nurse. CNA A stated she asked to treatment nurse to come right away, but the treatment nurse stated she was busy. CNA A stated she did not report the skin issue to the charge nurse. CNA A stated she did not leave the handle held shower head near the resident when she was not using it. CNA A stated she pointed the water away from the resident if it was not in use. Observation on 01/11/18 at 4:20 PM of Resident #2's wound revealed it was located on her lower back above her coccyx. Toward her right hip was a circular area approximately 5 to 6 inches wide, tapering down to the left hip into a strip approximately 2 inches wide. The wound as a whole appeared to be approximately 8 inches long from right to left hip. The skin in the large circular area appeared red and raw, except for a small area in the middle that appeared to be healing. In an interview on 1/11/18 at 4:50 PM the Administrator stated maintenance opens all the faucets, in all the shower rooms, and lets the hot water run before testing the water temperature because the more the water runs, the hotter it gets. He stated letting the water run in all the shower rooms for a period of time ensured they received a more accurate water temperature. He stated they test water temperatures by letting water collect in a cup then check they check the temperature. He stated if the water was too hot, they shut down the shower and adjust the settings on the water tanks. The administrator stated water temperatures of 112-114 degrees were too high. The Administrator stated December 22, 2017 was the last time he was aware of the plumber coming to the facility for water temperature issues. Record review of letter, dated 01/11/18, from the local plumber identified by the facility as the plumber who had been addressing the water temperature issue revealed the following were dates they . spent working on the tempering valves and related piping .: 12/07/17 (4 hours (hrs)), 12/08/17 (4 hrs), 12/11/17 (3 hrs), 12/12/17 (8 hrs), 12/13/17 (5 hrs), 12/14/17 (4 hrs), 12/15/17 (5 hrs), 12/21/17 (2 hrs), and 12/22/17 (2 hrs) In an interview on 01/17/18 at 12:00 PM the Administrator stated the DON informed him after she was notified that there was a skin issue with one of the residents, but he stated he did not know the details of the injury at that time. The Administrator stated once he got the details he began the investigation. The Administrator stated he and the DON completed the investigation into the incident involving Resident #2. The Administrator stated after it was determined the injury was caused by the water temperature being too high he shut down the showers, notified his supervisor, and brought in plumbers to address temperature. The Administrator stated a water temperature of 119 degrees F was a concerning number. He stated he was aware that the regulation was 100 to 110. The Administrator stated if the water did reach temperatures above 110 degrees F they would shut that shower down until they could get the right temperature. According to the American Burn Association (ABA) individuals with physical challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The ABA also indicated that sensory impairments can result in decreased sensation . so the person may not realize if something is too hot. The ABA identified a 100 degrees Fahrenheit as a safe temperatures for bathing. According to the ABA a third degree burn can occur at the following identified water temperatures (in degrees Fahrenheit) in the identified amounts of time: 155 degrees in 1 second 148 degrees in 2 seconds 140 degrees in 5 seconds 133 degrees in 15 seconds 127 degrees in 1 minute 124 degrees in 3 minutes 120 degrees in 5 minutes http://ameriburn.org/wp-content/uploads/2017/04/scaldinjuryeducatorsguide.pdf (accessed 01/26/17) Record review of the facility's Water Temperature Log, from 12/07/17 through 01/15/18, revealed the following temperatures for the D Hall shower that were above 120 degrees Fahrenheit: 12/07/17 125 degrees (No documentation for temperatures of D Hall shower on 12/09/17, 12/11/17-12/18/17) 12/20/17 130 (4:55 PM) 12/22/17 121 (3:30 PM) 12/23/17 121 (9:25 AM) 12/24/17 125 (9:00 AM) (No documentation for temperatures of D Hall shower on 12/28/17, 12/29/17, and 12/31/17) 01/05/18 124 (9:00 AM) 138 (2:00 PM) (No documentation for temperatures of D Hall shower on 01/07/18) 01/08/18 135 (8:00 AM) In an interview on 01/12/18 at 12:01 PM the Regional Director of Operations (RDO) stated the facility did not have a policy on water temperatures and/or quality of care. Record review of a Resident Roster by halls, dated 01/15/18, revealed 22 people resided on D Hall and would receive their showers in the D hall shower room.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse and neglect for 2 of 7 residents reviewed for abuse and neglect (Resident #1 and #2). The facility failed to assess and develop individualized interventions to address Resident #1's and Resident #2's aggressive behavior while in the dining room. This failure resulted in Resident #2 fracturing a hip. An Immediate Jeopardy situation was identified on 8/17/17. The Immediate Jeopardy was removed on 08/18/17; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 46 residents who routinely use the dining room at risk for decreased quality of life, fear, and significant injury such [MEDICAL CONDITION] slips. Findings included: Observation on 8/15/17 between 7:30 a.m. and 8:00 a.m. of the facility's only dining room revealed there were 25 residents in the dining room. There was one nurse getting a resident's vital signs and checking the resident's oxygen tank. The nurse left without acknowledging any of the other residents. The Maintenance Assistant J assisted in bringing in Resident to the dining room and acknowledged residents in the dining room. The majority of residents were dressed and groomed. Independent residents had coffee, dependent residents did not have any fluids. Staff brought the residents into the dining area, dropped them off and immediately left. The staff did not respond to residents who held up cups of coffee (The residents did not seem to expect them to) overall the dining room remains empty of staff. At 7:52 a.m. breakfast trays in the main dining room began to be served. There were two aides serving breakfast (there was no nurse observed in the dining room). At 7:58 CNA C began passing juice/ milk. During an interview on 8/15/17 at 7:35 a.m. Resident #7 said yes, this is what breakfast is usually like, usually we get breakfast at 8:30 a.m. if we're lucky. Resident #7 said the residents could not get more than one cup coffee during meal times.(Staff continued to bring residents into dining room without acknowledging other residents.) During an interview on 8/15/17 at 7:45 a.m. Resident #8 said this was typically what breakfast was like. During the entrance conference on 8/15/17 at 8:35 a.m. the Administrator said the incidents were resident to resident altercation. She said Resident #1 and Resident #2 were in the dining room and no one knows exactly what happened. She said Resident #1 was getting coffee and Resident #2 went to Resident #1. She said Resident #1 pushed Resident #2; then Resident #2 pushed Resident #1; and Resident #1 pushed Resident #2 again. She said Resident #2 fell and broke his hip. After hospitalization Resident #2 went to another facility. The Administrator said Resident #1 remained the psychiatric hospital where he was still at. The Administrator said Resident #1 was not usually aggressive but if someone started something he would defend himself. She said Resident #1 had history of being verbally aggressive but not physically aggressive. The Administrator denied any history of aggression between the both residents. She said again Resident #1 would not start anything, but would finish it; but Resident #2 would start verbally and it antagonized Resident #1. RESIDENT #1 Review of Resident #1's undated Face Sheet documented he was a [AGE] year old male admitted to the facility on [DATE]. He was discharged as of 7/31/17. He had [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE]. Review of Resident #1's 6/7/17 14-day MDS documented in part: He scored a 9 of 15 on his mental status exam indicating he was moderately cognitively impaired. He showed signs of [MEDICAL CONDITION] including inattention and disorganized thinking. Resident #1 showed he scored a 1/27 indicators of depression but showed no behaviors. Resident #1 needed supervision for the following ADLs (Activities of Daily Living): transfers, walking, locomotion, eating, and hygiene. He needed assistance of one for dressing & bathing. Resident #1 had no range of motion impairment & used no devices. Resident #1 was occasionally incontinent of bladder &frequently incontinent of bowel. Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was on a scheduled pain medication but reported no pain. He had no falls. Resident #1 took no triggering medications as of June 7. Review of Resident #1's Care Plan documented, in part: 5/31/17 Problem: Behavior Problem as evidenced by resident yelling/ hollering & cursing at others, refusing to wear socks & shows (showers) at times, lay down on cement outside during the day per his preference related to [DIAGNOSES REDACTED]. Goal: Will have no evidence of increase with behavior problems every day by review date. Approach: Start date 3/15/17: Administer medications as ordered and monitored for side effects, effectiveness. Start date 3/15/17: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. Start date 3/15/17 Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Update 5/08/17: Resident with behaviors toward staff, refusing care, resisting redirection, hit staff yelling at staff member. MD notified and new order received for psychiatric hospital to evaluate and treat as indicated. 5/31/17 Problem: Psychosocial Well-Being: At risk for hallucinations, delusions, && behavior related to [DIAGNOSES REDACTED]. Goal: Resident will interact appropriately with staff, other residents, resident will have no episodes of hallucinations, delusions and behaviors over next quarter. Approach: Start Date: 3/1/17: Administer medications as ordered, monitor effectiveness and notify MD if indicated. Start Date: 3/1/17: Assign consistent care givers as able. Start Date: 3/1/17: Assist resident in identifying situation that triggers false beliefs Start Date: 3/1/17: Assist resident in identifying the effects of his behaviors on others Start Date: 3/1/17: Do not confront, argue against, or deny resident's thoughts. Start Date: 3/1/17: Maintain a calm environment and approach to redirect. Review of Resident #1's Nurse's Notes documented, in part: 6/03/17: At 8:03 a.m. Staff alerted nurse to dining area, stated resident poured milk on another resident sitting at table in dining room. Other nurse stated she did not see the incident, a couple of residents stated they did see incident. This nurse attempted to move resident from dining area but attempt failed, resident became very angry, and hostile, this nurse then removed table mate to another table. 7/05/17: At 5:00 p.m. this nurse called down to dining room by CNA, upon entering dining room noted resident and Resident #2 from Station #1 having verbal altercation with each other. Resident #2 bumped Resident #1 with his walker causing Resident #1 to get more Angry. Then Resident #2 attempted to swing at Resident #1 and missed causing Resident #1 to become off balance and fall in dining room on his bottom dropping two cups of juice on the floor. Residents both agreed to not argue with each other anymore. No injuries noted between either resident. 7/24/17 9:51 a.m. at 6:45 a.m. Resident and another resident were both found on the floor by the kitchen. Resident states he was getting coffee and another resident hit him so he pushed the other resident to the ground and also fell to the ground. Denies hurting himself or pain. Assisted up to standing position easily. Moves all extremities without problems. No skin or injuries noted. Fall was unwitnessed so neuro checks in progress. No complaints. Has been ambulating in hall without problems. 7/28/17 12:17 p.m. Resident has been really agitated this morning. He first complained of pain on his legs and medicated as prescribed. Then he requested to have his water pitcher and his cup filled with ice, which was done, but he kept asking for more ice. He became really agitated when he was told that his pitcher and cup were filled up and could not contain more ice. He started by dumping the contents of his cup on the floor, and requested more ice. The he started yelling at staff people for not being helpful, and repeatedly said, well you better kill me now or send me to jail. Later he got caught propelling himself on the floor, twice, and became even more angry whenever requested to get off the floor. He kept requesting to be either killed or sent to jail. New Orders received: - UA (urinalysis) for agitation - Refer to psychiatric hospital for evaluation. 7/29/17 7:27 p.m. Resident refused medication, he became angry and threw a cup of water and medication all over the floor. Redirected resident with quiet conversation, he accepted ice water but not medication. 7/30/17 6:12 p.m. Resident has had multiple witnessed falls today in the dining room. It has been reported that he has not hit head in any incident, but he continuously attempts to get out of wheelchair and stand at table or ambulate via walking. He is confused, angry, agitated and non-complaint. He has repeated been asked to stay in wheelchair, ask for assistance, been monitored as close to a one-on-one basis as possible throughout shift. He threw his juice all over this nurse at evening meal due to him wanting more sugar to put in his juice. He also threw juice and food at a resident that was sitting at the same table. He was removed from the dining room, ate soup in his room but returned to the dining area. Review of Resident #1's 24-Hour Report documented, in part: 7/30/17 fell multiple times - threw water and juice multiple times. Continue need for redirection. Review of Resident #1's Social Service Notes documented, in part: 7/24/17 SW (Social Worker) was informed by staff that Resident #1 got into an altercation with another male resident this morning. He also made remarks like just shoot me. Referral to Psychiatric Hospital. 7/31/17 SW Spoke with resident to see how he was doing. He said that he felt sore all over and nobody would do anything for him. He was upset because he stated he had no socks or underwear so he refused to take his meds this morning. SW explained that missing his meds would not make him feel any better but it was his way of getting back at the nurse because he couldn't find clothes. His voice became louder as we spoke even when the CNA brought his clean things and said she was about to shower him. He said he wished he was in jail or would just die so he could stop hurting and people would stop telling him what to do and he wouldn't get the medical care he needed. He the said he would rather be dead. Referral has already been made to Psychiatric Hospital. Review of Resident #1's July 2017 Behavior Flow Sheet documented the only day the facility documented behaviors on 7/29/17. RESIDENT #2 Review of Resident #2's undated Face Sheet documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 7/13/17 quarterly MDS documented in part: He scored a 12 of 15 indicating he was mostly cognitively intact but showed signs of [MEDICAL CONDITION] including inattention and disorganized thinking. Resident #2 scored a 3 of 27 on his mood scale indicating possible depression but showed no behaviors. Resident #2 needed supervision for all ADLs including transfers, walking, locomotion, dressing, eating, and hygiene. Resident #2 had no range of motion impairments. He used a walker and a wheelchair. Resident #2 was occasionally incontinent of bladder and bowel. His [DIAGNOSES REDACTED]. Resident #2 had no pain and had one fall with no injuries in the 30 days prior to the MDS. He had no skin impairments, including skin tears. Resident #2 was on an antidepressant for 7 of 7 days prior to the assessment. Resident #2 was on [MEDICAL TREATMENT]. Review of Resident #2's Care Plan dated 10/10/16 documented, in part: Problem: Behavioral Symptoms: Resident has episodes of adverse behavior(s) as evidenced by: verbally aggression - cursing, yelling/ screaming at others, physically throwing objects; unreliable historian at times and attempts to manipulate staff in the past; with history of verbally entices others (baits to encourage conflict others) related to depression/ anxiety and [MEDICAL CONDITION]. Resident is at risk of injury from others. Goal: Resident will have number of behavioral episodes will decrease and remain free from injury from others throughout the next quarter. Approach: Attempt to redirect resident to safe area when increased behavior noted. - Start Date 3/01/17: Anticipate behavior and re-direct when in close proximity to others that might invoke aggression. - Start Date 3/01/17: Assess for triggers that may contribute / prompt behaviors - Start Date 3/01/17: behavior monitoring per facility policy - Start Date 3/01/17: ensure staff is aware of resident's behaviors and successful interventions. - Start Date 3/01/17: give medications per orders - Start Date 3/01/17: maintain calm environment Review of Resident #2's Nurse's Notes documented: 7/05/17 1:38 p.m. Resident stated to this nurse that he was signing out to go to store, went to nursing station and ADON attempted to speak with him. Resident became angry and threw a pen across the room. Called Dr. and received an order to place a wander guard on resident., he got mad and yelled at the ADON and refused to wear the wanderguard, then he ambulated to the door and went out of the building. This nurse went out and tried to calm resident down and help him to the store. He still refused to put on wander guard at this time. 7/05/17: At 5:00 p.m. this nurse called down to dining room by CNA, upon entering dining room noted resident and Resident #2 from Station #1 having verbal altercation with each other. Resident #2 bumped Resident #1 with his walker causing Resident #1 to get more Angry. Then Resident #2 attempted to swing at Resident #1 and missed causing Resident #1 to become off balance and fall in dining room on his bottom dropping two cups of juice on the floor. Residents both agreed to not argue with each other anymore. No injuries noted between either resident. 7/24/17 at 7:41 a.m. Resident ambulated to hallway to get coffee. Resident #2 stated that both residents began to yell (at) each other, then resident hit the other resident in the face with fist. The other resident hit him back and he fell to the ground. He did not hit his head complained of right hip and right leg pain. Gave [MEDICATION NAME] 50 mg (milligrams) per doctor's order, also received order to send to ER. Review of Resident #2's Social Service Notes documented; 7/24/17 8:47 a.m. SW was informed by staff that Resident #2 got into an altercation with another male resident. Resident #2 hit the other resident and that resident pushed Resident #2 causing him to fall. Resident #2 was transferred to the ER and SW made a referral the the psychiatric facility. 7/24/17 1:05 p.m. Resident #2 is currently on [MEDICAL TREATMENT] so psychiatric facility would not accept him. His behaviors have been escalating so SW spoke with is sister regarding placement elsewhere. Review of Resident #2's 7/24/17 Provider Self-Reporting of Incidents for Resident #2 documented, in part: No witnesses at the time but the residents verbalized what occurred and statements agreed. Review of the attached 7/24/17 x-ray results provided by the hospital documented Acute subcapital right [MEDICAL CONDITION] with mild varus angulation. Review of the 7/24/17 Provider Self-Reporting of Incidents for Resident #2 documented, in part: No one witnessed it but did see residents in the floor and both residents verbalized what transpired. During an interview on 8/15/17 at 1:25 p.m. Licensed Vocational Nurse (LVN) A said she had been at the facility for 6 months. LVN A said in cases of behavior management she usually reported to the Charge Nurses immediately. She said in cases of physical altercations she would separate the residents and try to calm them down or leave them alone if safe. LVN A said can tell when a resident is beginning to get agitated when they started talking loud, making threats, and talking ugly to the care givers. LVN A said wen that happened they let the Charge Nurse and know & try to redirect. LVN A said Resident #1 was currently at the psychiatric facility. LVN A said Resident #1 was upset because he wanted to go home and he heard that if he's ugly enough the facility will let him go home. LVN A added he was not safe at home and his family did not want him there because he was not safe. LVN A said they knew when Resident #1 was beginning to pick a fight when he would staring down the other male residents that he had problems with. LVN A said when the other male residents looked back he would challenge that resident with 'what you looking at?'. LVN A said when that happens staff try to intervene. LVN A said she was at the facility day of incident but Resident #1 said someone tripped him but the other residents in the dining room said no one tripped him. LVN A confirmed there were no staff witnesses. LVN A said the facility had in-services on how to deal with behaviors - usually walk away if the resident was safe; remove them (the resident) from the situation if possible. LVN A said they liked to have 2 people deal with the problem resident. When asked if they had enough staff for that LVN A responded, No, we don't really have the staff for that but we make it happen. LVN A identified aggressive residents in the facility as: Resident #1, Resident #2 who goes around preaching at other people who of course don't want to hear it. During an interview on 8/15/17 at 1:40 p.m. Certified Nurse Aide (CNA) B said she had been an aide a couple of years but had been at the facility approximately six months. She said with resident with behaviors the aides just just had to have patience with them. CNA B said the aides tried to redirect the residents by talking to them, sometimes if you upset them or get someone else and alternate care giver. She said when they notice a resident begin to get aggressive, they just tell the Charge Nurse so they (the Charge Nurse) can intervene. She said they redirected male residents as they could and sometimes getting another male to interact with them helped. She said they aides would back off and come back or if they knew what they like the aides would get it for them. CNA B said Resident #1 started started getting real agitated right before he left and she did not know why. CNA B said he was impatient and would knock over an entire drink if did not get his ice fast enough. CNA B said he was ok with her but he would become more and more agitated very quickly. CNA B said she did not what would set him off but he threw cups and knocked tables over. CNA B said there were a couple of men in the dining room that he got into arguments with. CNA B said she could see it was leading up to a fight, but the staff would intervene by separating when they could. CNA B said he would talk about his family a lot and wanted to go home. CNA B said she did not remember Resident #2. When asked what role the social worker played with behavior interview CNA B asked is she the one with the short hair? I see her talking to residents but don't know what it's about. CNA B said she saw the nurses intervene with behaviors more often. When asked if the 8/15/17 breakfast observation was typical she said we try to do the best we can and we do what we can. Today was a little faster than usual. CNA B said usually there was 1 nurse, and 3 aides in dining room and sometimes the medication aide would help. During an interview on 8/16/17 at 1:50 p.m. CNA D said she did not see behaviors from the residents very often. CNA D said she managed aggressive behavior by calming them down, talking to them, give them time to calm down then return with help. CNA D described aggressive behavior as hitting, biting, or kicking. CNA D said aggressive behavior meant lashing out or pushing. CNA D said the only residents she had seen argue or get aggressive with each other was Resident #1 and Resident #2 in the dining room and she thought it took place about three months ago. CNA D said to redirect them they were separated them and it went easy. CNA D said it was the only time she saw them arguing and it was the only time she ever saw either resident exhibit aggressive behavior. CNA D said if the aides saw aggressive behavior they were supposed to report it to the the Charge Nurse or the Administrator. During an interview on 8/16/17 beginning at 2:07 p.m. the SW said she had been at the facility for almost 3 months. She said she assessed residents for behaviors when the nursing staff made the referral. The SW said she even made up a notebook, or if she was in the building they would just come and tell her what was going on. She said she tried to do the assessment on the resident to see if it was pain or if something happened and tried to figure out what the real issues was. The SW said she would let the resident vent and let them talk. She said usually the resident would have like seven things going on at once, so (you) have to let them go on until done to figure out. She said she had to figure out if staff were making it worse, then remove the staff from the situation. The SW said if it was a repetitive behavior she would look for another cause such as medication changes or something new like the family came and visited. She said a lot of the time she heard the residents say the Nurse 'said this and accused me of this and no one is listening to me'. The SW said she usually dealt with the nurses, and only occasionally the CNA's. She said she was involved with the trending of behaviors but she was not always here when behaviors happened to trend them. She said she was trying to get better with the notebook referral system. In the same interview, the SW described Resident #1 as easily agitated and confrontational. She said he could usually be redirected. She said a lot of times she would take him on a walk or smoke a cigarette. She said if felts threatened or if someone was in his face he would not to back down. The SW said she was not aware of any other triggers for behaviors. She said she was not aware of any pattern to his behaviors - he just did not want people messing with his stuff or in his space. Surveyor reviewed Resident #1's history of incidents with the SW. The SW said she would say the dining room over stimulated him and he's territorial. The SW said she was not made aware of these incidents. The SW said there was just not enough staff present at meal times and the staff were not paying attention to things when they were in the dining room. She said she remembered the nurse telling her about 7/28/17 incident. The SW said most of the time she not aware of a pattern until someone told her they were making a referral to the psychiatric hospital. In the same interview the SW was asked if the facility was equipped to deal with behavioral residents they had and she responded No. The doctor needs to be here more often, the aides aren't getting enough training in how to deal with behaviors. They'll go over the top with one resident but not do anything different with any of the other residents. There's no orientation. They don't stay calm, step back, not be argumentative, or talk about something else. During an interview on 8/16/17 at 2:15 p.m. CNA E said if she saw aggressive behavior between two residents she would report it quickly, redirect them without getting in between them. CNA E described aggressive behavior as angry facial expressions, pushing, and up in each other's faces. CNA E denied seeing any aggressive behavior by residents. She said she would report the behavior to the Charge Nurse. CNA E said she thought the most aggressive resident here in the facility was Resident #1. CNA E said I've not seen him act out but heard about him being aggressive toward staff and residents. During an interview on 8/16/17 at 2:40 p.m. CNA F said she managed aggressive behavior by redirecting and reporting it to the charge nurse. She said she would use calming tone of voice. CNA F described aggressive behavior as angry, frustrated, throwing things, yelling and thrashing out. She said if she saw two residents fighting she would try to separate them, try to calm them down. CNA F said the most aggressive resident in the facility was Resident #1. CNA F said I've seen him throw hot coffee, yell out at staff. I was scared of him and never got within arm's length. The residents were scared to be close if they saw him with coffee. During an interview on 8/16/17 at 3:40 p.m. the Director of Nurses (DON) said acknowledged on Resident #1's behavior monitoring forms the 7/24/17 physical aggression should be documented and 7/28/17 the afternoon shift did doc behavior and the day shift did not. She said the staff should document the behavior monitoring sheets according to what medication was for. The DON said if the medication was for an anti-depressant the staff would not necessarily documented the behaviors on it. Again, asked which medication the behavior monitoring form was for. The DON said in this case it was going to be for [MEDICATION NAME] Acid because it was for manic episodes. When asked what Resident #1's triggers were the DON said the Nurse Practitioner for the Psychiatrist looked at him. The DON said she had never seen Resident #1 be aggressive. The DON stated Resident #2 would try to set Resident #1 off intentionally and it was a personality conflict and Resident #1 was provoked. The DON said she did not know if someone looked back to see if either had pattern of behavior. The DON said patterns the staff would look for would be if behavior happened over and over at a certain time. When informed of the pattern of behaviors in the dining room the DON said she had him at previous facility so (she) saw him in a different light: he loved to stay outside and lay on ground. When asked how she expected the staff to redirect the residents she said it depended on the situation. She said if 2 people were arguing then she expected the staff to separate them and find out what caused the argument. She said a lot of time if separate and drop it they'll forget about it. During an interview on 8/16/17 at 4:10 p.m. the Administrator said was asked if the behavior monitoring forms needed to be separate for each medication she replied what did the DON say? When asked what the policy documented she said would have to verify it. She was shown Resident #1's behavior monitoring form and acknowledged she did not see an identifying medication. She said she had to dig out our policy, we had this before and I'll have to look at it again. She acknowledged how the form was being used now was definitely not effective. She described Resident #1 as a resident who generally walked around and talked to people. She said he was frequently involved with activities and she would have to look to see what set him off those days. Couldn't say what set him off on the days there was the fight between Resident #1 and Resident #2 She said the facility checked Resident #1 for a Urinary Tract Infection. During an interview on 8/17/17 at 10:20 a.m. Resident #7 said Resident #1 had been sent out of the facility twice. Resident #7 described Resident #1 as mean, hateful, and loud. She said he hit a [AGE] year old female with his fist several months ago. Resident #7 said she reported it and the facility did nothing about it. Resident #7 said he's going to hurt someone bad. Resident #7 stated Resident #1 was very strong. She stated she not afraid for her own safety but was afraid for the residents who could not speak up for themselves. She stated the man behind her is borderline retarded and crippled and would not be able to defend himself if Resident #1 targeted him. Resident #7 stated Resident #1 would intentionally pick on people who could not defend themselves; he picks on people he thinks he can get by with. In the same interview, Resident #7 stated Resident #1 grabbed her arm once and she yelled out and a male came over to help. She stated she yelled and the staff did not come but Resident #1 finally let go because she threatened him. During the same interview, Resident #7 said there was another man who was just as bad who got sent out (Resident #2) and she did not understand why Resident #1 was not. Resident #7 stated Resident #8 had [MEDICAL CONDITION] but said Resident #8 has said she was afraid of Resident #1 when some of the incidents happened in the dining room. (Resident #7 teared up.) She said Resident #1 needed to be someplace where the staff know how to calm things down before it happens. She said it doesn't take anything to turn him on. Review of the facility's April 2013 policy and procedure on Abuse and Neglect - Assessment and Recognition documented, in part: The nurse will assess the individual and documented related findings. Assessment data will include: 1. Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior); 2. The nurse will report findings to the physician. As needed, the physician will assess the resident to verify or clarify such findings, especially if the cause or source of the problem is unclear. 3. As part of the initial assessment, the physician will help identify individuals who have a history of being abused or neglected. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 4. The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents with unmanaged problematic behaviors. 5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect, such as, inappropriate management of problematic behavior. Treatment / Management The physician and staff will address causes of problematic resident behavior where possible, such as mania, [MEDICAL CONDITION], and medication side effects. Review of the facility's February 2014 Abuse Investigations policy and procedure documented, in part: All report of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Review of the facility's August 2006 policy and procedure on Abuse Prevention Program documented, in part: Our residents have the right to be free from abuse, neglect, misappropriation of resident property , corporal punishment and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone included, but not necessarily limited to: other residents. Mandated staff training/ orientation and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. Identification of occurrences and patterns of potential resident to resident abuse. Review of the facility's 5/11/17 in-service on Dealing with Combative/ Aggressive Behavior documented, in part: Risk Factors for Geriatric Patients: Within in the geriatric population, the causes of assaultive behavior can be grouped into three categories: - Patient Factors - Elderly patients with a [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit abuse and neglect for 2 of 7 residents (#1 and #2) reviewed for abuse and neglect. The facility failed to follow thier policy and procedure preventing resident neglect when they failed to address the aggressive behaviors of Resident #1 and Resident #2. On 08/16/17 an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 08/18/17, the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could place 46 residents who routinely use the dining room at risk for decreased quality of life, fear, and significant injury such as burn or slips. Findings included: Review of the facility's April 2013 policy and procedure on Abuse and Neglect - Assessment and Recognition documented, in part: The nurse will assess the individual and documented related findings. Assessment data will include: 1. Behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior); 2. The nurse will report findings to the physician. As needed, the physician will assess the resident to verify or clarify such findings, especially if the cause or source of the problem is unclear. 3. As part of the initial assessment, the physician will help identify individuals who have a history of being abused or neglected. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 4. The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents with unmanaged problematic behaviors. 5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect, such as, inappropriate management of problematic behavior. Treatment / Management The physician and staff will address causes of problematic resident behavior where possible, such as mania, [MEDICAL CONDITION], and medication side effects. Review of the facility's February 2014 Abuse Investigations policy and procedure documented, in part: All report of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Review of the facility's August 2006 policy and procedure on Abuse Prevention Program documented, in part: Our residents have the right to be free from abuse, neglect, misappropriation of resident property , corporal punishment and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone included, but not necessarily limited to: other residents. Comprehensive policies and procedures have been developed to aide our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Mandated staff training/ orientation and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. Identification of occurrences and patterns of potential resident to resident abuse. Observation on 8/15/17 between 7:30 a.m. and 8:00 a.m. of the facility's only dining room revealed there were 25 residents in the dining room. There was one nurse getting a resident's vital signs and checking the resident's oxygen tank. The nurse left without acknowledging any of the other residents. The Maintenance Assistant J assisted in bringing in Resident to the dining room and acknowledged residents in the dining room. The majority of residents were dressed and groomed. Independent residents had coffee, dependent residents did not have any fluids. Staff brought the residents into the dining area, dropped them off and immediately left. The staff did not respond to residents who held up cups of coffee (The residents did not seem to expect them to) overall the dining room remains empty of staff. At 7:52 a.m. breakfast trays in the main dining room began to be served. There were two aides serving breakfast (there was no nurse observed in the dining room). At 7:58 CNA C began passing juice/ milk. During an interview on 8/15/17 at 7:35 a.m. Resident #7 said yes, this is what breakfast is usually like, usually we get breakfast at 8:30 a.m. if we're lucky. Resident #7 said the residents could not get more than one cup coffee during meal times.(Staff continued to bring residents into dining room without acknowledging other residents.) During an interview on 8/15/17 at 7:45 a.m. Resident #8 said this was typically what breakfast was like. During the entrance conference on 8/15/17 at 8:35 a.m. the Administrator said the incidents were resident to resident altercation. She said Resident #1 and Resident #2 were in the dining room and no one knows exactly what happened. She said Resident #1 was getting coffee and Resident #2 went to Resident #1. She said Resident #1 pushed Resident #2; then Resident #2 pushed Resident #1; and Resident #1 pushed Resident #2 again. She said Resident #2 fell and broke his hip. After hospitalization Resident #2 went to another facility. The Administrator said Resident #1 remained the psychiatric hospital where he was still at. The Administrator said Resident #1 was not usually aggressive but if someone started something he would defend himself. She said Resident #1 had history of being verbally aggressive but not physically aggressive. The Administrator denied any history of aggression between the both residents. She said again Resident #1 would not start anything, but would finish it; but Resident #2 would start verbally and it antagonized Resident #1. RESIDENT #1 Review of Resident #1's undated Face Sheet documented he was a [AGE] year old male admitted to the facility on [DATE]. He was discharged as of 7/31/17. He had [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE]. Review of Resident #1's 6/7/17 14-day MDS documented in part: He scored a 9 of 15 on his mental status exam indicating he was moderately cognitively impaired. He showed signs of [MEDICAL CONDITION] including inattention and disorganized thinking. Resident #1 showed he scored a 1/27 indicators of depression but showed no behaviors. Resident #1 needed supervision for the following ADLs (Activities of Daily Living): transfers, walking, locomotion, eating, and hygiene. He needed assistance of one for dressing & bathing. Resident #1 had no range of motion impairment & used no devices. Resident #1 was occasionally incontinent of bladder &frequently incontinent of bowel. Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was on a scheduled pain medication but reported no pain. He had no falls. Resident #1 took no triggering medications as of June 7. Review of Resident #1's Care Plan documented, in part: 5/31/17 Problem: Behavior Problem as evidenced by resident yelling/ hollering & cursing at others, refusing to wear socks & shows (showers) at times, lay down on cement outside during the day per his preference related to [DIAGNOSES REDACTED]. Goal: Will have no evidence of increase with behavior problems every day by review date. Approach: Start date 3/15/17: Administer medications as ordered and monitored for side effects, effectiveness. Start date 3/15/17: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. Start date 3/15/17 Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Update 5/08/17: Resident with behaviors toward staff, refusing care, resisting redirection, hit staff yelling at staff member. MD notified and new order received for psychiatric hospital to evaluate and treat as indicated. 5/31/17 Problem: Psychosocial Well-Being: At risk for hallucinations, delusions, && behavior related to [DIAGNOSES REDACTED]. Goal: Resident will interact appropriately with staff, other residents, resident will have no episodes of hallucinations, delusions and behaviors over next quarter. Approach: Start Date: 3/1/17: Administer medications as ordered, monitor effectiveness and notify MD if indicated. Start Date: 3/1/17: Assign consistent care givers as able. Start Date: 3/1/17: Assist resident in identifying situation that triggers false beliefs Start Date: 3/1/17: Assist resident in identifying the effects of his behaviors on others Start Date: 3/1/17: Do not confront, argue against, or deny resident's thoughts. Start Date: 3/1/17: Maintain a calm environment and approach to redirect. Review of Resident #1's Nurse's Notes documented, in part: 6/03/17: At 8:03 a.m. Staff alerted nurse to dining area, stated resident poured milk on another resident sitting at table in dining room. Other nurse stated she did not see the incident, a couple of residents stated they did see incident. This nurse attempted to move resident from dining area but attempt failed, resident became very angry, and hostile, this nurse then removed table mate to another table. 7/05/17: At 5:00 p.m. this nurse called down to dining room by CNA, upon entering dining room noted resident and Resident #2 from Station #1 having verbal altercation with each other. Resident #2 bumped Resident #1 with his walker causing Resident #1 to get more Angry. Then Resident #2 attempted to swing at Resident #1 and missed causing Resident #1 to become off balance and fall in dining room on his bottom dropping two cups of juice on the floor. Residents both agreed to not argue with each other anymore. No injuries noted between either resident. 7/24/17 9:51 a.m. at 6:45 a.m. Resident and another resident were both found on the floor by the kitchen. Resident states he was getting coffee and another resident hit him so he pushed the other resident to the ground and also fell to the ground. Denies hurting himself or pain. Assisted up to standing position easily. Moves all extremities without problems. No skin or injuries noted. Fall was unwitnessed so neuro checks in progress. No complaints. Has been ambulating in hall without problems. 7/28/17 12:17 p.m. Resident has been really agitated this morning. He first complained of pain on his legs and medicated as prescribed. Then he requested to have his water pitcher and his cup filled with ice, which was done, but he kept asking for more ice. He became really agitated when he was told that his pitcher and cup were filled up and could not contain more ice. He started by dumping the contents of his cup on the floor, and requested more ice. The he started yelling at staff people for not being helpful, and repeatedly said, well you better kill me now or send me to jail. Later he got caught propelling himself on the floor, twice, and became even more angry whenever requested to get off the floor. He kept requesting to be either killed or sent to jail. New Orders received: - UA (urinalysis) for agitation - Refer to psychiatric hospital for evaluation. 7/29/17 7:27 p.m. Resident refused medication, he became angry and threw a cup of water and medication all over the floor. Redirected resident with quiet conversation, he accepted ice water but not medication. 7/30/17 6:12 p.m. Resident has had multiple witnessed falls today in the dining room. It has been reported that he has not hit head in any incident, but he continuously attempts to get out of wheelchair and stand at table or ambulate via walking. He is confused, angry, agitated and non-complaint. He has repeated been asked to stay in wheelchair, ask for assistance, been monitored as close to a one-on-one basis as possible throughout shift. He threw his juice all over this nurse at evening meal due to him wanting more sugar to put in his juice. He also threw juice and food at a resident that was sitting at the same table. He was removed from the dining room, ate soup in his room but returned to the dining area. Review of Resident #1's 24-Hour Report documented, in part: 7/30/17 fell multiple times - threw water and juice multiple times. Continue need for redirection. Review of Resident #1's Social Service Notes documented, in part: 7/24/17 SW (Social Worker) was informed by staff that Resident #1 got into an altercation with another male resident this morning. He also made remarks like just shoot me. Referral to Psychiatric Hospital. 7/31/17 SW Spoke with resident to see how he was doing. He said that he felt sore all over and nobody would do anything for him. He was upset because he stated he had no socks or underwear so he refused to take his meds this morning. SW explained that missing his meds would not make him feel any better but it was his way of getting back at the nurse because he couldn't find clothes. His voice became louder as we spoke even when the CNA brought his clean things and said she was about to shower him. He said he wished he was in jail or would just die so he could stop hurting and people would stop telling him what to do and he wouldn't get the medical care he needed. He the said he would rather be dead. Referral has already been made to Psychiatric Hospital. Review of Resident #1's July 2017 Behavior Flow Sheet documented the only day the facility documented behaviors on 7/29/17. RESIDENT #2 Review of Resident #2's undated Face Sheet documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 7/13/17 quarterly MDS documented in part: He scored a 12 of 15 indicating he was mostly cognitively intact but showed signs of [MEDICAL CONDITION] including inattention and disorganized thinking. Resident #2 scored a 3 of 27 on his mood scale indicating possible depression but showed no behaviors. Resident #2 needed supervision for all ADLs including transfers, walking, locomotion, dressing, eating, and hygiene. Resident #2 had no range of motion impairments. He used a walker and a wheelchair. Resident #2 was occasionally incontinent of bladder and bowel. His [DIAGNOSES REDACTED]. Resident #2 had no pain and had one fall with no injuries in the 30 days prior to the MDS. He had no skin impairments, including skin tears. Resident #2 was on an antidepressant for 7 of 7 days prior to the assessment. Resident #2 was on [MEDICAL TREATMENT]. Review of Resident #2's Care Plan dated 10/10/16 documented, in part: Problem: Behavioral Symptoms: Resident has episodes of adverse behavior(s) as evidenced by: verbally aggression - cursing, yelling/ screaming at others, physically throwing objects; unreliable historian at times and attempts to manipulate staff in the past; with history of verbally entices others (baits to encourage conflict others) related to depression/ anxiety and [MEDICAL CONDITION]. Resident is at risk of injury from others. Goal: Resident will have number of behavioral episodes will decrease and remain free from injury from others throughout the next quarter. Approach: Attempt to redirect resident to safe area when increased behavior noted. - Start Date 3/01/17: Anticipate behavior and re-direct when in close proximity to others that might invoke aggression. - Start Date 3/01/17: Assess for triggers that may contribute / prompt behaviors - Start Date 3/01/17: behavior monitoring per facility policy - Start Date 3/01/17: ensure staff is aware of resident's behaviors and successful interventions. - Start Date 3/01/17: give medications per orders - Start Date 3/01/17: maintain calm environment Review of Resident #2's Nurse's Notes documented: 7/05/17 1:38 p.m. Resident stated to this nurse that he was signing out to go to store, went to nursing station and ADON attempted to speak with him. Resident became angry and threw a pen across the room. Called Dr. and received an order to place a wander guard on resident., he got mad and yelled at the ADON and refused to wear the wanderguard, then he ambulated to the door and went out of the building. This nurse went out and tried to calm resident down and help him to the store. He still refused to put on wander guard at this time. 7/05/17: At 5:00 p.m. this nurse called down to dining room by CNA, upon entering dining room noted resident and Resident #2 from Station #1 having verbal altercation with each other. Resident #2 bumped Resident #1 with his walker causing Resident #1 to get more Angry. Then Resident #2 attempted to swing at Resident #1 and missed causing Resident #1 to become off balance and fall in dining room on his bottom dropping two cups of juice on the floor. Residents both agreed to not argue with each other anymore. No injuries noted between either resident. 7/24/17 at 7:41 a.m. Resident ambulated to hallway to get coffee. Resident #2 stated that both residents began to yell (at) each other, then resident hit the other resident in the face with fist. The other resident hit him back and he fell to the ground. He did not hit his head complained of right hip and right leg pain. Gave [MEDICATION NAME] 50 mg (milligrams) per doctor's order, also received order to send to ER. Review of Resident #2's Social Service Notes documented; 7/24/17 8:47 a.m. SW was informed by staff that Resident #2 got into an altercation with another male resident. Resident #2 hit the other resident and that resident pushed Resident #2 causing him to fall. Resident #2 was transferred to the ER and SW made a referral the the psychiatric facility. 7/24/17 1:05 p.m. Resident #2 is currently on [MEDICAL TREATMENT] so psychiatric facility would not accept him. His behaviors have been escalating so SW spoke with is sister regarding placement elsewhere. Review of Resident #2's 7/24/17 Provider Self-Reporting of Incidents for Resident #2 documented, in part: No witnesses at the time but the residents verbalized what occurred and statements agreed. Review of the attached 7/24/17 x-ray results provided by the hospital documented Acute subcapital right [MEDICAL CONDITION] with mild varus angulation. Review of the 7/24/17 Provider Self-Reporting of Incidents for Resident #2 documented, in part: No one witnessed it but did see residents in the floor and both residents verbalized what transpired. During an interview on 8/15/17 at 1:25 p.m. Licensed Vocational Nurse (LVN) A said she had been at the facility for 6 months. LVN A said in cases of behavior management she usually reported to the Charge Nurses immediately. She said in cases of physical altercations she would separate the residents and try to calm them down or leave them alone if safe. LVN A said can tell when a resident is beginning to get agitated when they started talking loud, making threats, and talking ugly to the care givers. LVN A said wen that happened they let the Charge Nurse and know & try to redirect. LVN A said Resident #1 was currently at the psychiatric facility. LVN A said Resident #1 was upset because he wanted to go home and he heard that if he's ugly enough the facility will let him go home. LVN A added he was not safe at home and his family did not want him there because he was not safe. LVN A said they knew when Resident #1 was beginning to pick a fight when he would staring down the other male residents that he had problems with. LVN A said when the other male residents looked back he would challenge that resident with 'what you looking at?'. LVN A said when that happens staff try to intervene. LVN A said she was at the facility day of incident but Resident #1 said someone tripped him but the other residents in the dining room said no one tripped him. LVN A confirmed there were no staff witnesses. LVN A said the facility had in-services on how to deal with behaviors - usually walk away if the resident was safe; remove them (the resident) from the situation if possible. LVN A said they liked to have 2 people deal with the problem resident. When asked if they had enough staff for that LVN A responded, No, we don't really have the staff for that but we make it happen. LVN A identified aggressive residents in the facility as: Resident #1, Resident #2 who goes around preaching at other people who of course don't want to hear it. During an interview on 8/15/17 at 1:40 p.m. Certified Nurse Aide (CNA) B said she had been an aide a couple of years but had been at the facility approximately six months. She said with resident with behaviors the aides just just had to have patience with them. CNA B said the aides tried to redirect the residents by talking to them, sometimes if you upset them or get someone else and alternate care giver. She said when they notice a resident begin to get aggressive, they just tell the Charge Nurse so they (the Charge Nurse) can intervene. She said they redirected male residents as they could and sometimes getting another male to interact with them helped. She said they aides would back off and come back or if they knew what they like the aides would get it for them. CNA B said Resident #1 started started getting real agitated right before he left and she did not know why. CNA B said he was impatient and would knock over an entire drink if did not get his ice fast enough. CNA B said he was ok with her but he would become more and more agitated very quickly. CNA B said she did not what would set him off but he threw cups and knocked tables over. CNA B said there were a couple of men in the dining room that he got into arguments with. CNA B said she could see it was leading up to a fight, but the staff would intervene by separating when they could. CNA B said he would talk about his family a lot and wanted to go home. CNA B said she did not remember Resident #2. When asked what role the social worker played with behavior interview CNA B asked is she the one with the short hair? I see her talking to residents but don't know what it's about. CNA B said she saw the nurses intervene with behaviors more often. When asked if the 8/15/17 breakfast observation was typical she said we try to do the best we can and we do what we can. Today was a little faster than usual. CNA B said usually there was 1 nurse, and 3 aides in dining room and sometimes the medication aide would help. During an interview on 8/16/17 at 1:50 p.m. CNA D said she did not see behaviors from the residents very often. CNA D said she managed aggressive behavior by calming them down, talking to them, give them time to calm down then return with help. CNA D described aggressive behavior as hitting, biting, or kicking. CNA D said aggressive behavior meant lashing out or pushing. CNA D said the only residents she had seen argue or get aggressive with each other was Resident #1 and Resident #2 in the dining room and she thought it took place about three months ago. CNA D said to redirect them they were separated them and it went easy. CNA D said it was the only time she saw them arguing and it was the only time she ever saw either resident exhibit aggressive behavior. CNA D said if the aides saw aggressive behavior they were supposed to report it to the the Charge Nurse or the Administrator. During an interview on 8/16/17 beginning at 2:07 p.m. the SW said she had been at the facility for almost 3 months. She said she assessed residents for behaviors when the nursing staff made the referral. The SW said she even made up a notebook, or if she was in the building they would just come and tell her what was going on. She said she tried to do the assessment on the resident to see if it was pain or if something happened and tried to figure out what the real issues was. The SW said she would let the resident vent and let them talk. She said usually the resident would have like seven things going on at once, so (you) have to let them go on until done to figure out. She said she had to figure out if staff were making it worse, then remove the staff from the situation. The SW said if it was a repetitive behavior she would look for another cause such as medication changes or something new like the family came and visited. She said a lot of the time she heard the residents say the Nurse 'said this and accused me of this and no one is listening to me'. The SW said she usually dealt with the nurses, and only occasionally the CNA's. She said she was involved with the trending of behaviors but she was not always here when behaviors happened to trend them. She said she was trying to get better with the notebook referral system. In the same interview, the SW described Resident #1 as easily agitated and confrontational. She said he could usually be redirected. She said a lot of times she would take him on a walk or smoke a cigarette. She said if felts threatened or if someone was in his face he would not to back down. The SW said she was not aware of any other triggers for behaviors. She said she was not aware of any pattern to his behaviors - he just did not want people messing with his stuff or in his space. Surveyor reviewed Resident #1's history of incidents with the SW. The SW said she would say the dining room over stimulated him and he's territorial. The SW said she was not made aware of these incidents. The SW said there was just not enough staff present at meal times and the staff were not paying attention to things when they were in the dining room. She said she remembered the nurse telling her about 7/28/17 incident. The SW said most of the time she not aware of a pattern until someone told her they were making a referral to the psychiatric hospital. In the same interview the SW was asked if the facility was equipped to deal with behavioral residents they had and she responded No. The doctor needs to be here more often, the aides aren't getting enough training in how to deal with behaviors. They'll go over the top with one resident but not do anything different with any of the other residents. There's no orientation. They don't stay calm, step back, not be argumentative, or talk about something else. During an interview on 8/16/17 at 2:15 p.m. CNA E said if she saw aggressive behavior between two residents she would report it quickly, redirect them without getting in between them. CNA E described aggressive behavior as angry facial expressions, pushing, and up in each other's faces. CNA E denied seeing any aggressive behavior by residents. She said she would report the behavior to the Charge Nurse. CNA E said she thought the most aggressive resident here in the facility was Resident #1. CNA E said I've not seen him act out but heard about him being aggressive toward staff and residents. During an interview on 8/16/17 at 2:40 p.m. CNA F said she managed aggressive behavior by redirecting and reporting it to the charge nurse. She said she would use calming tone of voice. CNA F described aggressive behavior as angry, frustrated, throwing things, yelling and thrashing out. She said if she saw two residents fighting she would try to separate them, try to calm them down. CNA F said the most aggressive resident in the facility was Resident #1. CNA F said I've seen him throw hot coffee, yell out at staff. I was scared of him and never got within arm's length. The residents were scared to be close if they saw him with coffee. During an interview on 8/16/17 at 3:40 p.m. the Director of Nurses (DON) said acknowledged on Resident #1's behavior monitoring forms the 7/24/17 physical aggression should be documented and 7/28/17 the afternoon shift did doc behavior and the day shift did not. She said the staff should document the behavior monitoring sheets according to what medication was for. The DON said if the medication was for an anti-depressant the staff would not necessarily documented the behaviors on it. Again, asked which medication the behavior monitoring form was for. The DON said in this case it was going to be for [MEDICATION NAME] Acid because it was for manic episodes. When asked what Resident #1's triggers were the DON said the Nurse Practitioner for the Psychiatrist looked at him. The DON said she had never seen Resident #1 be aggressive. The DON stated Resident #2 would try to set Resident #1 off intentionally and it was a personality conflict and Resident #1 was provoked. The DON said she did not know if someone looked back to see if either had pattern of behavior. The DON said patterns the staff would look for would be if behavior happened over and over at a certain time. When informed of the pattern of behaviors in the dining room the DON said she had him at previous facility so (she) saw him in a different light: he loved to stay outside and lay on ground. When asked how she expected the staff to redirect the residents she said it depended on the situation. She said if 2 people were arguing then she expected the staff to separate them and find out what caused the argument. She said a lot of time if separate and drop it they'll forget about it. During an interview on 8/16/17 at 4:10 p.m. the Administrator said was asked if the behavior monitoring forms needed to be separate for each medication she replied what did the DON say? When asked what the policy documented she said would have to verify it. She was shown Resident #1's behavior monitoring form and acknowledged she did not see an identifying medication. She said she had to dig out our policy, we had this before and I'll have to look at it again. She acknowledged how the form was being used now was definitely not effective. She described Resident #1 as a resident who generally walked around and talked to people. She said he was frequently involved with activities and she would have to look to see what set him off those days. Couldn't say what set him off on the days there was the fight between Resident #1 and Resident #2 She said the facility checked Resident #1 for a Urinary Tract Infection. During an interview on 8/17/17 at 10:20 a.m. Resident #7 said Resident #1 had been sent out of the facility twice. Resident #7 described Resident #1 as mean, hateful, and loud. She said he hit a [AGE] year old female with his fist several months ago. Resident #7 said she reported it and the facility did nothing about it. Resident #7 said he's going to hurt someone bad. Resident #7 stated Resident #1 was very strong. She stated she not afraid for her own safety but was afraid for the residents who could not speak up for themselves. She stated the man behind her is borderline retarded and crippled and would not be able to defend himself if Resident #1 targeted him. Resident #7 stated Resident #1 would intentionally pick on people who could not defend themselves; he picks on people he thinks he can get by with. In the same interview, Resident #7 stated Resident #1 grabbed her arm once and she yelled out and a male came over to help. She stated she yelled and the staff did not come but Resident #1 finally let go because she threatened him. During the same interview, Resident #7 said there was another man who was just as bad who got sent out (Resident #2) and she did not understand why Resident #1 was not. Resident #7 stated Resident #8 had [MEDICAL CONDITION] but said Resident #8 has said she was afraid of Resident #1 when some of the incidents happened in the dining room. (Resident #7 teared up.) She said Resident #1 needed to be someplace where the staff know how to calm things down before it happens. She said it doesn't take anything to turn him on. Review of the facility's 5/11/17 in-service on Dealing with Combative/ Aggressive Behavior documented, in part: Risk Factors for Geriatric Patients: Within in the geriatric population, the causes of assaultive (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent resident to resident altercations for 2 of 7 residents (#1 and #2) reviewed for supervision. Resident #1and #2 had a known history of fighting. On 7/24/17, in the dining room, Resident #1 and Resident #2 got into another altercation. There were no staff present to intervene or prevent the altercation. An Immediate Jeopardy was identified on 08/17/17. While the IJ was removed on 08/18/17, the facility remained out of compliance at a severity level of actual harm with potential for more than minimum harm at a scope of pattern because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. This failure placed 46 residents who routinely used the dining room at risk for social isolation for being afraid to go to the dining room or serious injury. Findings included: Observation on 8/15/17 between 7:30 a.m. and 8:00 a.m. of the facility's only dining room revealed there were 25 residents in the dining room. There was one nurse getting a resident's vital signs and checking the resident's oxygen tank. The nurse left without acknowledging any of the other residents. The Maintenance Assistant J assisted in bringing in Resident to the dining room and acknowledged residents in the dining room. The majority of residents were dressed and groomed. Independent residents had coffee, dependent residents did not have any fluids. Staff brought the residents into the dining area, dropped them off and immediately left. The staff did not respond to residents who held up cups of coffee (The residents did not seem to expect them to) overall the dining room remains empty of staff. At 7:52 a.m. breakfast trays in the main dining room began to be served. There were two aides serving breakfast (there was no nurse observed in the dining room). At 7:58 CNA C began passing juice/ milk. During an interview on 8/15/17 at 7:35 a.m. Resident #7 said yes, this is what breakfast is usually like, usually we get breakfast at 8:30 a.m. if we're lucky. Resident #7 said the residents could not get more than one cup coffee during meal times.(Staff continued to bring residents into dining room without acknowledging other residents.) During an interview on 8/15/17 at 7:45 a.m. Resident #8 said this was typically what breakfast was like. During the entrance conference on 8/15/17 at 8:35 a.m. the Administrator said the incidents were resident to resident altercation. She said Resident #1 and Resident #2 were in the dining room and no one knows exactly what happened. She said Resident #1 was getting coffee and Resident #2 went to Resident #1. She said Resident #1 pushed Resident #2; then Resident #2 pushed Resident #1; and Resident #1 pushed Resident #2 again. She said Resident #2 fell and broke his hip. After hospitalization Resident #2 went to another facility. The Administrator said Resident #1 remained the psychiatric hospital where he was still at. The Administrator said Resident #1 was not usually aggressive but if someone started something he would defend himself. She said Resident #1 had history of being verbally aggressive but not physically aggressive. The Administrator denied any history of aggression between the both residents. She said again Resident #1 would not start anything, but would finish it; but Resident #2 would start verbally and it antagonized Resident #1. RESIDENT #1 Review of Resident #1's undated Face Sheet documented he was a [AGE] year old male admitted to the facility on [DATE]. He was discharged as of 7/31/17. He had [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE]. Review of Resident #1's 6/7/17 14-day MDS documented in part: He scored a 9 of 15 on his mental status exam indicating he was moderately cognitively impaired. He showed signs of delirium including inattention and disorganized thinking. Resident #1 showed he scored a 1/27 indicators of depression but showed no behaviors. Resident #1 needed supervision for the following ADLs (Activities of Daily Living): transfers, walking, locomotion, eating, and hygiene. He needed assistance of one for dressing & bathing. Resident #1 had no range of motion impairment & used no devices. Resident #1 was occasionally incontinent of bladder &frequently incontinent of bowel. Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was on a scheduled pain medication but reported no pain. He had no falls. Resident #1 took no triggering medications as of June 7. Review of Resident #1's Care Plan documented, in part: 5/31/17 Problem: Behavior Problem as evidenced by resident yelling/ hollering & cursing at others, refusing to wear socks & shows (showers) at times, lay down on cement outside during the day per his preference related to [DIAGNOSES REDACTED]. Goal: Will have no evidence of increase with behavior problems every day by review date. Approach: Start date 3/15/17: Administer medications as ordered and monitored for side effects, effectiveness. Start date 3/15/17: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. Start date 3/15/17 Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Update 5/08/17: Resident with behaviors toward staff, refusing care, resisting redirection, hit staff yelling at staff member. MD notified and new order received for psychiatric hospital to evaluate and treat as indicated. 5/31/17 Problem: Psychosocial Well-Being: At risk for hallucinations, delusions, && behavior related to [DIAGNOSES REDACTED]. Goal: Resident will interact appropriately with staff, other residents, resident will have no episodes of hallucinations, delusions and behaviors over next quarter. Approach: Start Date: 3/1/17: Administer medications as ordered, monitor effectiveness and notify MD if indicated. Start Date: 3/1/17: Assign consistent care givers as able. Start Date: 3/1/17: Assist resident in identifying situation that triggers false beliefs Start Date: 3/1/17: Assist resident in identifying the effects of his behaviors on others Start Date: 3/1/17: Do not confront, argue against, or deny resident's thoughts. Start Date: 3/1/17: Maintain a calm environment and approach to redirect. Review of Resident #1's Nurse's Notes documented, in part: 6/03/17: At 8:03 a.m. Staff alerted nurse to dining area, stated resident poured milk on another resident sitting at table in dining room. Other nurse stated she did not see the incident, a couple of residents stated they did see incident. This nurse attempted to move resident from dining area but attempt failed, resident became very angry, and hostile, this nurse then removed table mate to another table. 7/05/17: At 5:00 p.m. this nurse called down to dining room by CNA, upon entering dining room noted resident and Resident #2 from Station #1 having verbal altercation with each other. Resident #2 bumped Resident #1 with his walker causing Resident #1 to get more Angry. Then Resident #2 attempted to swing at Resident #1 and missed causing Resident #1 to become off balance and fall in dining room on his bottom dropping two cups of juice on the floor. Residents both agreed to not argue with each other anymore. No injuries noted between either resident. 7/24/17 9:51 a.m. at 6:45 a.m. Resident and another resident were both found on the floor by the kitchen. Resident states he was getting coffee and another resident hit him so he pushed the other resident to the ground and also fell to the ground. Denies hurting himself or pain. Assisted up to standing position easily. Moves all extremities without problems. No skin or injuries noted. Fall was unwitnessed so neuro checks in progress. No complaints. Has been ambulating in hall without problems. 7/28/17 12:17 p.m. Resident has been really agitated this morning. He first complained of pain on his legs and medicated as prescribed. Then he requested to have his water pitcher and his cup filled with ice, which was done, but he kept asking for more ice. He became really agitated when he was told that his pitcher and cup were filled up and could not contain more ice. He started by dumping the contents of his cup on the floor, and requested more ice. The he started yelling at staff people for not being helpful, and repeatedly said, well you better kill me now or send me to jail. Later he got caught propelling himself on the floor, twice, and became even more angry whenever requested to get off the floor. He kept requesting to be either killed or sent to jail. New Orders received: - UA (urinalysis) for agitation - Refer to psychiatric hospital for evaluation. 7/29/17 7:27 p.m. Resident refused medication, he became angry and threw a cup of water and medication all over the floor. Redirected resident with quiet conversation, he accepted ice water but not medication. 7/30/17 6:12 p.m. Resident has had multiple witnessed falls today in the dining room. It has been reported that he has not hit head in any incident, but he continuously attempts to get out of wheelchair and stand at table or ambulate via walking. He is confused, angry, agitated and non-complaint. He has repeated been asked to stay in wheelchair, ask for assistance, been monitored as close to a one-on-one basis as possible throughout shift. He threw his juice all over this nurse at evening meal due to him wanting more sugar to put in his juice. He also threw juice and food at a resident that was sitting at the same table. He was removed from the dining room, ate soup in his room but returned to the dining area. Review of Resident #1's 24-Hour Report documented, in part: 7/30/17 fell multiple times - threw water and juice multiple times. Continue need for redirection. Review of Resident #1's Social Service Notes documented, in part: 7/24/17 SW (Social Worker) was informed by staff that Resident #1 got into an altercation with another male resident this morning. He also made remarks like just shoot me. Referral to Psychiatric Hospital. 7/31/17 SW Spoke with resident to see how he was doing. He said that he felt sore all over and nobody would do anything for him. He was upset because he stated he had no socks or underwear so he refused to take his meds this morning. SW explained that missing his meds would not make him feel any better but it was his way of getting back at the nurse because he couldn't find clothes. His voice became louder as we spoke even when the CNA brought his clean things and said she was about to shower him. He said he wished he was in jail or would just die so he could stop hurting and people would stop telling him what to do and he wouldn't get the medical care he needed. He the said he would rather be dead. Referral has already been made to Psychiatric Hospital. Review of Resident #1's July 2017 Behavior Flow Sheet documented the only day the facility documented behaviors on 7/29/17. RESIDENT #2 Review of Resident #2's undated Face Sheet documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 7/13/17 quarterly MDS documented in part: He scored a 12 of 15 indicating he was mostly cognitively intact but showed signs of delirium including inattention and disorganized thinking. Resident #2 scored a 3 of 27 on his mood scale indicating possible depression but showed no behaviors. Resident #2 needed supervision for all ADLs including transfers, walking, locomotion, dressing, eating, and hygiene. Resident #2 had no range of motion impairments. He used a walker and a wheelchair. Resident #2 was occasionally incontinent of bladder and bowel. His [DIAGNOSES REDACTED]. Resident #2 had no pain and had one fall with no injuries in the 30 days prior to the MDS. He had no skin impairments, including skin tears. Resident #2 was on an antidepressant for 7 of 7 days prior to the assessment. Resident #2 was on dialysis. Review of Resident #2's Care Plan dated 10/10/16 documented, in part: Problem: Behavioral Symptoms: Resident has episodes of adverse behavior(s) as evidenced by: verbally aggression - cursing, yelling/ screaming at others, physically throwing objects; unreliable historian at times and attempts to manipulate staff in the past; with history of verbally entices others (baits to encourage conflict others) related to depression/ anxiety and traumatic brain injury. Resident is at risk of injury from others. Goal: Resident will have number of behavioral episodes will decrease and remain free from injury from others throughout the next quarter. Approach: Attempt to redirect resident to safe area when increased behavior noted. - Start Date 3/01/17: Anticipate behavior and re-direct when in close proximity to others that might invoke aggression. - Start Date 3/01/17: Assess for triggers that may contribute / prompt behaviors - Start Date 3/01/17: behavior monitoring per facility policy - Start Date 3/01/17: ensure staff is aware of resident's behaviors and successful interventions. - Start Date 3/01/17: give medications per orders - Start Date 3/01/17: maintain calm environment Review of Resident #2's Nurse's Notes documented: 7/05/17 1:38 p.m. Resident stated to this nurse that he was signing out to go to store, went to nursing station and ADON attempted to speak with him. Resident became angry and threw a pen across the room. Called Dr. and received an order to place a wander guard on resident., he got mad and yelled at the ADON and refused to wear the wanderguard, then he ambulated to the door and went out of the building. This nurse went out and tried to calm resident down and help him to the store. He still refused to put on wander guard at this time. 7/05/17: At 5:00 p.m. this nurse called down to dining room by CNA, upon entering dining room noted resident and Resident #2 from Station #1 having verbal altercation with each other. Resident #2 bumped Resident #1 with his walker causing Resident #1 to get more Angry. Then Resident #2 attempted to swing at Resident #1 and missed causing Resident #1 to become off balance and fall in dining room on his bottom dropping two cups of juice on the floor. Residents both agreed to not argue with each other anymore. No injuries noted between either resident. 7/24/17 at 7:41 a.m. Resident ambulated to hallway to get coffee. Resident #2 stated that both residents began to yell (at) each other, then resident hit the other resident in the face with fist. The other resident hit him back and he fell to the ground. He did not hit his head complained of right hip and right leg pain. Gave Tramadol 50 mg (milligrams) per doctor's order, also received order to send to ER. Review of Resident #2's Social Service Notes documented; 7/24/17 8:47 a.m. SW was informed by staff that Resident #2 got into an altercation with another male resident. Resident #2 hit the other resident and that resident pushed Resident #2 causing him to fall. Resident #2 was transferred to the ER and SW made a referral the the psychiatric facility. 7/24/17 1:05 p.m. Resident #2 is currently on dialysis so psychiatric facility would not accept him. His behaviors have been escalating so SW spoke with is sister regarding placement elsewhere. Review of Resident #2's 7/24/17 Provider Self-Reporting of Incidents for Resident #2 documented, in part: No witnesses at the time but the residents verbalized what occurred and statements agreed. Review of the attached 7/24/17 x-ray results provided by the hospital documented Acute subcapital right hip fracture with mild varus angulation. Review of the 7/24/17 Provider Self-Reporting of Incidents for Resident #2 documented, in part: No one witnessed it but did see residents in the floor and both residents verbalized what transpired. During an interview on 8/15/17 at 1:25 p.m. Licensed Vocational Nurse (LVN) A said she had been at the facility for 6 months. LVN A said in cases of behavior management she usually reported to the Charge Nurses immediately. She said in cases of physical altercations she would separate the residents and try to calm them down or leave them alone if safe. LVN A said can tell when a resident is beginning to get agitated when they started talking loud, making threats, and talking ugly to the care givers. LVN A said wen that happened they let the Charge Nurse and know & try to redirect. LVN A said Resident #1 was currently at the psychiatric facility. LVN A said Resident #1 was upset because he wanted to go home and he heard that if he's ugly enough the facility will let him go home. LVN A added he was not safe at home and his family did not want him there because he was not safe. LVN A said they knew when Resident #1 was beginning to pick a fight when he would staring down the other male residents that he had problems with. LVN A said when the other male residents looked back he would challenge that resident with 'what you looking at?'. LVN A said when that happens staff try to intervene. LVN A said she was at the facility day of incident but Resident #1 said someone tripped him but the other residents in the dining room said no one tripped him. LVN A confirmed there were no staff witnesses. LVN A said the facility had in-services on how to deal with behaviors - usually walk away if the resident was safe; remove them (the resident) from the situation if possible. LVN A said they liked to have 2 people deal with the problem resident. When asked if they had enough staff for that LVN A responded, No, we don't really have the staff for that but we make it happen. LVN A identified aggressive residents in the facility as: Resident #1, Resident #2 who goes around preaching at other people who of course don't want to hear it. During an interview on 8/15/17 at 1:40 p.m. Certified Nurse Aide (CNA) B said she had been an aide a couple of years but had been at the facility approximately six months. She said with resident with behaviors the aides just just had to have patience with them. CNA B said the aides tried to redirect the residents by talking to them, sometimes if you upset them or get someone else and alternate care giver. She said when they notice a resident begin to get aggressive, they just tell the Charge Nurse so they (the Charge Nurse) can intervene. She said they redirected male residents as they could and sometimes getting another male to interact with them helped. She said they aides would back off and come back or if they knew what they like the aides would get it for them. CNA B said Resident #1 started started getting real agitated right before he left and she did not know why. CNA B said he was impatient and would knock over an entire drink if did not get his ice fast enough. CNA B said he was ok with her but he would become more and more agitated very quickly. CNA B said she did not what would set him off but he threw cups and knocked tables over. CNA B said there were a couple of men in the dining room that he got into arguments with. CNA B said she could see it was leading up to a fight, but the staff would intervene by separating when they could. CNA B said he would talk about his family a lot and wanted to go home. CNA B said she did not remember Resident #2. When asked what role the social worker played with behavior interview CNA B asked is she the one with the short hair? I see her talking to residents but don't know what it's about. CNA B said she saw the nurses intervene with behaviors more often. When asked if the 8/15/17 breakfast observation was typical she said we try to do the best we can and we do what we can. Today was a little faster than usual. CNA B said usually there was 1 nurse, and 3 aides in dining room and sometimes the medication aide would help. During an interview on 8/16/17 at 1:50 p.m. CNA D said she did not see behaviors from the residents very often. CNA D said she managed aggressive behavior by calming them down, talking to them, give them time to calm down then return with help. CNA D described aggressive behavior as hitting, biting, or kicking. CNA D said aggressive behavior meant lashing out or pushing. CNA D said the only residents she had seen argue or get aggressive with each other was Resident #1 and Resident #2 in the dining room and she thought it took place about three months ago. CNA D said to redirect them they were separated them and it went easy. CNA D said it was the only time she saw them arguing and it was the only time she ever saw either resident exhibit aggressive behavior. CNA D said if the aides saw aggressive behavior they were supposed to report it to the the Charge Nurse or the Administrator. During an interview on 8/16/17 beginning at 2:07 p.m. the SW said she had been at the facility for almost 3 months. She said she assessed residents for behaviors when the nursing staff made the referral. The SW said she even made up a notebook, or if she was in the building they would just come and tell her what was going on. She said she tried to do the assessment on the resident to see if it was pain or if something happened and tried to figure out what the real issues was. The SW said she would let the resident vent and let them talk. She said usually the resident would have like seven things going on at once, so (you) have to let them go on until done to figure out. She said she had to figure out if staff were making it worse, then remove the staff from the situation. The SW said if it was a repetitive behavior she would look for another cause such as medication changes or something new like the family came and visited. She said a lot of the time she heard the residents say the Nurse 'said this and accused me of this and no one is listening to me'. The SW said she usually dealt with the nurses, and only occasionally the CNA's. She said she was involved with the trending of behaviors but she was not always here when behaviors happened to trend them. She said she was trying to get better with the notebook referral system. In the same interview, the SW described Resident #1 as easily agitated and confrontational. She said he could usually be redirected. She said a lot of times she would take him on a walk or smoke a cigarette. She said if felts threatened or if someone was in his face he would not to back down. The SW said she was not aware of any other triggers for behaviors. She said she was not aware of any pattern to his behaviors - he just did not want people messing with his stuff or in his space. Surveyor reviewed Resident #1's history of incidents with the SW. The SW said she would say the dining room over stimulated him and he's territorial. The SW said she was not made aware of these incidents. The SW said there was just not enough staff present at meal times and the staff were not paying attention to things when they were in the dining room. She said she remembered the nurse telling her about 7/28/17 incident. The SW said most of the time she not aware of a pattern until someone told her they were making a referral to the psychiatric hospital. In the same interview the SW was asked if the facility was equipped to deal with behavioral residents they had and she responded No. The doctor needs to be here more often, the aides aren't getting enough training in how to deal with behaviors. They'll go over the top with one resident but not do anything different with any of the other residents. There's no orientation. They don't stay calm, step back, not be argumentative, or talk about something else. During an interview on 8/16/17 at 2:15 p.m. CNA E said if she saw aggressive behavior between two residents she would report it quickly, redirect them without getting in between them. CNA E described aggressive behavior as angry facial expressions, pushing, and up in each other's faces. CNA E denied seeing any aggressive behavior by residents. She said she would report the behavior to the Charge Nurse. CNA E said she thought the most aggressive resident here in the facility was Resident #1. CNA E said I've not seen him act out but heard about him being aggressive toward staff and residents. During an interview on 8/16/17 at 2:40 p.m. CNA F said she managed aggressive behavior by redirecting and reporting it to the charge nurse. She said she would use calming tone of voice. CNA F described aggressive behavior as angry, frustrated, throwing things, yelling and thrashing out. She said if she saw two residents fighting she would try to separate them, try to calm them down. CNA F said the most aggressive resident in the facility was Resident #1. CNA F said I've seen him throw hot coffee, yell out at staff. I was scared of him and never got within arm's length. The residents were scared to be close if they saw him with coffee. During an interview on 8/16/17 at 3:40 p.m. the Director of Nurses (DON) said acknowledged on Resident #1's behavior monitoring forms the 7/24/17 physical aggression should be documented and 7/28/17 the afternoon shift did doc behavior and the day shift did not. She said the staff should document the behavior monitoring sheets according to what medication was for. The DON said if the medication was for an anti-depressant the staff would not necessarily documented the behaviors on it. Again, asked which medication the behavior monitoring form was for. The DON said in this case it was going to be for Valproic Acid because it was for manic episodes. When asked what Resident #1's triggers were the DON said the Nurse Practitioner for the Psychiatrist looked at him. The DON said she had never seen Resident #1 be aggressive. The DON stated Resident #2 would try to set Resident #1 off intentionally and it was a personality conflict and Resident #1 was provoked. The DON said she did not know if someone looked back to see if either had pattern of behavior. The DON said patterns the staff would look for would be if behavior happened over and over at a certain time. When informed of the pattern of behaviors in the dining room the DON said she had him at previous facility so (she) saw him in a different light: he loved to stay outside and lay on ground. When asked how she expected the staff to redirect the residents she said it depended on the situation. She said if 2 people were arguing then she expected the staff to separate them and find out what caused the argument. She said a lot of time if separate and drop it they'll forget about it. During an interview on 8/16/17 at 4:10 p.m. the Administrator said was asked if the behavior monitoring forms needed to be separate for each medication she replied what did the DON say? When asked what the policy documented she said would have to verify it. She was shown Resident #1's behavior monitoring form and acknowledged she did not see an identifying medication. She said she had to dig out our policy, we had this before and I'll have to look at it again. She acknowledged how the form was being used now was definitely not effective. She described Resident #1 as a resident who generally walked around and talked to people. She said he was frequently involved with activities and she would have to look to see what set him off those days. Couldn't say what set him off on the days there was the fight between Resident #1 and Resident #2 She said the facility checked Resident #1 for a Urinary Tract Infection. During an interview on 8/17/17 at 10:20 a.m. Resident #7 said Resident #1 had been sent out of the facility twice. Resident #7 described Resident #1 as mean, hateful, and loud. She said he hit a [AGE] year old female with his fist several months ago. Resident #7 said she reported it and the facility did nothing about it. Resident #7 said he's going to hurt someone bad. Resident #7 stated Resident #1 was very strong. She stated she not afraid for her own safety but was afraid for the residents who could not speak up for themselves. She stated the man behind her is borderline retarded and crippled and would not be able to defend himself if Resident #1 targeted him. Resident #7 stated Resident #1 would intentionally pick on people who could not defend themselves; he picks on people he thinks he can get by with. In the same interview, Resident #7 stated Resident #1 grabbed her arm once and she yelled out and a male came over to help. She stated she yelled and the staff did not come but Resident #1 finally let go because she threatened him. During the same interview, Resident #7 said there was another man who was just as bad who got sent out (Resident #2) and she did not understand why Resident #1 was not. Resident #7 stated Resident #8 had Alzheimer's disease but said Resident #8 has said she was afraid of Resident #1 when some of the incidents happened in the dining room. (Resident #7 teared up.) She said Resident #1 needed to be someplace where the staff know how to calm things down before it happens. She said it doesn't take anything to turn him on. Review of the facility's revised October 2010 policy and procedure on Problematic Behavior Management - Clinical Protocol documented, in part: Assessment and Recognition: Nursing staff will document the nature, duration, and associated features of any changes over time in behavior, cognition, or mood. Treatment/ Management: The staff will use protocols to identify pertinent interventions, other than medications, for the nature and causes of the individual's problematic behavior. The Physician will help identify and authorize appropriate, targeted (that is, cause-specific where possible) and symptomatic treatments. If a psychiatric consultant is called to help manage behavioral issues, the Attending Physician will retain an active role by reviewing the consultant's recommendations, addressing medical issues that affect mood, cognition, and function; monitoring for complications related to treatment, and evaluating subsequent progress. Monitoring: If the resident is being treated for [REDACTED]. Review of the facility's 5/11/17 in-service on Dealing with Combative/ Aggressive Behavior documented, in part: Risk Factors for Geriatric Patients: Within in the geriatric population, the causes of assaultive behavior can be grouped into three categories: - Patient Factors - Elderly patients with a [DIAGNOSES REDACTED]. - Environmental Favors - Environmental factors that can trigger assaultive behavior include limited body space and excessive environmental stimuli that result in confusion and aggression. - Caregiver Factors - CNA's can help to prevent the incidence of assault by recognizing the potential risk factors associated with fear and anxiety in the elderly. An awareness of each patient's individual needs can help to eliminate patient outbursts of anger, decrease agitation and help in providing a safe atmosphere. Therapeutic Communication: CNA's can be instrumental in de-escalating violent behavior and aggression. It may be possible to de-escalate a potential violent encounter and restore order for an aggressive patient. Reasons for Assaultive Behavior Intimidation - Intimidation can have a number of meanings. Intimidation can mean making someone do something they don't(TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services based on the comprehensive assessment, to promote healing, prevent infection, and prevent new pressure ulcers or deep tissue injuries from developing for of 3 of 6 residents reviewed for pressure injuries. (Resident #1, #4 and #17). a) The facility did not treat and did not notify the physician of Resident #1's stage III pressure ulcer to the coccyx for two weeks. The facility did not implement nutritional recommendations to aide wound healing for ten days. b) The facility did not correctly assess and prevent Resident #17 from developing a Deep Tissue Injury (DTI), identified on 3/07/17. c) Resident #4 had recommendations by the Dietician on 01/22/17 regarding pressure ulcer to sacral area, the facility failed to implement the recommendations of Calcium plus vitamin D and multi-vitamin with iron was not implemented until 2/01/17, ten days after orders were written. This failure could place 13 residents with pressure ulcers at risk of worsening pressure ulcers. Findings included: Resident #1 Physician orders [REDACTED].#1 was [AGE] years of age and was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #1's Braden scale assessment dated [DATE] documented a score of 12 which indicated she was at high risk for pressure ulcers (10-12 High Risk). Review of Resident #1's Minimum Data Set assessment dated [DATE] documented in part: The resident had clear speech and was usually understood; Resident #1's Brief Interview for Mental Status documented a score of 04 (00-07 indicates severe impairment). Resident #1 required extensive assist with 2 persons for bed mobility and transfers. She required extensive assist with 1 person for dressing, toileting, and hygiene. Resident #1 was frequently incontinent of bowel and bladder. Resident #1 was checked yes for being at risk for pressure ulcers. Review of Resident #1's Care Plan revised on 2/03/17 documented in part: Category: Pressure Ulcer. Resident presented with wound to left stump r/t caused from pressure d/t (due to) bilateral prosthesis. Approaches: administer medications as ordered and monitor side effects, provide pressure relieving cushion while up in wheelchair. Category: Pressure Ulcer. Actual pressure ulcer AEB (as evidenced by): noted stage III pressure ulcer to coccyx during skin rounds on 2/01/17. Approach: Provide supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing; administer treatments as ordered and monitor effectiveness. Review of Resident #1's Nutrition Care Recommendations dated 1/22/17 documented in part: Concerns/Problems: Weight loss, pressure sore and hydration. [DIAGNOSES REDACTED]. Consider LCS, Vitamin C, zinc for 60 days and Juven, calcium plus vitamin D, and encourage fluids. Review of Resident #1's Medication Flow-sheet dated 1/1/17 - 1/31/17 had no documentation of dietician recommendations made for LCS, vitamin C, zinc, Juven and calcium plus vitamin D on 1/22/16. Review of Non-Pressure Skin condition Record dated 1/31/17 documented in part: Left stump-length 2 centimeters (cm) x 2.6 cm. Nutritional Interventions: Vitamin Therapy. Review of Resident #1's Physician order [REDACTED]. Vitamin C 500 mg (milligrams) 1 oral every day for 14 days start date 2/01/17. Vitamin D3 tablet 1,000 unit amount 2, oral every day for 14 days start date 2/01/17. Zinc sulfate tablet 220 mg (mg) 1 oral every day or 14 days start date 2/01/17. Calcium 600 +D3 tablet 600 mg (1500 mg)=200 units 1 oral twice a day start date 2/01/17. (Nutritional recommendations from 1/22/17 were not implemented until 2/1/17, 10 days later). Review of Resident #1's wound flow-sheet for 1/01/17 to 1/31/17 had no treatment documented for wounds to coccyx area. Resident #1 had orders for a full body skin assessment once a day on Friday. There was no documentation that Resident #1 had a pressure sore before the documentation on 2/01/17. Review of the skin assessment dated [DATE] documented Resident #1 had a stage III pressure ulcer and the measurements of pressure ulcer were 2.1 cm (centimeters) by 1.6 cm x 2 cm. (According to www.npuap.org accessed 02/17/17, a Stage III pressure ulcer is . Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed ). Review of Resident #1's resident progress notes dated 01/18/17 to 1/31/17 indicated Resident #1 had a wound to her left stump but there was no documentation for any pressure ulcers to Resident #1's coccyx area. Review of Resident #1's progress note dated 2/01/17 at 7:35 a.m. this nurse (Assistant Director of Nurses ADON A) doing skin assessment after shower, noted new pressure ulcer stage III to coccyx. Certified Nurse Aide (CNA) B informed ADON A she had reported wound to the treatment nurse two weeks ago. This nurse (ADON A) cleansed, measured and applied new dressing and informed Resident #1 of wound. Resident #1 has wheelchair cushion. Informed resident to turn and reposition every 2 hours and to limit time up in wheelchair d/t (due to) wound. This nurse informed Director of Nurses (DON) and had her come assess wound before dressing was applied. New orders wrote for wound care and for nutrition protocol. Family and physician notified of wound. Gave order for nutrition protocol to charge nurse to transcribe to MAR (medication administration record). During an observation on 2/13/17 at 10:35 a.m. Licensed Vocational Nurse (LVN) C entered Resident #1's room to do wound care. Resident #1 was observed with a pressure ulcer about the size of a small egg to the middle of her coccyx. There was no drainage or odor. During an interview on 02/13/17 at 9:45 a.m. CNA B said the first time she notified the treatment nurse of Resident #1's coccyx area around January 18th the area was the size of the tip of her little finger. She said it was a white area and then it opened up and got a lot bigger. She said she had to tell the treatment nurse a couple of times about Resident #1's wound before she did anything. She said the treatment nurse put a brown patch on it a couple of times. CNA B said she told her charge nurse about Resident #1's sore around the same time she told the treatment nurse. CNA B said she asked the night CNA why she hadn't reported Resident #1's pressure ulcer to anyone and the night CNA told CNA B she didn't report it because she thought someone else had reported it. When asked by the surveyor why she did not report to anyone that Resident #1 never had a dressing on it or that the wound was getting worse, CNA B said she had already reported it to the treatment nurse and her charge nurse. She said she was putting [MEDICATION NAME] on the area after each incontinent care. During an interview on 02/13/17 at 8:30 a.m. ADON A said CNA B notified her on 2/1/17 that Resident #1 had a sore on coccyx. ADON A said CNA B had notified the treatment nurse (treatment nurse quit on 1/24/17) about 3 weeks ago that Resident #1 had a sore on her coccyx. She said CNA B informed her that the treatment nurse had done two treatments to Resident #1's coccyx ulcer. ADON A said no one else knew about Resident #1's pressure ulcer. During an interview on 2/13/17 at 8:30 a.m. the DON said they found other things the treatment nurse had not documented and treatments that she had not done so she was let go. The DON said CNA B informed the treatment nurse about Resident #1's pressure ulcer (around the 18th of January) and assumed treatments were being done. She said she had looked for documentation on Resident #1's wound and wound care but could not find any. She said the treatment nurse did not even document Resident 1's pressure ulcer in the 24-hour log. The DON said she thought the treatment nurse's last day to work at the facility was on 1/20/17. During an interview with the Administrator, DON and the ADON on 2/13/17 at 8:30 a.m. the Administrator said when CNA B first informed the treatment nurse about Resident #1's coccyx the area was only red, not open. During an interview on 2/13/17 at 9:02 a.m. Resident #1 said they found her pressure ulcer about 2 weeks ago. Resident #1 said she did not remember the treatment nurse ever doing wound care for her. During an interview on 2/13/17 at 9:33 a.m. the charge nurse for Resident #'1's hall said the pressure ulcer had been reported to the treatment nurse some time ago but she did not know about it until the ADON told her about it on 2/01/17. During an interview on 02/13/17 at 2:30 p.m. the DON said she was not aware of any documentation that the CNA informed the treatment nurse of Resident #1's pressure ulcer. She said they had done an in-service for the aides on 2/01/17 informing them if they see a wound not being treated or a dressing not applied to inform the DON, ADON's or the administrator. The DON said there was no skin assessments for Resident #1 except for the ones on 1/06/17 and 1/13/17 which were documented on the MAR and it only had the nurses initials that a full body skin assessment had been done. A full body assessment was supposed to be done every Friday. The wound treatment sheet documented only the nurses initial that an assessment had been done, there was no space for an actual skin assessment. During an interview on 2/16/17 at 10:16 a.m. the Administrator said the treatment nurse worked as the treatment nurse from 1/06/17 to 1/19/17 and her last day was 1/23/17. During an interview on 02/16/17 at 7:46 a.m. the nurse who was the treatment nurse at the facility said when she was employed at the facility Resident #1 had an area on her coccyx that was red but was blanchable. She said she told the CNA's to apply lantispetic after incontinent care and to turn Resident #1 every 2 hours. She said Resident #1 did not have a cushion in her wheelchair so she put one in. She said she was pulled from working as the treatment nurse because the census was down to be the charge nurse on hall C. She said the nurses had to do their own treatments. She said CNA B told her Resident #1's skin was dry and flaky. During an interview on 2/14/17 at 3:20 p.m. Resident #1's physician said Resident #1's pressure ulcers were not that bad. He acknowledged the issue was that Resident #1 had not received wound care for at least three weeks. Resident #17 Review of Resident #17's face sheet, undated, indicated he was [AGE] years of age and was admitted on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #17's Braden scale assessment dated [DATE] documented a score of 12 which indicated she was at high risk for pressure ulcers (10-12 High Risk). Review of Resident #17's Minimum Data Set assessment dated [DATE] documented in part: The resident had clear speech and was usually understood; Resident #17 was severely cognitively impaired. Resident #17 required extensive assist with 2 persons for bed mobility and transfers, dressing, toileting, and hygiene. Resident #17 was always incontinent of bowel and bladder. Resident #17 was checked yes for being at risk for pressure ulcers. Review of Resident #17's Care Plan revised on 01/06/17 documented in part: Problem: Self care deficient AEB requires total assist with all ADL's (activities of daily living). Approach: Provide total assist of 2 staff with bed mobility and provide total assist of 1-2 staff with personal hygiene. Problem: at risk for impaired skin integrity r/t (related to) impaired mental status, dependent on geri-chair for mobility-wheeled per staff x 1, monitor for skin breakdown, incontinent of bowel and bladder, with a [DIAGNOSES REDACTED]. Approaches: Turn and reposition every 2 hours and as needed, monitor skin during all ADL care. Review of Resident #17's wound flow-sheet for 2/01/17 to 2/28/17 had no treatment documentation for treatment of [REDACTED].#17 had orders for a full body skin assessment weekly on Tuesdays and to apply moisture barrier ointment to bilateral lower extremities as needed. Review of the skin assessment dated [DATE] through 2/21/17 documented Resident #17 had no skin issues on 2/14/17 and 2/21/17. Review of Resident #17's Skin Identification Form documented Resident #17 had no skin break down on his buttocks but had a DTI 1.5 x 1 x ?. (According to www.npuap.org accessed 03/07/17-NPAUP's proposed definition, is A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. (NPAUP, 2002). Review of Resident #17's Wound Treatment Flow sheet dated 3/01/17 through 3/31/17 documented in part: DTI left lateral ankle 1.5 x 1 cm cleanse with wound cleaner, apply skin prep, cover with foam dressing, secure with tape. Change every day and as needed. Review of physician's telephone orders dated 3/07/17 documented in part: -Float heels while in bed and in geri-chair. -Use pillows for positioning while in bed and up in geri-chair -Unstageable to left lateral ankle. Observation on 3/07/17 at 9:32 a.m. Resident #17's was sitting in his geri-chair and was observed to have on his left lateral ankle had a small amount of sanguineous fluid with a dark area surrounding the area about the size of a quarter. During an interview on 3/07/17 at 9:32 a.m. the LVN E said Resident #17's had been identified this morning to have a DTI to his left ankle. She said the doctor had been notified and they were waiting for orders for wound care. During an interview on 3/07/17 at 2:44 p.m. Assistant Director of Nurses (ADON) F said Resident #17 had fractured his left leg which made his leg lay awkward and caused a lot of pressure on his left lateral ankle. She said ankle protectors would have caused Resident #17 to have worse pressure sores. She said Resident #17's foot probably could have been elevated to prevent Resident #17 from developing the DTI. ADON E said is was really hard to put pillows under his legs because it caused pain to his knee if raised too high. She said when he laid on his left side it put pressure on that ankle. She said he was on an air mattress which helped prevent pressure injuries. She said when Resident #17 was up in his geri-chair there was no problem. During an observation on 3/07/17 at 3:50 p.m. CNA H pulled back Resident #17's cover so observation of how the foot was laid when in bed. Resident #17's left lateral ankle rested on a pillow. The CNA H said he would put Resident #17's foot on pillows at night to relieve the pressure on Resident #17's ankle. CNA H acknowledged that the ankle was laid directly on the pillow which could cause pressure on the ankle. During an interview on 3/07/17 LVN G said Resident #17's leg was so heavy when he was in bed it caused a lot of pressure to his ankle. During an interview on 3/07/17 at 3:55 p.m. the Nurse Practitioner (NP) said Resident #17 had very heavy legs and was very hard to position in bed. She acknowledged that staff were aware of the pressure Resident #17 placed on his ankle and they should position Resident #17 to prevent injuries. She acknowledged the dark around the wound could be a problem but did not stage the wound at this time. During a telephone interview 3/08/17 at 4:15 p.m., ADON F said they were keeping Resident #17's ankle as an Unstageable DTI because she could not go back and and restage even though the NP did not stage it. She said the NP wanted to wait to see what the DTI would do, if anything. Review of a faxed copy of a progress note for Resident #17 dated 3/08/17 documented in part: -The physician after a discussion regarding Resident #17, the NP said the nursing home had the left lower extremity arranged to the get the pressure off with pillows that had generally worked quite well. But due to the extreme weight of Resident #17's left lower extremity, his dementia and his inability to cooperate, this had not been totally successful. Even when arranged with support, due to the weight of the leg, he actually crushed the support pillows. -Impression: Stage 2 decubitus of the left lower lateral malleolus. In retrospect with the area being discolored due to previous casting, I (Resident #17's physician) feel this is probably a chronic discoloration and that is likely not a true deep tissue injury Plan: -Skin care to the current area of stage 2 pressure sore. -Will explore every avenue to keep the pressure off the lower extremities. -Will make every effort to keep the pressure off any bony prominence's and skin, in general. Review of the facility's pressure ulcer/skin break down protocol dated revised on February 2014 documented, in part: -The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss and a history of pressure ulcer (s). -In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments, including support surfaces; and all active diagnosis. -The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. Review of the facility's Resident's Rights policy dated 2/15/17 documented, in part: Your rights to safety and good care: -Your facility must provide services to keep your physical and mental health, and sense of satisfaction with yourself at their highest practical levels RESIDENT #4 Review of Resident #4's undated physician orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of Resident #4's Braden scale assessment dated [DATE] documented a score of 12 which indicated she was at high risk for pressure ulcers (10-12 High Risk). Review of Resident #4's Nutrition Care Recommendations dated 1/22/17 documented in part: Concerns/Problems: Pressure Ulcer/abnormal labs: Consider calcium plus vitamin D and multi-vitamin with iron. Review of Resident #'4's Care Plan revised on 1/30/17 documented in part: Category: Pressure Ulcers. Resident #4 is at risk for pressure ulcer due to impaired sensory, moisture, nutrition and being chair-fast. Approaches: Monitor nutritional intake, nutrition consult, offer nutrition supplements, water and do skin assessments. Category Nutritional Status. Resident #4 has a potential nutritional problem AEB impaired daily decision making, decreased food consumption at times, hydration, requires assist with meals, with increase risk r/t continues with [DIAGNOSES REDACTED]. Approaches: Provide and serve diet as ordered, provide supplements as ordered, RD (registered dietician) to evaluate, make changes and recommendations as needed. Review of Resident #4's MDS assessment dated [DATE] documented in part: Resident #4 had clear speech, usually understood and understands. Resident #4 BIMS scored a 12 (08-12 indicates moderately impaired). Resident #4 was totally dependent for staff for all activities of daily living. Review of Resident #4's Physician order [REDACTED]. Start date 2/01/17: Calcium 600 + vitamin D3 tablet; 600 mg. twice daily. (Diagnosis: [REDACTED]. Start date 2/01/17 Daily multiple vitamin with iron 1 tablet once a day (DX: pressure ulcer of other site, stage III). During an interview on 2/16/17 at 2:30 p.m., Resident #4's physician said he was not aware of when they (meaning him and his nurse practitioner) are given the dietician recommendations. During an interview on 2/16/17 at 2:33 p.m. ADON A said the dietician comes in every month on Sunday and Monday. She said there are no set dates for when the dietician comes but it has to be monthly. She said when the dietician writes her recommendations she then gives them to her or the DON. She said recommendations for new residents could take a few weeks due to not having a full time dietician. During an interview 2/16/17 at 2:34 p.m. the Administrator said the dietician's recommendations should have a turn around of no more than 48 hours. He said the reports are given to the DON and then she gives them to the nurse practitioner. He said the last time the dietician came was on 1/22/17. He said he has made a recommendation for a dietician to be hired at the facility and was waiting to hear from corporate. Review of the Nutritional Assessment policy revised on 12/2011 documented in part: A nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Policy Interpretation and Implementation: The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within correct initial assessment timeframe's) and as indicated by change in condition that places the resident at risk for impaired nutrition. Dietician: An estimate of calorie, protein, nutrient and fluid needs; whether the resident's current intake is adequate to meet his or her nutritional needs and special food formulations. A list provided by the DON on 2/13/17 documented there were 13 residents with pressure ulcers.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 9 residents (Residents #1) reviewed for supervision. The facility failed to follow their 9/30/15 post-incident plan of care for providing Resident #1 with staff/ family supervision while going to outside appointments. As a result, Resident #1 eloped from an outside appointment while under the facility's care on 2/29/16. On 04/ 05/16 an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to deficient practice with the potential for more than minimal harm at a pattern on 04/07/16. The facility remained out of compliance as they had not yet monitored their plan for effectiveness. These failures could place the 26 residents the facility identified as a medium to high risk for elopement to leave the facility unsupervised and place them in situations that could result in harm or death. Findings included: RESIDENT #1 Review of Resident #1's 2/04/16 Face Sheet showed he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Face Sheet Additional Information Section identified Resident #1 as an elopement risk and a fall risk. Review of Resident #1's 1/23/16 quarterly MDS (Minimum Data Set) Assessment documented: - His mental status was 13/15 (indicating he was cognitively intact); - His behaviors included wandering 4 - 6 days in the seven days prior to the assessment; - His ability to walk was independent with limited assistance of one staff. He had no Range of Motion impairments and used no mobility devices. - He had one fall since the last assessment with no injury. Review of Resident #1's 7/29/15 Care Plan (revised, date unknown) documented, in part: Exhibits alteration in mood/behavior as evidenced by: wandering at times; wandered away from MD (medical doctor) office when out of facility related to disease process and with additional risk related to [DIAGNOSES REDACTED]. Review of Resident #1's 9/30/15 Incident/Accident Report (the first elopement) documented, in part: Resident ambulated 4 blocks from appointment without any assistance; stated that the receptionist at appointment told him to go meet his brother at the restaurant on the street. Immediate actions taken: Staff went searching for resident immediately after appointment. Staff notified this facility that resident had eloped from their facility. Resident located. Resident was provided with safe environment and returned to the facility by van driver. Resident was assessed for injury, none was noted, no mental or physical distress was noted to resident; denies pain/ discomfort, questions or concerns. Post incident actions included: Resident to be accompanied by staff member or family member for all future appointments. Review of Resident #1's Interdisciplinary Team Progress Note dated 2/29/16 (the second elopement) documented, in part: The Director of Nurses (DON) was informed at approximately 10:35 a.m. (on 2/29/16) by the van driver via telephone that the driver left Resident #1 in the waiting room of the Radiology Department at the hospital and told the resident not to leave his chair, that she was going to go park the van. The driver stated when she returned to the Radiology Department Resident #1 was not in his seat. The DON and Assistant Director of Nurses (ADON) immediately left the facility and went to the hospital; we notified hospital police that resident was missing, we also made a report with the city police department, after a thorough search of the hospital with hospital staff, police officers and security officers. The cameras were reviewed and it was noted that resident had left the hospital at approximately 10:27 a.m. via the street entrance. The DON and the ADON immediately left the hospital and began a search of premises, as well as nursing home facility members searched in their vehicles. The DON then went to a restaurant where (Resident #1) would meet his brother for lunch prior to his nursing home admission. We searched the surrounding businesses by the hospital, as well as restaurants in close proximity. This nurse was notified that resident was located on the street, approximately 1.5 miles from facility at approximately 1:20 p.m. by resident's sister. Resident had stated to his sister he was going to his mother's house on the street which was approximately 4 blocks from where he was located. Resident was located, unharmed. Resident stated a man bought him some tacos and a drink at one of the taco stands before being located on the street. Resident's sister brought resident back to facility. Head to toe assessment was performed, no injuries were noted. DON asked resident if he had fallen while walking and he denied falling but did state he had to sit for a brief moment because his back started to hurt from walking. The Doctor was made aware at 3:15 p.m., no orders were given. Resident's family stated they did not want resident to wear any kind of wanderguard bracelet. No physical or mental stress noted to resident at this time. Review of the 3/04/16 follow up Interdisciplinary Team Progress Note documented, in part: It was a confirmed elopement. Responsible Party (RP) was attempted to be notified. RP was also informed that resident will be supervised 1 on 1 at all appointments outside the facility by a facility staff members secondary to this incident. Review of Resident #1's 7/17/15 Elopement Risk Assessment documented he was not an elopement risk. Review of Resident #1's 9/29/15 Elopement Risk Assessment identified risk factors to include independently ambulatory, predisposing diagnoses, alert and oriented x 2 (person and place, but not necessarily time), and his cognitive status. The Elopement risk documented Resident #1 was at risk for elopement. Review of Resident #1's 4/06/16 Elopement Risk Assessment documented he scored a 7 on the elopement risk assessment, which was considered low risk. During the entrance conference on 3/31/16 at 11:15 a.m. DON said the van driver took Resident #1 to an outpatient x-ray at the local hospital. She said the driver checked Resident #1 in and left to park the van. The DON said when the driver returned Resident #1 was gone. The DON said Resident #1 had previously eloped from a previous doctor's appointment and they were aware of his history of wandering. She said the facility was not responsible for the first elopement (9/30/15) as Resident #1 was already at the doctor's office when he eloped. She said they found Resident #1 around the area he used to live. During an interview on 4/05/16 at 3:43 p.m. CNA C said she had worked at the facility for about 2 years. She confirmed she was the driver when Resident #1 eloped from his appointment on 9/30/15. CNA C said on that date Resident #1 was still a new admission to them and they did not know he was an elopement risk. She confirmed she left him at the doctor's appointment and left to drive someone else. CNA C said when she returned the receptionist said he walked off. CNA C said I was like, what do you mean he walked off? In the same interview, CNA C confirmed she was aware he had a history of [REDACTED].#1 did not have any changes in condition between the September appointment and 2/29/16 appointment that would make him less of an elopement risk. During the interview, CNA C said there was no one to go with her that day (2/29/16) as the facility was working short. CNA C acknowleged she left Resident #1 unattended because she had to park the van in the hospital parking lot. She said for Resident #1 to walk that far she would have needed a wheelchair. CNA C said it took 8 minutes for her to leave him in the waiting area, park the van, and return to the waiting are. She said by that time he was gone. She said Resident #1 did not say anything about not wanting to go to the appointment. She again said she did not bring anyone to the appointment with her because they were short staffed that day but she did not remember thinking that anything bad would happen. In the same interivew CNA C said if she could not find anyone to go with her for Resident #1's routine doctor's appointments, she could park right at the front and she could go in with Resident #1. CNA C said Resident #1 was the only resident who was a flight risk at appointments. She said since that appointment, she has brought someone with her in case she had to leave. During the same interview, CNA C described Resident #1 as someone who liked to smoke and drink coffee. She said he walked the halls all day long if he could. CNA C said she was not aware of Resident #1 making any attempts to leave the facility. She said Resident #1 was mostly with it (cognitively) and he would notice and remember if she did something different with her hair or things like that. When asked if Resident #1 could cross the street safely, CNA C said she thought he could because he did cross the street. Observation on 3/31/16 at 7:00 p.m. of the most direct way from the local hospital to the location Resident #1 was found at showed it was 1.6 miles. The walk was approximately 60% residential with a paved surface (i.e. sidewalk, parking lot) 70% of the way. There was one crosswalk. The resident would have had to pass one of the high schools and one active construction site. There were three five lane roads Resident #1 would cross to get to his destination going through downtown traffic. Review of the weather history web site, on 2/29/16 it was 66.9 degrees Fahrenheit at 10:53 a.m. and 73.9 degrees F at 12:53 p.m. (https://www.wunderground.com/history/airport/KMAF/2016/2/29/DailyHistory.html) During an interview on 4/01/16 at 10:00 a.m. Licensed Vocational Nurse (LVN) A described Resident #1 as a really nice guy. She said he frequently needed reminding to slow down or he would trip over his feet because of his shoes. LVN A said Resident #1 preferred to stay to himself and wanted everything on time. She said he went to a doctor's appointment once a month to get a shot for tremors. LVN A said she was not sure of the medication but it calmed him down. She said he went for the shots at the end of the month and the whole process took about half an hour. LVN A said Resident #1 was alert and oriented times two (name and place, but not necessarily time); she said he had good days and bad days. LVN A said her opinion was he could not cross a street safely because his concentration was not that good. LVN A said she worked the day he eloped (2/29/16) from the hospital. She said the driver took Resident #1 to his appointment and about 30 minutes after that the driver called to report Resident #1 had stepped out of the hospital and she (LVN A) needed to notify the family. LVN A said the ADON and the DON left to help look for him. She said when she called the family the family was ok and just said they would come help the facility search for Resident #1. LVN A said the family found Resident #1 because Resident #1 was on his way to his mother's house. She said normally the facility sent one other person with the driver. LVN A said when she set up the appointment, the driver asked who would go with her. LVN A said she told the driver she would call the sister to see if the sister could come, but the sister was unsure if she could make it or not. LVN A said when she told the driver that, the driver said we'll figure it out but she wanted someone to go with her, but it did not work out that way. She said she never looked at Resident #1's care plan. She said she found out about appointments through the computer program. During an interview and observation on 4/01/16 at 10:10 a.m. Resident #1 said he remembered leaving the hospital. He said the driver dropped him off and he walked out the door and that was it. Resident #1 was aware of his surroundings. He was steady on his feet but walked slowly, occasionally one foot would shuffle across the floor. During an interview on 4/01/16 at 10:40 a.m. the Administrator said he was new and knew absolutely nothing about Resident #1's history. He was informed of the care plan and the 9/30/15 appointment where he eloped. He was informed the face sheet documented he was an elopement risk. He was informed the care plan documented he would have 2 people at appointments with him. He said if he was our resident he was our responsibility. The Administrator acknowledged there was an issue with how the 2/29/16 appointment was handled. During an interview on 4/01/16 at 10:50 a.m. LVN B said appointments were handled by the transportation aide. She said there was one or two people depending on the resident. She said if a resident was heavy care or a handful then two people would go to the appointment. LVN B said she did not work Resident #1's hall and did not know why 2 people were not sent. During an interview on 4/01/16 at 11:15 a.m. the DON said the facility staff brought Resident #1 inside to the appointment and left him in the waiting area. She said the driver had to leave him to park the van. The DON asked when did the hospital become responsible? What else is she (the driver) supposed to do, get the van towed or have him walk 90 feet when he's a fall risk? We dropped him off, he was in the hospital's care. During an interview on 4/05/16 at 3:53 p.m. Resident #1's doctor said Resident #1 was able to carry on a conversation, his speech was clear and he ambulated independently. When asked if Resident #1 could safely cross a street he said he didn't know if he was qualified to assess that since (he) wasn't a psychiatrist or neurologist. The doctor said he probably was able to get to where he was going. The doctor said he had been made aware of the elopement attempt after the resident had returned to the facility. Review of the facility's 3/04/15 policy and procedure on Resident Elopement documented, in part: staff shall investigate and report all cases of missing residents. Review of the facility's 3/04/15 policy and procedure on Care of Resident Following Elopement Episode documented, in part: The residents plan of care will be reviewed and updated with interventions deemed appropriate to maintain the resident's presence and safety. During an interview on 4/05/16 at 3:55 p.m. the Administrator was informed of the Immediate Jeopardy situation. The Administrator said CNA C could have brought anyone with her to the appointment; or she could have rescheduled. During an interview on 4/05/16 at 4:15 p.m. CNA D said she had been at the facility for over a year. She said she predominately worked the hall Resident #1 resided on. CNA D said Resident #1 liked to wander the facility and smoke. CNA D said Resident #1 did not give anyone any problems and was usually in the lobby or his room. CNA D said Resident #1 seemed with it if you talked with him for a short period of time. CNA D said Resident #1 was reluctant to answer questions beyond yes or no, she said complex answers were broken. CNA D was asked if Resident #1 would be able to safely cross the street and CNA D said no. CNA D said Resident #1 had never tried to leave the facility to her knowledge. During an interview on 4/06/16 at 8:50 a.m. the Administrator said CNA C could have asked the hospital police to watch Resident #1, she could have had the van towed but at the end of the day Resident #1 would have been safe. Review of the facility's accepted 4/07/16 Plan of Removal documented: Measures put in place to ensure the violation will not recur include: - All residents will be assessed for an elopement risk under Elopement Risk Assessment form to determine a risk level or low, medium, or high scored by a point system by 4/06/16. All residents scored at a high risk will fall under the new wrist band policy and will be given a colored wrist band for their transport. - Van Driver, (CNA C) has been removed from her van driving responsibilities and has been re-assigned to the floor. All drivers moving forward will be trained and fully understand our new wrist band policy prior to transporting residents. This will be completed 4/06/16. - In-service for all staff will included the definition of the colored bracelet that will identify resident as an high elopement risk, and any management staff or designated staff member can be the responsible personnel during the transport along with how they can identify an elopement risk via resident face sheet if a bracelet would potentially be misplaced from residents person. This will be completed on 4/06/16. - The station charge nurse will be responsible to assure that a high risk resident has a supervisory employee for the transport and the driver will be responsible to assure that each high risk resident has a supervising employee prior to leaving the building. - The drivers will be in-serviced/ trained by facility ADON (Assistant Director of Nurses) for staffing/training. - All elopement risk residents will be identified on their face sheets and updated quarterly with their scheduled MDS or significant change MDS. This will be completed by 4/06/16. - Residents identified for elopement risk as evidenced by a designated color bracelet which will be applied by the DON/Designee and worn by resident at all times during transport by staff outside of facility. This practice will started with today ' s residents scheduled for transportation 4/06/16. - All staff employees including weekend staff will be in-serviced before working their next scheduled shift by 4/06/16. - Two Elopement Binders will be created, one for station 1 and one for station 2. These binders will included the new elopement policy , resident elopement risk assessments, and colored bands to be applied during transport. Face sheets for all residents noting elopement risk. These binders will be in place by 4/06/16. - The charge nurse at each station will be the DON Designee assigned to manage the policy, each binder will have a sign out, sign in, colored band applied or colored band not required to document compliance. This task will be completed by 4/06/16. During an interview on 4/07/16 at 10:25 a.m. the Maintenance Director said he had taken over van driving duties. He said if a resident went to a doctor appointment and he was unable to park near a door someone had to go with them. He said if the person was a known elopement risk they had to take an extra person and the charge nurse was supposed to put an orange bracelet on the resident. He said if he did not know he could ask the charge nurse or the DON/ADON. During an interview on 4/07/16 at 10:30 a.m. LVN E said there was now a sign in book with face sheet and the resident's risk-level at the nurse's station (nurse's station 1). She said any resident who was a medium or high risk resident required a bracelet and an additional person to go with them. Observation at the same time, LVN E showed surveyor the sign in/ sign out book with the bracelets and the risk level. LVN E said in case the book at the nurse's station was unavailable, there were also sign out sheets up at the front desk. During an interview on 4/07/16 at 10:30 a.m. LVN F said appointments were scheduled. On the day of the appointment, the resident was to sign out at the nurses station. She said charge nurses had to check if the resident was a high-risk resident. LVN F said if the resident was high risk they got an orange bracelet. During an interview on 4/07/16 at 10:35 a.m. LVN G said there was a book of residents and the face sheet identified if the resident was an elopement risk or not. LVN G opened the book and showed surveyor that there was a face sheet with an elopement risk identified, a sign in/ out sheet, and the risk assessment for each resident at the second nurse's station (halls C and D). LVN G said if the resident was a high-risk resident then the resident had to have an orange wrist band and have someone with them at all times. She said the wrist band was to remind staff to let the nurses know when a resident was leaving or returning. During an interview on 4/07/16 at 10:40 a.m. LVN B said there was now an appointment book at the nurse's station and the nurses had to check the face sheet. She said if the resident was at risk they had to have an armband that was found in the book. She said nurses were responsible for signing in and out residents. Record review of the 4/04/16 in-service on Elopement Risk Identifier During Transport documented: All residents whom have been identified as an elopement risk will be wearing a colored bracelet at all times during transport as noted to the to the side of this sheet. If you notice the band is worn/dirty/coming off, please notify nursing management so we can place a new on the resident. This is for out of facility appointments. Bracelet will be placed on resident by DON/Designee before leaving facility. Record review of the 4/06/16 in-service on Elopement Risk Process for all nurses, documented: there is big blue binder at both station 1 and 2. The contents of these binders include the new elopement policy, resident's elopement risk assessment, colored bands to be applied to HIGH risk residents during facility transport and a sign-in/sign- out. On the bottom of the face sheets it is noted Elopement risk yes or no and the level (low, med (medium), high). If the resident is a HIGH RISK they MUST have on a colored band during facility transport. You as the CHARGE nurse are responsible for checking if your resident is going out with facility is a HIGH risk and putting the colored band on said resident. In order to keep up sin compliance you must sign-in and sign-out and whether or not said resident required a colored band. All residents will be accompanied by a trained staff member when out with facility transport to appointments/outings unless signed out by their responsible party. The supervising employee will remain with the resident the entire time. The charge nurse and driver are both responsible to ensure each resident has an escort during transport. Review of the new Elopement Risk Assessment documented all residents had been assessed as a high, medium or low risk as of 4/06/15. During an interview on 4/07/16 at 10:41 a.m. the Administrator was informed the IJ was lowered but the facility still remained out of compliance due to needing time to monitor the interventions for effectiveness. During an interview on 4/07/16 at 10:45 a.m. the DON said the facility trained their drivers and had followed the facility's policy on elopement because the facility's old assessment it was really up to the nurse to decide if the resident was or was not an elopement risk. She said the system breakdown that caused the IJ was CNA C not staying with the resident. The DON said CNA C could have gotten a hospital wheelchair and rolled him from the van to the waiting area. She said none of the staff asked her or either of the ADON's to go with them for the appointment. Review of the Elopement Risk Assessments completed by the facility on 4/6/16 documented there were 26 residents who were a medium/ high risk of elopement.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents for reviewed for accidents/incidents (Resident #1) as evidenced by: a) failure to identify risk and implement interventions for Resident #1 to address her condition associated with incomplete quadriplegia for compromised sensation to cold, heat and pain. The staff were not knowledgeable of Resident #1's risk of injury and the resident's care plan did not reflect precautions; and b) failure to place hot liquids in a proper container prior to giving the hot liquid to Resident #1. On 5/12/15 RN B gave Resident #1 hot liquid in a cup not designed to hold hot liquids causing burns that resulted in blisters to the palms of both hands. This deficient practice could affect the 28 resident identified on the accident/incident log at risk for incidents and accidents that could result in worsening of medical conditions, pain, and increased need for ADL assistance. Findings included: 1. Review of Resident #1's undated Face Sheet documented she was a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. An undated computer list of [DIAGNOSES REDACTED]. The DON provided a documented definition of this [DIAGNOSES REDACTED].#1's physician. The document dated 6/15/15 at 4:09 p.m. for skin sensation disturbance was tingling sensation in her (Resident #1) hands, under her skin. States mostly all patients will have DX (diagnoses): only way he can bill a B12 lab (lab result for vitamin B level) level. Review of Resident #1's Minimum (MDS) data set [DATE], significant change in status documented, in part: Resident #1 had a total of score of 13 on the BIMS (Brief Interview for Mental Status) that indicated her mental status was intact. Resident #1's functional status was documented as requiring extensive assistance of one person for dressing, eating, and person hygiene; transfers and bed mobility required the physical assistance of two persons; walking did not occur; and range of motion was impaired on both sides of upper and lower extremities. Review of Resident #1's Care Plan with the most recent review documented as 3/20/15 revealed it included the following (in part): Problem/Need: Problem onset up-dated 3/20/15: Impaired Skin integrity and continues at risk for impaired skin integrity AEB (as evidenced by): impaired mental status, impaired mobility, impaired skin sensitivity and requires the use of WC (wheelchair) for mobility/locomotion-wheeled per staff, continues with surgical wound, decreased consumption of food/fluids, with additional risks r/t (related to) psychoactive med's per MD orders. Goal: Skin will remain intact without evidence of further skin breakdown QD (every day) during the next 90 days. Will remain free from additional skin breakdown/irritation QD during the next 90 days. Approaches: Resident has blisters to bilateral palms and refuses treatments; Weekly skin checks; Report signs of infection (odor drainage, pain or redness); Weekly wound monitoring. (The care plan did not identify the date that blisters to bilateral palms were added to Resident #1's care plan. The care plan did not identify what Resident #1's skin sensitivity was or interventions associated with skin sensitivity). Problems/Need: Problem onset 1/10/14: Impaired cognition AEB some misunderstanding of situations at times Goal: Needs will be anticipated and met by staff daily during the next 90 days. Approaches: Encourage independent decision making. Problem/Need Problem onset 8/31/13: Self Care Deficit AEB requires total-extensive level of assist with ADLs (activities of daily living)/care QD with additional risk for decline r/t non-compliant at times r/t paralysis and contractures and femur fracture. Goal: (No goal identified) Approaches: Setup, cue and assist as needed with ADLs. Problem onset 1/10/14: At risk for alteration in mood/behaviors r/t AEB demanding/manipulative personality-r/t dx (diagnosis) of [DIAGNOSES REDACTED] (Resident #1 is a quadriplegic) with additional risk due to being judgmental/critical of others, and self pity. Goal: Will exhibit behavior of yelling at staff less than 1 x (time) in 90 days. Will exhibit behavior of making additional demands on staff less than 1 x a week over next 90 days. Approaches: Approach in calm manner. When confused or experiencing psychotic disturbances do not attempt to bring to reality. 2. Review of the Resident Incident Report for Resident #1 dated 5/13/15 at 12:00 p.m. documented the report was completed by LVN C. LVN C documented that CNA D told LVN C that Resident #1 had blisters to both hands. Resident #1 was interviewed and she said she was not sure what caused them. Resident #1 said that she was drinking hot cocoa in a cup on 5/12/15 but that it was not hot, she said the condition had happened before but more than 2 years ago. LVN C documented there were blisters to both of the resident's hands. LVN C documented that immediate actions taken was a skin assessment and incident investigation. LVN C documented Resident #1 refused any treatments to bilateral palms, stating she wanted them left open to air and they would go away on their own. Under Actions Taken, LVN C documented that first aid by LVN C was given on 5/13/15 at 3:50 p.m. and the type of aid was documented as Skin assessment, Resident (#1) refused tx (treatment) to area. LVN C documented that the resident's physician was notified on 5/13/15 at 3:00 p.m. and the DON was notified on 5/13/15 at 3:27 p.m. (There was no physical description of the location of the wounds on the resident's hands, the size of the blisters, the number of blisters, or the appearance of the blisters and surrounding skin on the report). A Post-Incident Action form attached to the Incident Report, repeated the date, time, and information regarding the incident as noted on the incident report, including the actions taken. Additionally, under, Activity at time: Consuming food/bev (beverage); and under Immediate Post Incident Action, the writer documented, Resident education to report any skin condition as soon as possible. 3. An un-dated, Resident Incident Follow Up form by an unidentified author (no signature in the completed by) section, documented a repeated narrative of the incident and actions taken. Under 24 hour follow up/ 24 Hour condition and injury appearance the writer documented vital signs and Resident continues with clear blisters to bilateral hands, resident continues to refuse treatment to bilateral hands, continues to state that she wants them LOTA and they will heal on their own. The report documented, Addressed in Care Plan 5/14/15. The section New orders as a result of the incident was not checked. 4. Review of the SBAR (Situation, Background, Assessment, and Recommendation) Communication Form and Progress note for RN's (registered nurse)/LPN (license practical nurse)/LVN's (licensed vocational nurse) dated 5/13/15 at 1500 p.m. (3:00 p.m.) and signed by LVN C documented that Resident #1 had fluid filled blisters (pockets), skin was intact, her pain intensity level on a scale of 1-10 was a 10, the resident was showing non-verbal signs of pain including grimacing, the condition started on 5/13/15, there were no changes in mental status, neurological, functional status, cardiovascular, abdominal/GI, GU/Urine behaviors, or respiratory. (The SBAR did not include any information that the resident's blisters were the result of being burned). The report documented that Resident #1's physician was notified on 5/13/15 at 3:00 p.m. Under Recommendations of Primary Clinician (if any), LVN C left this section blank. Under testing, which included choices such as blood tests, EKG, Urinalysis, Other, etc, all were unchecked. Under Interventions which included choices of new or change in medications, IV or subcutaneous fluids, increase oral fluids, oxygen, or Other (describe), all choices were unchecked. 5. Observation on 6/10/15 at 12:30 p.m. of Resident #1's hands showed she had two large crusty (scabbed) areas located on the outer edges of both her palms (running down the side of the palm to the the middle of the the lower palm). After surveyor intervention on 6/10/15 at 4:40 p.m. the treatment nurse (LVN A) took the following measurements of Resident #1's palms: Resident #1 right palm had a dried crusty area that measured 1.03 c.m. (centimeters) width by 4.5 cm. length cm. and the left palm measured 1.2 cm. width by 1.3 cm. length. There was no pervious documentation of the measurements of Resident #1's blistered palms. 6. During interviews on 6/10/15 at 4:40 p.m., 6/11/15 at 7:40 a.m. and 6/16/15 at 1:25 p.m., Resident #1 said she burned her hands while drinking hot chocolate in a red plastic cup given to her by RN B. Resident #1 said she knew that RN B had not meant any harm by giving her the hot cup. Resident #1 said that she had complained about being cold to RN B around noon, and RN B told her that she had the makings for a warm drink in her office. Resident #1 said that RN B had used a cup from RN B's office, and Resident #1 also thought the drink was made in RN B's office but she was unsure of that. Resident #1 said RN B told her she had double-cupped the drink (put one cup inside another) but Resident #1 was unable to say for sure whether she had seen two cups. She said she did not know what kind of cup was placed inside the outer cup. Resident #1 said that on the first day (5/13/15) the staff asked her what happened that caused the blisters and she first told them she did not know how it happened, but then told them about drinking the hot drink the day before. She said she had hesitated because she did not want to get RN B in trouble. She said she also told them that she had burned her hands from drinking hot coffee from a coffee shop cup in the past, but her hands did not burn to this extent and healed without medical treatment. Resident #1 said that the drink was hot but she took small sips. Resident #1 said she held the cup throughout the time she was drinking, and drank all of the contents. She said she never realized it was hot enough to burn her because she did not feel any pain while holding the cup. Resident #1 said LVN C spoke with her on 5/13/15. She said that he told her she needed to cover the blisters with a moisture bandage so she would not get an infection. Resident #1 said she declined the treatment because she thought moisture would increase the chances of bacteria. She said she knew better than that now and realized she was wrong. Resident #1 said the DON did come and talk to her and just verified that she did not want treatment. Resident #1 said that after that date, she could not remember any nurses, other than the wound care treatment nurse, looking at her hands. She said they might have, but she could not recall any specific nurses coming in. She said the treatment nurse (LVN A) was in her room every day to treat her other wounds. When discussing whether LVN A looked at the blisters on her hands every day, Resident #1 said she did not know. She said she could not remember how many times she looked at the blisters. She said she did not think she looked at them every day. She said, I can't really say that she did for sure, and I can't really say that she didn't for sure. Resident #1 said that at some time following 5/13/15, she noticed that the skin around the blister was red. She said she thought that meant it was healing, because she thought she had heard the wound care nurse say that was a good sign when they were observing her other wounds. When explained that redness could have been a sign of infection, Resident #1, said, Oh, I went around telling everyone how good they were doing and how they were healing. She said she noticed a green color too and did not think that was a bad sign either. When discussing whether the blisters remained intact or ever popped, Resident #1 said they both popped approximately a week after she had them. She said they did not pop at the same time. Resident #1 said that when the staff at the wound care center saw her hands, they told her that her hands needed to be wrapped. Resident #1 said that she told them that she preferred them open to air and the wound care staff told her that it was very important to cover the wounds. Resident #1 said she allowed the wound care staff to wrap her hands. Resident #1 said she told LVN A that she thought she might remove the bandage and just leave them open again. When asked how LVN A responded to her comment, Resident #1 said, She agreed with me. She said that she began to smell a foul odor to one of her hands and she suspected something was wrong. She said that she reported to LVN F that her hand was green and had an odor. When asked about her knowledge of risks associated with infection (such as delayed healing, increased scarring, potential for spread of infection, etc), Resident #1 could not identify any of the risks of infection. She knew that infection caused an odor and a green color. 7. During an interview on 6/11/15 at 2:00 p.m., RN B said that she was no longer employed by the facility, but at the time of the incident she was the Assistant Director of Nurses. RN B said that on 5/12/15, Resident #1 was complaining of chills. RN B said that she made Resident #1 hot chocolate and served it to the resident in a red plastic cup that she had. RN B said that she double-cupped it, explaining she placed one plastic cup inside another one. She said she served the hot chocolate in this manner because she did not have a Styrofoam cup and when she went to the kitchen and asked the kitchen staff for a cup, they told her they did not have any. RN B said that the kitchen staff she talked to spoke very little English and she was not sure the kitchen staff really understood her question. RN B said that she was not informed at any time on 5/12/15 that the resident had any problems after having the drink. She said that she was off work a couple of days and then she got sick and was in the hospital twelve days. RN B said it was not until she returned from sick leave that she learned from a CNA that Resident #1 had been burned by the drink. RN B said she discussed the incident with Resident #1 and apologized to the resident. RN B said the cup could have caused Resident #1 to get burned, but she thought at the time that by putting the hot chocolate in two of the cups, it would be okay. When discussing whether she thought Resident #1's medical condition of quadriplegia could have caused a decreased sensation of pain and heat, RN B said that was something she never thought about as a possibility. 8. During a telephone interview on 6/10/15 at 4:45 p.m., LVN C said that CNA D notified him of the need to look at Resident #1's hands some time close to lunch on 5/13/15. LVN C said he looked at Resident #1's hands and observed one continuous blister on each palm that if you could divide it, would be three or four. LVN C said She (Resident #1) told me it might be a reaction. She told me it came from heat. She told me it came from hot chocolate or hot tea. He said he did not measure or document a description of the blisters but would estimate they were each 4 cm x 5 cm. He said the reason he did not is because he thought it was the treatment nurse's responsibility to document the measurements and description of the blisters. LVN C said he offered to put a 4 x 4 pad with moisture on the blisters, but Resident #1 said she wanted to leave them open to air. LVN C said he had not received an order for [REDACTED]. LVN C said he called the physician and informed the physician that Resident #1 refused treatment, and the physician told him to just monitor the blisters. LVN C said that he notified the DON of his observation on 6/13/15 within 15 minutes of seeing the resident. When discussing that no telephone order was located and where he documented the physician's response, LVN C said, The orders should be somewhere, in the notes, or SBAR, or incident report. 9. During an interview on 6/10/15 at 3:00 p.m., LVN A said she was the wound care treatment nurse. She said she was notified of the blisters on 5/13/15 by CNA D. LVN A said, I didn't even know what it was at first. She said Resident #1 said she did not have any pain. She said Resident #1 told her that (RN B) gave her a hot cocoa and it burned her hands. The treatment nurse said at first they were just raised areas but then turned to blisters. The treatment nurse said she did not measure or describe the blisters during her weekly skin assessments or during her daily treatment of [REDACTED].#1 because she had no order to treat them (blisters). She said she guessed she should have documented them during the skin assessments. She said the orders for treatment were written by the wound care physician around 5/28/15. LVN A said she thought treatment began 2 days before Resident #1's appointment at the wound care clinic. The treatment nurse said she did not know Resident #1's blister had gotten infected she thought treatment was for preventive measures. LVN A said she never observed the blisters to be popped. When asked what the facility's process was when a resident refused care for a wound such as in this case, LVN A said, Click on a button, put the reason why, and sign it. When asked again, LVN A said she told Resident #1 on 5/13/15 that she was at risk of infection if she did not allow treatment, but she did not document anything because her refusal was in the incident report. 10. During an interview on 6/15/15 at 2:05 p.m., the DON said that she was notified of Resident #1's blisters on 5/13/15 and she assessed the resident. She said the blisters were clear and fluid-filled. She said that LVN C had talked to the physician that day and told the physician that the resident refused any treatment to the blisters. When asked what the physician said to do, the DON said, He didn't say anything to do. She said that Resident #1 at first had told her she did not know how the blisters had occurred, then said that RN B had given her hot chocolate the day before in a plastic cup and that could have caused it. The DON said Resident #1 said she never felt pain while holding the cup of hot chocolate, but the resident said she just had very sensitive skin and that is why she was burned. The DON said she also believed that Resident #1 just had very thin skin and asked the surveyor if the surveyor had looked and observed how thin Resident #1's skin was. When discussing whether she had spoken with the resident's physician regarding the burns to get his opinion about whether the issue was thin skin, she said she had not because it was common sense not to give a hot drink in that kind of a cup. The DON said that Resident #1 was served the hot drink in a plastic cup with an insulated cup inside of it. The DON stated, I'm assuming it was Styrofoam or something. The DON repeated several times that the resident had told her this had happened to her several times in the past and the resident had said she had healed up just fine. The DON said that the nurses offered to wrap them to pad the blisters but Resident #1 thought they would heal better left open to air. The DON said she told the resident that she could be at risk for infection. The DON said she did a 24-hour follow up and from then the staff were just monitoring. When discussing what she expected the staff to be doing if they were monitoring, such as how often, the DON said that usually it was every shift. When discussing whether the staff did monitor every shift, the DON said, It should have been, I'll have to look. The DON looked at her computer and then said, Well, there's monitoring every day. She then looked again and said there wasn't monitoring every day, but there was monitoring. When discussing that the record did not reflect any assessments of the blisters that included measurements or a physical description and who should have been doing that, the DON said that the computer program made it hard to do that. When discussing why she thought that Resident #1 was the one who identified that her wound had turned green in color and had an odor if the nurse's were monitoring the blisters, the DON said, I honestly can't tell you that. No one notified me they were opened. When discussing what actions she took to prevent future occurrences, the DON said she gave the resident an insulated mug to keep and she had an in-service with the staff. The DON provided an in-service dated 5/13/15. The full content documented on the in-service was, Please make sure hot liquids such as coffee, hot cocoa, hot tea, etc. are at the appropriate temperature. Never leave a cup of hot or warm liquids with a resident unattended who cannot drink or hold the cup without assistance. We must protect our residents from hot liquids. When discussing what she meant by appropriate temperature, she said, Well, like our water temperature. She then said that she guessed that was not applicable since staff could not be expected to carry thermometers and take temperatures of liquids. The in-service with staff did not address Resident #1's special needs due to decreased ability to feel pain or extreme temperatures (hot and cold.) The in-service did not address serving residents drinks in staff's personal cups or in cups/containers that were inappropriate for the contents. 11. During an interview on 6/17/15 at 9:50 a.m. CNA G said that she and CNA H were bathing Resident #1 and found the blisters and notified the nurse. CNA G said she just remembered that Resident #1 told her they gave her hot water in a plastic cup and she (CNA G) knew the resident was lying. 12. During an interview on 6/17/15 at 10:05 a.m., CNA I said that she was the one who first found Resident #1's blisters and she had gone to the DON to report them. CNA I said the DON told her that Resident #1 got those blisters all the time and Its' something she goes through. CNA I said she never knew Resident #1 was burned. She said the only instructions she received was not to bust the blisters. 13. During interviews on 6/16/15 at 2:15 p.m. and 6/17/15 at 9:10 a.m., the Administrator said she was out of town on vacation on 5/13/15 when the staff became aware that Resident #1 had been burned. The Administrator said she did not come back to work until 5/20/15 and when she saw Resident #1's hands, I was shocked. The Administrator said that Resident #1 had just gone on and on about this had happened to her before, Saying something about some kind of [DIAGNOSES REDACTED]. The Administrator said she thought it was a drink served in a cup inside a Styrofoam cup and the Styrofoam cup was a convenience store coffee cup, but she was not sure who had told her that. 14. During an interview on 6/17/15 at 4:18 p.m. with the resident's physician, when discussing whether Resident #1's physical condition contributed to her inability to feel the heat or pain while being receiving burns from a hot cup, Resident #1's physician said, You've seen her, what do you think! Resident #1's physician said that since Resident #1 was an incomplete quadriplegic, it was very possible she did not feel pain while being burned. He said that he doubted she could feel hot or cold, either. 15. Review of physician's notes for Resident #1 revealed notes dated 5/3/15 and 5/27/15. There were no entries indicating service between the two dates. The physician's note dated 5/27/15 was the first physician's note documenting that the resident had blistered areas on the palms of her hands. 16. Review of an Accident/Incident log dated from 4/09/2015 to 6/09/15 provided by the Administrator on 06/09/15 documented there 29 residents on the accident/incident log.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the physical status and need to alter treatment significantly for 1 of 3 residents reviewed for wound care. (Resident #1). Resident #1 received blisters to both palms of her hands [MEDICAL CONDITION] 5/12/15 and the physician was not contacted and did not order treatment for [REDACTED]. This failure could affect the six residents receiving wound care and result in residents not receiving timely or appropriate treatment to facilitate wound healing and could result in wound deterioration and infection. Findings included: 1. Review of Resident #1's undated Face Sheet documented she was a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. An undated computer list of [DIAGNOSES REDACTED]. The DON provided a documented definition of this [DIAGNOSES REDACTED].#1's physician. The document dated 6/15/15 at 4:09 p.m. for skin sensation disturbance was tingling sensation in her (Resident #1) hands, under her skin. States mostly all patients will have DX (diagnoses): only way he can bill (charge) a B12 lab level (lab result for vitamin B level). Review of Resident #1's Minimum Data Set updated 3/20/15, significant change in status documented, in part: Resident #1 had a total of score of 13 on the BIMS (Brief Interview for Mental Status) that indicated her mental status was intact. Resident #1's functional status was documented as requiring extensive assistance of one person for dressing, eating, and person hygiene; transfers and bed mobility required the physical assistance of two persons; walking did not occur; and range of motion was impaired on both sides of upper and lower extremities. Review of Resident #1's Care Plan with the most recent review documented as 3/20/15 revealed it included the following (in part): Problem/Need: Problem onset update 3/20/15: Impaired Skin integrity and continues at risk for impaired skin integrity AEB (as evidenced by): impaired mental status, impaired mobility, impaired skin sensitivity and requires the use of WC (wheelchair) for mobility/locomotion-wheeled per staff, continues with surgical wound, decreased consumption of food/fluids, with additional risks r/t (related to) psychoactive meds per MD orders. Goal: Skin will remain intact without evidence of further skin breakdown QD (every day) during the next 90 days. Will remain free from additional skin breakdown/irritation QD during the next 90 days. Approaches: Resident has blisters to bilateral palms and refuses treatments; Weekly skin checks; Report signs of infection (odor drainage, pain or redness); Weekly wound monitoring. Problems/Need: Problem onset 1/10/14: Impaired cognition AEB some misunderstanding of situations at times Goal: Needs will be anticipated and met by staff daily during the next 90 days. Approaches: Encourage independent decision making. Problem/Need Problem onset 8/31/13: Self Care Deficit AEB requires total-extensive level of assist with ADLs (activities of daily living)/care QD with additional risk for decline r/t non-compliant at times r/t paralysis and contractures and femur fracture. Goal: (No goal identified) Approaches: Setup, cue and assist as needed with ADLs. Problem onset 1/10/14: At risk for alteration in mood/behaviors r/t AEB demanding/manipulative personality-r/t dx (diagnosis) of [MEDICAL CONDITION] (Resident #1 is a quadriplegic) with additional risk due to being judgmental/critical of others, and self pity. Goal: Will exhibit behavior of yelling at staff less than 1 x (time) in 90 days. Will exhibit behavior of making additional demands on staff less than 1 x a week over next 90 days. Approaches: Approach in calm manner. When confused or experiencing psychotic disturbances do not attempt to bring to reality. 2. Review of the Resident Incident Report for Resident #1 dated 5/13/15 at 12:00 p.m. documented the report was completed by LVN C. LVN C documented that CNA D told LVN C that Resident #1 had blisters to both hands. Resident #1 was interviewed and she said she was not sure what caused them. Resident #1 said that she was drinking hot cocoa in a cup on 5/12/15 but that it was not hot, she said the condition had happened before but more than 2 years ago. LVN C documented there were blisters to both of the resident's hands. LVN C documented that immediate actions taken was a skin assessment and incident investigation. LVN C documented Resident #1 refused any treatments to bilateral palms, stating she wanted them left open to air and they would go away on their own. Under Actions Taken, LVN C documented that first aid by LVN C was given on 5/13/15 at 3:50 p.m. and the type of aid was documented as Skin assessment, Resident (#1) refused tx (treatment) to area. LVN C documented that the resident's physician was notified on 5/13/15 at 3:00 p.m. and the DON was notified on 5/13/15 at 3:27 p.m (there was no documentation of any physician orders given). (There was no physical description of the location of the wounds on the resident's hands, the size of the blisters, the number of blisters, or the appearance of the blisters and surrounding skin on the report). A Post-Incident Action (regarding incident for Resident #1) form attached to the Incident Report, repeated the date, time, and information regarding the incident as noted on the incident report, including the actions taken. Additionally, under, Activity at time: Consuming food/bev (beverage); and under Immediate Post Incident Action, the writer documented, Resident education to report any skin condition as soon as possible. An un-dated, Resident Incident Follow Up form by an unidentified author (no signature in the completed by) section, documented a repeated narrative of the incident and actions taken. Under 24 hour follow up/ 24 Hour condition and injury appearance the writer documented vital signs and Resident continues with clear blisters to bilateral hands, resident continues to refuse treatment to bilateral hands, continues to state that she wants them LOTA and they will heal on their own. The report documented, Addressed in Care Plan 5/14/15. The section New orders as a result of the incident was not checked. 3. Nursing Notes on 5/13/15 (date blisters were identified) revealed the following: 9:03 a.m.: LVN C documented that Resident #1's catheter was intact and the resident voiced no concerns, did not complain of urethral or bladder burning or distention. 3:29 p.m.: LVN C documented that he had received the report of the blisters. He documented that he assessed and interviewed the resident three times and she said that she did not know what exactly happened. He documented he notified the resident's family and the physician. (LVN C did not document assessment of the injury in the nursing note). 9:52 p.m.: The nurse documented that the resident had no complaints of discomfort, her left leg was in an immobilizer, she drank plenty of fluids, and she needed a urinalysis the next morning. (Hands/blisters were not mentioned in 9:52 p.m. note.) There were no other nursing notes for 5/13/15. 4. Review of the SBAR (Situation, Background, Assessment, and Recommendation) Communication Form and Progress note for RNs (registered nurse)/LPN (license practical nurse)/LVNs (licensed vocational nurse) dated 5/13/15 at 1500 p.m. (3:00 p.m.) and signed by LVN C documented that Resident #1 had fluid filled blisters (pockets), skin was intact, her pain intensity level on a scale of 1-10 was a 10, the resident was showing non-verbal signs of pain including grimacing, the condition started on 5/13/15, there were no changes in mental status, neurological, functional status, cardiovascular, abdominal/GI, GU/Urine behaviors, or respiratory. (The SBAR did not include any information that the resident's blisters were the result of being burned). The report documented that Resident #1's physician was notified on 5/13/15 at 3:00 p.m. Under Recommendations of Primary Clinician (if any), LVN C left this section blank. Under testing, which included choices such as blood tests, EKG, Urinalysis, Other, etc, all were unchecked. Under Interventions which included choices of new or change in medications, IV or subcutaneous fluids, increase oral fluids, oxygen, or Other (describe), all choices were unchecked. 5. A review of all physician's orders, including telephone orders from 5/13/15 through 5/26/15 revealed no physician's orders related to Resident #1's blisters/burns. 6. Review of the Departmental Notes (Nurse's notes) for the period 5/13/15 through 5/27/15 revealed the following notes contained information about Resident #1's blisters: 5/13/15 at 3:29 p.m.- CNA D reported to me (LVN C) that the resident (#1) had blisters to the palms of the hand. Unable to describe what happened because she just said that she (Resident #1) found herself with blisters. I (LVN C) assessed and interviewed the resident three times and she said that she doesn't know what exactly happened. Her Mom (Resident #1) notified and physician. Will continue to monitor. (documented by LVN C). 5/14/15 at 10:35 a.m.- Resident still sustains blisters on hands bilateral. C/O (complained) of no pain to blister areas. Will continue to monitor. (documented by LVN C). 5/15/15 at 2:38 p.m.- Still exhibits blisters to the hands. No s/s (signs and symptoms of infection noted to blister. (documented by LVN C). There were no nursing notes indicating nursing monitoring or assessment of Resident #1's blisters/burns occurred on 5/16/15, 5/17/15, 5/18/15, 5/19/15, 5/20/15, 5/21/15, 5/22/15, 5/23/15, or 5/24/15. 5/24/15 at 5:35 a.m. - Blisters healing on bilateral hands, no c/o pain. (documented by RN E). 5/25/15 at 9:36 p.m.- Blisters on bilateral palms the same, healing slowly, OTA (open to air), no s/s of infection. (documented by RN E). 5/26/15 at 9:11 p.m.- Blisters on bil (bilateral) palms the same, healing slowly, OTA, no signs and symptoms of infection. ( documented by RN E). 5/27/15 at 1:42 p.m.- New order to start [MEDICATION NAME] 100 mg (milligrams) by mouth, twice a day for seven days and [MEDICATION NAME] ointment to bilateral hand palms, twice a day for 7 days, for purulent (pus) and blisters to both hands. Wound culture obtained and sent to lab this am. vital signs. (documented by LVN F) 7. Review of Wound Assessment/Treatment Reports dated from 5/13/15 through 5/28/15 documented monitoring and treatment to wounds to the coccyx and the left heel. There was no documentation of monitoring, assessment, treatment or physician's orders for treatment of [REDACTED]. 8. Review of Skin Inspection Reports for Resident #1 from 5/1/15 through 6/5/15 revealed Skin Status of Skin not intact-Existing (referring to Resident #1's pressure ulcers) on each report. There was not a new entry after 5/12/15 to identify blisters to bilateral palms. 9. Review of Resident #1's Telephone Physician's Orders dated 5/27/2015 documented an order for [REDACTED]. 10. Lab reports for Resident #1 dated 5/27/15 [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) bacterial infection of the left hand and [DIAGNOSES REDACTED] oxytoca bacterial infection infection caused by bacteria) to the right hand. 11. Review of Resident #1's Telephone Physician's Orders dated 5/29/2015 documented orders for bactrim (antibiotic) twice a for 7 days secondary to gram negative bacilli to right hand [MEDICAL CONDITION] to the left hand. 12. Review of Wound Care Physician's Order dated 5/28/15 documented, in part: Left and Right hand: apply [MEDICATION NAME] gauze, kling (self-adhering gauze roll that gently sticks to itself as you wrap) tape to protect. 13. Review of the the May 2015 Treatment Administration Record revealed treatment dated 5/29/15, start date 5/30/15 documented, in part: Cleanse bilateral hands with wound cleanser pat dry apply [MEDICATION NAME] 4 X 4 and wrap with kerlix (type of gauze bandage), change everyday until healed. Documentation showed treatment was documented on 5/30 and 5/31/15. 14. During interviews on 6/10/15 at 4:40 p.m., 6/11/15 at 7:40 a.m. and 6/16/15 at 1:25 p.m., Resident #1 said she burned her hands while drinking hot chocolate in a red plastic cup given to her by RN B. Resident #1 said she knew that RN B had not meant any harm by giving her the hot cup. Resident #1 said that she had complained about being cold to RN B around noon, and RN B told her that she had the makings for a warm drink in her office. Resident #1 said RN B told her she had double-cupped the drink (put one cup inside another) but Resident #1 was unable to say for sure whether she had seen two cups. She said she did not know what kind of cup was placed inside the outer cup. Resident #1 said that on the next day (5/13/15) the staff asked her what happened that caused the blisters on her hands and she first told them she did not know how it happened, but then told them about drinking the hot drink the day before. She said she also told them that she had burned her hands from drinking hot coffee from a coffee shop cup in the past, but her hands did not burn to this extent and healed without medical treatment. Resident #1 said that the drink was hot but she took small sips. Resident #1 said she held the cup throughout the time she was drinking, and drank all of the contents. She said she never realized it was hot enough to burn her because she did not feel any pain while holding the cup. Resident #1 said LVN C spoke with her on 5/13/15. She said that he told her she needed to cover the blisters with a moisture bandage so she would not get an infection. Resident #1 said she declined the treatment because she thought moisture would increase the chances of bacteria. She said she knew better than that now and realized she was wrong. Resident #1 said the DON did come and talk to her and just verified that she did not want treatment. Resident #1 said that after that date, she could not remember any nurses, other than the wound care treatment nurse, looking at her hands. She said they might have, but she could not recall any specific nurses coming in. She said the treatment nurse (LVN A) was in her room every day to treat her other wounds. When discussing whether LVN A looked at the blisters on her hands every day, Resident #1 said she did not know. She said she could not remember how many times she looked at the blisters. She said she did not think she looked at them every day. She said, I can't really say that she did for sure, and I can't really say that she didn't for sure. Resident #1 said that at some time following 5/13/15, she noticed that the skin around the blister was red. She said she thought that meant it was healing, because she thought she had heard the wound care nurse say that was a good sign when they were observing her other wounds. When explained that redness could have been a sign of infection, Resident #1, said, Oh, I went around telling everyone how good they were doing and how they were healing. She said she noticed a green color too and did not think that was a bad sign either. When discussing whether the blisters remained intact or ever popped, Resident #1 said they both popped approximately a week after she had them. She said they did not pop at the same time. Resident #1 said that was when the staff at the wound care center saw her hands, they told her that her hands needed to be wrapped. Resident #1 said that she told them that she preferred them open to air and the wound care staff told her that it was very important to cover the wounds. Resident #1 said she allowed the wound care staff to wrap her hands (5/28/15). 15. During an interview on 6/11/15 at 2:00 p.m., RN B said that she was no longer employed by the facility, but at the time of the incident she was the Assistant Director of Nurses. RN B said that on 5/12/15, Resident #1 was complaining of chills. RN B said that she made Resident #1 hot chocolate and served it to the resident in a red plastic cup that she had. RN B said that she double-cupped it, explaining she placed one plastic cup inside another one. She said she served the hot chocolate in this manner because she did not have a Styrofoam cup and when she went to the kitchen and asked the kitchen staff for a cup, they told her they did not have any. RN B said that the kitchen staff she talked to spoke very little English and she was not sure the kitchen staff really understood her question. RN B said that she was not informed at any time on 5/12/15 that the resident had any problems after having the drink. She said that she was off work a couple of days and then she got sick and was in the hospital twelve days. RN B said it was not until she returned from sick leave that she learned from a CNA that Resident #1 had been burned by the drink. RN B said she discussed the incident with Resident #1 and apologized to the resident. RN B said the cup could have caused Resident #1 to get burned, but she thought at the time that by putting the hot chocolate in two of the cups, it would be okay. 16. During a telephone interview on 6/10/15 at 4:45 p.m., LVN C said that CNA D notified him of the need to look at Resident #1's hands some time close to lunch on 5/13/15. LVN C said he looked at Resident #1's hands and observed one continuous blister on each palm that if you could divide it, would be three or four. LVN C said She (Resident #1) told me it might be a reaction. She told me it came from heat. She told me it came from hot chocolate or hot tea. He said he did not measure or document a description of the blisters but would estimate they were each 4 cm x 5 cm. He said the reason he did not is because he thought it was the treatment nurse's responsibility to document the measurements and description of the blisters. LVN C said he offered to put a 4 x 4 pad with moisture on the blisters, but Resident #1 said she wanted to leave them open to air. LVN C said he had not received an order for [REDACTED].#1 refused treatment, and the physician told him to just monitor the blisters. LVN C said that he notified the DON of his observation on 5/13/15 within 15 minutes of seeing the resident. When discussing that no telephone order was located and where he documented the physician's response, LVN C said, The orders should be somewhere, in the notes, or SBAR, or incident report. (None of the documents listed contained information regarding the physician's response). 17. During an interview on 6/10/15 at 3:00 p.m., LVN A said she was the wound care treatment nurse. She said she was notified of the blisters on 5/13/15 by CNA D. LVN A said, I didn't even know what it was at first. She said Resident #1 told her that (RN B) gave her a hot cocoa and it burned her hands. LVN A said at first they were just raised areas but then turned to blisters. LVN A said she did not measure or describe the blisters during her weekly skin assessments or during her daily treatment of [REDACTED].#1 because she had no order to treat them (blisters). LVN A said she did not know Resident #1's blisters had gotten infected she thought treatment was for preventive measures. 18. During an interview on 6/16/15 at 1:30 p.m. regarding the nurses notes written on 5/27/15 (New order to start [MEDICATION NAME] 100 mg by mouth, twice a day for seven days and [MEDICATION NAME] ointment to bilateral hand palms, twice a day for 7 days, for purulent and blisters to both hands. Wound culture obtained and sent to lab this am) LVN F said he was informed of Resident #1's blisters on her hands during report. LVN F said he went to assess Resident #1's hands and noticed a grayish purulent drainage to one blister on the left hand and a intact blister to the right hand (LVN F was unsure if the left or the right hand blister had the grayish purulent drainage). LVN F said he thought it was the physician's first time to see the blisters but he was not sure. LVN F said it was not the first time for him to hear about the blister. (LVN F documented in the Nurses Notes for Resident #1 on 5/14/15 at 10:35 a.m.-Medication follow-up-[MEDICATION NAME] 50 mg tablet (pain med)-2 tabs-medication effective. There was no documentation regarding Resident #1's blisters to her hands). LVN F said he had heard about the blister from another nurse but could not remember when. LVN F said Resident #1 had told him the blisters just naturally occurred and that the blister had occurred before. LVN F said he informed Resident #1 that the doctor had ordered an antibiotic due to her hands being infected. 19. Review of Physician's Progress Notes dated 5/27/15 documented, in part, Patient with blistered, crusted areas on palms of hands. 20. During an interview on 6/15/15 at 2:05 p.m., the DON said that she was notified of Resident #1's blisters on 5/13/15 and she assessed the resident. She said the blisters were clear and fluid-filled. She said that LVN C had talked to the physician that day and told the physician that the resident refused any treatment to the blisters. When asked what the physician said to do, the DON said, He didn't say anything to do. She said that Resident #1 at first had told her she did not know how the blisters had occurred, then said that RN B had given her hot chocolate the day before in a plastic cup and that could have caused it. The DON said Resident #1 said she never felt pain while holding the cup of hot chocolate, but the resident said she just had very sensitive skin and that is why she was burned. The DON said she also believed that Resident #1 just had very thin skin and asked the surveyor if the surveyor had looked and observed how thin Resident #1's skin was. When discussing whether she had spoken with the resident's physician regarding [MEDICAL CONDITION] get his opinion about whether the issue was thin skin, she said she had not. 21. During an interview on 6/17/15 at 4:18 p.m. with the resident's physician, when discussing whether Resident #1's physical condition contributed to her inability to feel the heat or pain while [MEDICAL CONDITION] a hot cup, Resident #1's physician said, You've seen her, what do you think! Resident #1's physician said that since Resident #1 was an incomplete quadriplegic, it was very possible she did not feel pain while being burned. He said that he doubted she could feel hot or cold, either. He said he was notified of the blisters on her hands the day he wrote an order for [REDACTED].#1's physician was asked specifically if he gave any staff at the facility orders to just monitor Resident #1's blisters. The physician said that he did not. He repeated that the first order he gave was when he wrote orders for the wound cultures (that order dated 5/27/15). 22. Review of physician's notes for Resident #1 revealed notes dated 5/3/15 and 5/27/15. There were no entries indicating service between the two dates. The physician's note dated 5/27/15 was the first physician's note documenting that the resident had blistered areas on the palms of her hands. 23. Review of the facility's policy for change of Condition dated effective 1/13/15 and revision date 3/04/15 documented, in part: Purpose: To ensure the highest level of care of our residents and to alleviate the need for a transfer out of the facility. 1. If a resident has a change of condition, the nurse aide should notify the charge nurse of the slightest change in resident condition in order for the nurse to assess and complete a SBAR to ensure that we are monitoring an a acute illness prior to being an emergency. 2. Upon completion of SBAR it is to be the initiation of a Nurses Note for that change of condition. Original SBAR goes into the chart and a copy is provided to the DON/ADON office for communication and for use in the stand up meeting the next morning. 3. Notification of the family and physician is then completed. The doctor should be asked if resident treatment can be completed in the facility. If a resident is to stay in facility they are to be placed in focus charting and monitored for changes. 4. If the physician sees the need to send the resident to the emergency room . 5. If the resident is to stay in facility they are to be placed in focus charting and monitored for changes. 24. LVN A provided a list on 6/10/15 that identified six residents who required wound care.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 residents (Resident #1), who had a [DIAGNOSES REDACTED]. a) failure to assess, closely monitor, and provide treatments/interventions for Resident #1 when she was found to have blisters resulting [MEDICAL CONDITION] both her palms on 5/13/15. [MEDICAL CONDITION] determined to have been caused by the resident holding a thin, uninsulated plastic cup of hot liquid given to her by RN B; and b) failure to provide Resident #1 with education on the benefits of treatment, the risks and potential outcomes associated with infection, and the prevention and signs/symptoms of infection related to blisters [MEDICAL CONDITION] both of her palms so Resident #1 could make an informed choice regarding treatment. These failures placed the six residents who received wound care at risk of not being assessed for quality of care which could result in serious medical complications, need for increased medication, decline in condition, and the need for hospitalization . Findings included: 1. Review of Resident #1's undated Face Sheet documented she was a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. An undated computer list of [DIAGNOSES REDACTED]. The DON provided a documented definition of this [DIAGNOSES REDACTED].#1's physician. The document dated 6/15/15 at 4:09 p.m. for skin sensation disturbance was tingling sensation in her (Resident #1) hands, under her skin. States mostly all patients will have DX (diagnoses): only way he can bill a B12 lab level (lab result for vitamin B level). Review of Resident #1's Minimum (MDS) data set [DATE], significant change in status documented, in part: Resident #1 had a total of score of 13 on the BIMS (Brief Interview for Mental Status) that indicated her mental status was intact. Resident #1's functional status was documented as requiring extensive assistance of one person for dressing, eating, and person hygiene; transfers and bed mobility required the physical assistance of two persons; walking did not occur; and range of motion was impaired on both sides of upper and lower extremities. Review of Resident #1's Care Plan with the most recent review documented as 3/20/15 included the following (in part): Problem/Need: Problem onset up-dated 3/20/15: Impaired Skin integrity and continues at risk for impaired skin integrity AEB (as evidenced by): impaired mental status, impaired mobility, impaired skin sensitivity and requires the use of WC (wheelchair) for mobility/locomotion-wheeled per staff, continues with surgical wound, decreased consumption of food/fluids, with additional risks r/t (related to) psychoactive meds per MD orders. Goal: Skin will remain intact without evidence of further skin breakdown QD (every day) during the next 90 days. Will remain free from additional skin breakdown/irritation QD during the next 90 days. Approaches: Resident has blisters to bilateral palms and refuses treatments; Weekly skin checks; Report signs of infection (odor drainage, pain or redness); Weekly wound monitoring. Problems/Need: Problem onset 1/10/14: Impaired cognition AEB some misunderstanding of situations at times. Goal: Needs will be anticipated and met by staff daily during the next 90 days. Approaches: Encourage independent decision making. Problem/Need Problem onset 8/31/13: Self Care Deficit AEB requires total-extensive level of assist with ADLs (activities of daily living)/care QD with additional risk for decline r/t non-compliant at times r/t paralysis and contractures and femur fracture. Goal: (No goal identified) Approaches: Setup, cue and assist as needed with ADLs. Problem onset 1/10/14: At risk for alteration in mood/behaviors r/t AEB demanding/manipulative personality-r/t dx (diagnosis) of [MEDICAL CONDITION] (Resident #1 is a quadriplegic) with additional risk due to being judgmental/critical of others, and self pity. Goal: Will exhibit behavior of yelling at staff less than 1 x (time) in 90 days. Will exhibit behavior of making additional demands on staff less than 1 x a week over next 90 days. Approaches: Approach in calm manner. When confused or experiencing psychotic disturbances do not attempt to bring to reality. 2. Review of the Resident Incident Report for Resident #1 dated 5/13/15 at 12:00 p.m. documented the report was completed by LVN C. LVN C documented that CNA D told LVN C that Resident #1 had blisters to both hands. Resident #1 was interviewed and she said she was not sure what caused them. Resident #1 said that she was drinking hot cocoa in a cup on 5/12/15 but that it was not hot; she said the condition had happened before but more than 2 years ago. LVN C documented there were blisters to both of the resident's hands. LVN C documented that immediate actions taken was a skin assessment and incident investigation. LVN C documented Resident #1 refused any treatments to bilateral palms, stating she wanted them LOTA (left open to air) and they would go away on their own. Under Actions Taken, LVN C documented that first aid by LVN C was given on 5/13/15 at 3:50 p.m. and the type of aid was documented as Skin assessment, Resident (#1) refused tx (treatment) to area. LVN C documented that the resident's physician was notified on 5/13/15 at 3:00 p.m. and the DON was notified on 5/13/15 at 3:27 p.m. (There was no physical description of the location of the wounds on the resident's hands, the size of the blisters, the number of blisters, or the appearance of the blisters and surrounding skin on the report). A Post-Incident Action form attached to the Incident Report, repeated the date, time, and information regarding the incident as noted on the incident report, including the actions taken. Additionally, under, Activity at time: Consuming food/bev (beverage); and under Immediate Post Incident Action, the writer documented, Resident education to report any skin condition as soon as possible. An un-dated, Resident Incident Follow Up form by an unidentified author (no signature in the completed by) section, documented a repeated narrative of the incident and actions taken. Under 24 hour follow up/ 24 Hour condition and injury appearance the writer documented vital signs and Resident continues with clear blisters to bilateral hands, resident continues to refuse treatment to bilateral hands, continues to state that she wants them LOTA and they will heal on their own. The report documented, Addressed in Care Plan 5/14/15. The section New orders as a result of the incident was not checked. 3. Observation on 6/10/15 at 12:30 p.m. of Resident #1's hands showed she had two large crusty (scabbed) areas located on the outer edges of both her palms (running down the side of the palm to the the middle of the the lower palm). (Following intervention by surveyors), During an observation on 6/10/15 at 4:40 p.m. LVN A took the following measurements of Resident #1's healing injuries on her palms: Resident #1's right palm had a dried crusty area that measured 1.03 c.m. (centimers) width by 4.5 cm.length cm. and the left palm measured 1.2 cm.width by 1.3 cm. length. There was no previous documentation of the measurements of Resident #1's blistered palms. 4. Review of the SBAR (Situation, Background, Assessment, and Recommendation) Communication Form and Progress note for RNs (registered nurses)/LPN (license practical nurses)/LVNs (licensed vocational nurse) dated 5/13/15 at 1500 p.m. (3:00 p.m.) and signed by LVN C documented that Resident #1 had fluid filled blisters (pockets), skin was intact, her pain intensity level on a scale of 1-10 was a 10, the resident was showing non-verbal signs of pain including grimacing, the condition started on 5/13/15, there were no changes in mental status, neurological, functional status, cardiovascular, abdominal/GI, GU/Urine behaviors, or respiratory. (The SBAR did not include any information that the resident's blisters were the result of being burned). The report documented that Resident #1's physician was notified on 5/13/15 at 3:00 p.m. Under Recommendations of Primary Clinician (if any), LVN C left this section blank. Under testing, which included choices such as blood tests, EKG, Urinalysis, Other, etc, all were unchecked. Under Interventions which included choices of new or change in medications, IV or subcutaneous fluids, increase oral fluids, oxygen, or Other (describe), all choices were unchecked. 5. Nursing Notes on 5/13/15 (date blisters were identified) revealed the following: 9:03 a.m.: LVN C documented that Resident #1's catheter was intact and the resident voiced no concerns, did not complain of urethral or bladder burning or distention. 3:29 p.m.: LVN C documented that he had received the report of the blisters. He documented that he assessed and interviewed the resident three times and she said that she did not know what exactly happened. He documented he notified the resident's family and the physician. (LVN C did not documented any assessment results in the nursing note). 9:52 p.m.: The nurse documented that the resident had no complaints of discomfort, her left leg was in an immobilizer, she drank plenty of fluids, and she needed a urinalysis the next morning. (Hands/blisters were not mentioned in 9:52 p.m. note.) There were no other nursing notes for 5/13/15. 6. A review of all physician's orders, including telephone orders from 5/13/15 through 5/26/15 revealed no physician's orders related to Resident #1's blisters/burns. 7. Review of the Departmental Notes (Nurse's notes) for the period 5/13/15 through 5/27/15 revealed the following notes contained information about Resident #1's blisters: 5/13/15 at 3:29 p.m.- CNA D reported to me (LVN C) that the resident (#1) had blisters to the palms of the hand. Unable to describe what happened because she just said that she (Resident #1) found herself with blisters. I (LVN C) assessed and interviewed the resident three times and she said that she doesn't know what exactly happened. Her Mom (Resident #1) notified and physician. Will continue to monitor. (documented by LVN C). 5/14/15 at 10:35 a.m.- Resident still sustains blisters on hands bilateral. C/O (complained) of no pain to blister areas. Will continue to monitor. (documented by LVN C). 5/15/15 at 2:38 p.m.- Still exhibits blisters to the hands. No s/s (signs and symptoms of infection noted to blister. (documented by LVN C). 5/24/15 at 5:35 a.m. - Blisters healing on bilateral hands, no c/o pain. (documented by RN E). 5/25/15 at 9:36 p.m.- Blisters on bilateral palms the same, healing slowly, OTA (open to air), no s/s of infection. (documented by RN E). 5/26/15 at 9:11 p.m.- Blisters on bil (bilateral) palms the same, healing slowly, OTA, no signs and symptoms of infection. (documented by RN E). 5/27/15 at 1:42 p.m.- New order to start [MEDICATION NAME] 100 mg (milligrams) by mouth, twice a day for seven days and [MEDICATION NAME] ointment to bilateral hand palms, twice a day for 7 days, for purulent (pus) and blisters to both hands. Wound culture obtained and sent to lab this am. vital signs. (documented by LVN F). There were no nursing notes indicating nursing monitoring or assessment of Resident #1's blisters/burns occurred on 5/16/15, 5/17/15, 5/18/15, 5/19/15, 5/20/15, 5/21/15, 5/22/15, 5/23/15, or 5/24/15. 8. Review of Wound Assessment Reports dated from 5/13/15 through 5/28/15 documented monitoring and treatment to wounds to the coccyx and the left heel. There was no documentation of monitoring, assessment, or treatment of [REDACTED]. 9. Review of Skin Inspection Reports for Resident #1 from 5/1/15 through 6/5/15 revealed Skin Status of Skin not intact-Existing on each report. There was not a new entry after 5/12/15 to identify blisters to bilateral palms. 10. Review of Resident #1's Telephone Physician's Orders dated 5/27/2015 documented an order for [REDACTED]. 11. 19. Review of Physician's Progress Notes dated 5/27/15 documented, in part, Patient with blistered, crusted areas on palms of hands. 12. Lab reports for Resident #1 dated 5/27/15 [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) bacterial infection of the left hand and [DIAGNOSES REDACTED] oxytoca bacterial infection to the right hand. 13. A Physician's Telephone Order for Resident #1, dated 5/29/2015 documented orders for bactrim (antibiotic) twice a for 7 days secondary to gram negative bacilli to right hand [MEDICAL CONDITION] to the left hand. 14. A Wound Care Center Physician's Order dated 5/28/15 (Resident #1 was at wound care for treatment of [REDACTED].#1 documented, in part: Left and Right hand: apply [MEDICATION NAME] gauze, kling tape to protect. 15. A Treatment Administration Record for Resident #1 dated 5/29/15, start date 5/30/15 documented, in part: Cleanse bilateral hands with wound cleanser pat dry apply [MEDICATION NAME] 4 X 4 and wrap with kerlix, change everyday until healed. Documentation showed treatment was documented on 5/30 and 5/31/15. 16. During interviews on 6/10/15 at 4:40 p.m., 6/11/15 at 7:40 a.m. and 6/16/15 at 1:25 p.m., Resident #1 said she burned her hands while drinking hot chocolate in a red plastic cup given to her by RN B. Resident #1 said she knew that RN B had not meant any harm by giving her the hot cup. Resident #1 said that she had complained about being cold to RN B around noon, and RN B told her that she had the makings for a warm drink in her office. Resident #1 said that RN B had used a cup from RN B's office, and Resident #1 also thought the drink was made in RN B's office but she was unsure of that. Resident #1 said RN B told her she had double-cupped the drink (put one cup inside another) but Resident #1 was unable to say for sure whether she had seen two cups. She said she did not know what kind of cup was placed inside the outer cup. Resident #1 said that on the first day (5/13/15) the staff asked her what happened that caused the blisters and she first told them she did not know how it happened, but then told them about drinking the hot drink the day before. She said she had hesitated because she did not want to get RN B in trouble. She said she also told them that she had burned her hands from drinking hot coffee from a coffee shop cup in the past, but her hands did not burn to this extent and healed without medical treatment. Resident #1 said the drink was hot but she took small sips. Resident #1 said she held the cup throughout the time she was drinking, and drank all of the contents. She said she never realized it was hot enough to burn her because she did not feel any pain while holding the cup. Resident #1 said LVN C spoke with her on 5/13/15. She said that he told her she needed to cover the blisters with a moisture bandage so she would not get an infection. Resident #1 said she declined the treatment because she thought moisture would increase the chances of bacteria. She said she knew better than that now and realized she was wrong. Resident #1 said the DON did come and talk to her and just verified that she did not want treatment. Resident #1 said that after that date, she could not remember any nurses, other than the wound care treatment nurse, looking at her hands. She said they might have, but she could not recall any specific nurses coming in. She said the treatment nurse (LVN A) was in her room every day to treat her other wounds. When discussing whether LVN A looked at the blisters on her hands every day, Resident #1 said she did not know. She said she could not remember how many times she looked at the blisters. She said she did not think she looked at them every day. She said, I can't really say that she did for sure, and I can't really say that she didn't for sure. Resident #1 said that at some time following 5/13/15, she noticed that the skin around the blister was red. She said she thought that meant it was healing, because she thought she had heard the wound care nurse say that was a good sign when they were observing her other wounds. When explained that redness could have been a sign of infection, Resident #1, said, Oh, I went around telling everyone how good they were doing and how they were healing. She said she noticed a green color too and did not think that was a bad sign either. When discussing whether the blisters remained intact or ever popped, Resident #1 said they both popped approximately a week after she had them. She said they did not pop at the same time. Resident #1 said that when the staff at the wound care center saw her handson 5/28/15, they told her that her hands needed to be wrapped. Resident #1 said that she told them that she preferred them open to air and the wound care staff told her that it was very important to cover the wounds. Resident #1 said she allowed the wound care staff to wrap her hands. Resident #1 said she told LVN A that she thought she might remove the bandage and just leave them open again. When asked how LVN A responded to her comment, Resident #1 said, She agreed with me. She said that she began to smell a foul odor to one of her hands and she suspected something was wrong. She said that she reported to LVN F that her hand was green and had an odor. When asked about her knowledge of risks associated with infection (such as delayed healing, increased scarring, potential for spread of infection, etc), Resident #1 could not identify any of the risks of infection. She knew that infection caused an odor and a green color. 17. A Wound Care Physician order from the hospital wound management center on 5/28/15 at 1345 (1:45 p.m.) documented Resident #1's hands were wrapped for protection. 18. During an interview on 6/11/15 at 2:00 p.m., RN B said that she was no longer employed by the facility, but at the time of the incident she was the Assistant Director of Nurses. RN B said that on 5/12/15, Resident #1 was complaining of chills. RN B said that she made Resident #1 hot chocolate and served it to the resident in a red plastic cup that she had. RN B said that she double-cupped it, explaining she placed one plastic cup inside another one. She said she served the hot chocolate in this manner because she did not have a Styrofoam cup and when she went to the kitchen and asked the kitchen staff for a cup, they told her they did not have any. RN B said that the kitchen staff she talked to spoke very little English and she was not sure the kitchen staff really understood her question. RN B said that she was not informed at any time on 5/12/15 that the resident had any problems after having the drink. She said that she was off work a couple of days and then she got sick and was in the hospital twelve days. RN B said it was not until she returned from sick leave that she learned from a CNA that Resident #1 had been burned by the drink. RN B said she discussed the incident with Resident #1 and apologized to the resident. RN B said the cup could have caused Resident #1 to get burned, but she thought at the time that by putting the hot chocolate in two of the cups, it would be okay. When discussing whether she thought Resident #1's medical condition of [MEDICAL CONDITION] could have caused a decreased sensation of pain and heat, RN B said that was something she never thought about as a possibility. When discussing the facility's policy with regard to an acute condition such as a burn like Resident #1's, RN B said the physician would be notified. She said if the staff was given an order to monitor, a telephone order would be written, a nurse's note, an SBAR would be completed, and it would be added to the 24 hour report. She said these things would prompt the resident into being on priority charting. RN B said the resident's hand should have been looked at several times each shift and an entry of that assessment made every shift. 19. During a telephone interview on 6/10/15 at 4:45 p.m., LVN C said that CNA D notified him of the need to look at Resident #1's hands some time close to lunch on 5/13/15. LVN C said he looked at Resident #1's hands and observed one continuous blister on each palm that if you could divide it, would be three or four. LVN C said She (Resident #1) told me it might be a reaction. She told me it came from heat. She told me it came from hot chocolate or hot tea. He said he did not measure or document a description of the blisters but would estimate they were each 4 cm x 5 cm. He said the reason he did not is because he thought it was the treatment nurse's responsibility to document the measurements and description of the blisters. LVN C said he offered to put a 4 x 4 pad with moisture on the blisters, but Resident #1 said she wanted to leave them open to air. LVN C said he had not received an order for [REDACTED].#1 refused treatment, and the physician told him to just monitor the blisters. LVN C said that he notified the DON of his observation on 6/13/15 within 15 minutes of seeing the resident. When discussing that no telephone order was located and where he documented the physician's response, LVN C said, The orders should be somewhere, in the notes, or SBAR, or incident report. 20. During an interview on 6/10/15 at 3:00 p.m., LVN A said she was the wound care treatment nurse. She said she was notified of the blisters on 5/13/15 by CNA D. LVN A said, I didn't even know what it was at first. She said Resident #1 said she did not have any pain. She said Resident #1 told her that (RN B) gave her a hot cocoa and it burned her hands. The treatment nurse said at first they were just raised areas but then turned to blisters. The treatment nurse said she did not measure or describe the blisters during her weekly skin assessments or during her daily treatment of [REDACTED].#1 because she had no order to treat them (blisters). She said she guessed she should have documented them during the skin assessments. She said the orders for treatment were written by the wound care physician around 5/28/15. LVN A said she thought treatment began 2 days before Resident #1's appointment at the wound care clinic. The treatment nurse said she did not know Resident #1's blister had gotten infected she thought treatment was for preventive measures. LVN A said she never observed the blisters to be popped. When asked what the facility's process was when a resident refused care for a wound such as in this case, LVN A said, Click on a button, put the reason why, and sign it. When asked again, LVN A said she told Resident #1 on 5/13/15 that she was at risk of infection if she did not allow treatment, but she did not document anything because her refusal was in the incident report. 21. During an interview on 6/16/15 at 1:30 p.m. regarding the nurses notes written on 5/27/15 (see nurses notes documented above on 5/27/15 at 1:42 p.m.) LVN F said he was informed of Resident #1's blisters on her hands during report. LVN F said he went to assess Resident #1's hands and noticed a grayish purulent drainage to one blister on the left hand and a intact blister to the right hand (LVN F was unsure if the left or the right hand blister had the grayish purulent drainage). LVN F said he thought it was the physician's first time to see the blisters but he was not sure. LVN F said it was not the first time for him to hear about the blister. (LVN F documented in the Nurses Notes for Resident #1 on 5/14/15 at 10:35 a.m.-Medication follow-up-[MEDICATION NAME] 50 mg tablet(pain med)-2 tabs-medication effective. There was no documentation regarding Resident #1's blisters to her hands). LVN F said he had heard about the blister from another nurse but could not remember when. LVN F said Resident #1 had told him the blisters just naturally occurred and that the blister had occurred before. LVN F said he informed Resident #1 that the doctor had ordered an antibiotic due to her hands being infected. 22. During an interview on 6/15/15 at 2:05 p.m., the DON said that she was notified of Resident #1's blisters on 5/13/15 and she assessed the resident. She said the blisters were clear and fluid-filled. She said that LVN C had talked to the physician that day and told the physician that the resident refused any treatment to the blisters. When asked what the physician said to do, the DON said, He didn't say anything to do. She said that Resident #1 at first had told her she did not know how the blisters had occurred, then said that RN B had given her hot chocolate the day before in a plastic cup and that could have caused it. The DON said Resident #1 said she never felt pain while holding the cup of hot chocolate, but the resident said she just had very sensitive skin and that is why she was burned. The DON said she also believed that Resident #1 just had very thin skin and asked the surveyor if the surveyor had looked and observed how thin Resident #1's skin was. When discussing whether she had spoken with the resident's physician regarding [MEDICAL CONDITION] get his opinion about whether the issue was thin skin, she said she had not. The DON said that Resident #1 was served the hot drink in a plastic cup with an insulated cup inside of it. The DON stated, I'm assuming it was Styrofoam or something. The DON repeated several times that the resident had told her this had happened to her several times in the past and the resident had said she had healed up just fine. The DON said that the nurses offered to wrap them to pad the blisters but Resident #1 thought they would heal better left open to air. The DON said she told the resident that she could be at risk for infection. The DON said she did a 24-hour follow up and from then the staff were just monitoring. When discussing what she expected the staff to be doing if they were monitoring, such as how often, the DON said that usually it was every shift. When discussing whether the staff did monitor every shift, the DON said, It should have been, I'll have to look. The DON looked at her computer and then said, Well, there's monitoring every day. She then looked again and said there wasn't monitoring every day, but there was monitoring. When discussing that the record did not reflect any assessments of the blisters that included measurements or a physical description and who should have been doing that, the DON said that the computer program made it hard to do that. When discussing why she thought that Resident #1 was the one who identified that her wound had turned green in color and had an odor if the nurse's were monitoring the blisters, the DON said, I honestly can't tell you that. No one notified me they were opened. When discussing what actions she took to prevent future occurrences, the DON said she gave the resident an insulated mug to keep and she had an in-service with the staff. The DON provided an in-service dated 5/13/15. The full content documented on the in-service was, Please make sure hot liquids such as coffee, hot cocoa, hot tea, etc. are at the appropriate temperature. Never leave a cup of hot or warm liquids with a resident unattended who cannot drink or hold the cup without assistance. We must protect our residents from hot liquids. When discussing what she meant by appropriate temperature, she said, Well, like our water temperature. She then said that she guessed that was not applicable since staff could not be expected to carry thermometers and take temperatures of liquids. The in-service with staff did not address Resident #1's special needs due to decreased ability to feel pain or extreme temperatures (hot and cold.). The in-service did not address serving residents drinks in staff's personal cups or in cups/containers that were inappropriate for the contents. 23. During an interview on 6/17/15 at 9:50 a.m. CNA G said that she and CNA H were bathing Resident #1 and found the blisters and notified the nurse. CNA G said she just remembered that Resident #1 told her they gave her hot water in a plastic cup and she (CNA G) knew the resident was lying. 24. During an interview on 6/17/15 at 10:05 a.m., CNA I said that she was the one who first found Resident #1's blisters and she had gone to the DON to report them. CNA I said the DON told her that Resident #1 got those blisters all the time and Its' something she goes through. CNA I said she never knew Resident #1 was burned. She said the only instructions she received was not to bust the blisters. 25. During interviews on 6/16/15 at 2:15 p.m. and 6/17/15 at 9:10 a.m., the Administrator said she was out of town on vacation on 5/13/15 when the staff became aware that Resident #1 had been burned. The Administrator said she did not come back to work until 5/20/15 and when she saw Resident #1's hands, I was shocked. The Administrator said that Resident #1 had just gone on and on about this had happened to her before, Saying something about some kind of [DIAGNOSES REDACTED]. The Administrator said she thought it was a drink served in a cup inside a Styrofoam cup and the Styrofoam cup was a convenience store coffee cup, but she was not sure who had told her that. 26. During an interview on 6/17/15 at 10:40 a.m., the Social Worker said she was not notified or consulted regarding Resident #1's refusal to have her blisters covered and did not speak with the resident to ensure she was making an informed decision. The social worker said she did not even know the injury had occurred until Resident #1 had bandages. 27. During an interview on 6/17/15 at 4:18 p.m. with the resident's physician, when discussing whether Resident #1's physical condition contributed to her inability to feel the heat or pain while being [MEDICAL CONDITION] a hot cup, Resident #1's physician said, You've seen her, what do you think! Resident #1's physician said that since Resident #1 was an incomplete quadriplegic, it was very possible she did not feel pain while being burned. He said that he doubted she could feel hot or cold, either. He said he was notified of the blisters on her hands the day he wrote an order for [REDACTED].#1's physician was asked specifically if he gave any staff at the facility orders to just monitor Resident #1's blisters. The physician said that he did not. He repeated that the first order he gave was when he wrote orders for the wound cultures. 28. Review of physician's notes for Resident #1 revealed notes dated 5/3/15 and 5/27/15. There were no entries indicating service between the two dates. The physician's note dated 5/27/15 was the first physician's note documenting that the resident had blistered areas on the palms of her hands. 29. Review of the facility's policy for change of Condition dated effective 1/13/15 and revision date 3/04/15 documented, in part: Purpose: To ensure the highest level of care of our residents and to alleviate the need for a transfer out of the facility. 1. If a resident has a change of condition, the nurse aide should notify the cha

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessments and plan of care for 1 of 10 residents reviewed who received blood sugar monitoring. (Resident #4). The facility failed to: A. Administer insulin in the dosage prescribed by the physician for three days ([DATE], [DATE], and [DATE]). The nursing staff administered 10 units of insulin instead of 14 units which could prevent the blood sugar from being lowered for three days. B. Notify the physician timely of high blood sugars on [DATE] ("HI" which indicated over 600 mg/dl) and [DATE] (431 mg/dl). The physician orders stated he was to be notified for blood sugars over 401. The normal blood sugar is between 70 mg/dl and 120 mg/dl. C. Notify the physician of a critically low blood sugar of 30 mg/dl on [DATE] at 2:00 a.m. On [DATE] at 12:15 a.m. Resident #4 was found perspiring profusely and shaking, pale and clammy. Her blood sugar was 23 mg/dl. She became unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated and she was transported to the hospital where she expired at 2:05 a.m. This failure could place 20 insulin dependent residents at risk for delay in treatment, serious complications and/or death. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE] at 1:30 p.m. While the IJ was removed on [DATE] at 11:00 a.m., the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. These failures resulted in the physician not being involved in the management of critical medical conditions for Resident #4. The findings included: 1. Review of Resident #4's closed record Face Sheet dated [DATE] revealed a [AGE] year old who was readmitted to the facility on [DATE] with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #4 was discharged on [DATE] to the hospital where she passed away. Review of Resident #4's most recent Minimum Data Set ((MDS) dated [DATE] revealed that she could make herself understood and could understand others, had clear speech, was severely cognitively impaired, required extensive assistance of one person for transfers, dressing, and eating, extensive assistance of two persons for toileting and hygiene, used a walker and wheelchair for mobility, was totally dependent on staff for showers, was frequently incontinent of bowels and bladder, had pressure sores, and had [DIAGNOSES REDACTED]. Review of Resident #4's "Care Plan" dated [DATE] under the problem "Return to community deemed not feasible at this time...unable to care for self on own" revealed Resident receiving [MEDICATION NAME] and Humalog for diabetes. Resident #4's "Care Plan" did not address diabetic care, how to treat low and high blood sugars, blood sugar monitoring before meals and at bedtime, snacks, emergency care, or when to notify the physician and family. Review of Resident #4's physician orders dated [DATE] revealed the following orders: "[MEDICATION NAME] 100 units/ml, inject 10 units at bedtime, Accuchecks (a small amount of blood is taken from a finger and placed in a glucometer to get a blood sugar reading) before meals and at bedtime per sliding scale. Humalog ,[DATE]- 2 units ,[DATE]- 4 units ,[DATE] -6 units ,[DATE]- 8 units ,[DATE]- 10 units Over 401 Notify MD " "[MEDICATION NAME]® is a long-acting insulin used to treat adults with type 2 diabetes and adults and pediatric patients (children 6 years and older) with type 1 diabetes for the control of high blood sugar. " Source dated [DATE]: <http://www.[MEDICATION NAME].com/> "The most common side effect of insulin, including [MEDICATION NAME]®, is low blood sugar ([DIAGNOSES REDACTED]), which may be serious. Some people may experience symptoms such as shaking, sweating, fast heartbeat, and blurred vision. Severe [DIAGNOSES REDACTED] may be serious and life threatening. It may cause harm to your heart or brain." Source dated [DATE]: <http://www.[MEDICATION NAME].com/> "Humalog is a fast-acting insulin that begins to work very quickly. If you use this medication with meal, use it within 15 minutes before or just after you eat... Low blood sugar ([DIAGNOSES REDACTED]) can happen to everyone who has diabetes. Symptoms include headache, hunger, sweating, confusion, irritability, dizziness, or feeling shaky. If you have severe [DIAGNOSES REDACTED] and cannot eat or drink, use a [MEDICATION NAME] injection. Your doctor can prescribe a [MEDICATION NAME] emergency injection kit and tell you how to use it. Also watch for signs of high blood sugar ([MEDICAL CONDITION]) such as increased thirst, increased urination, hunger, dry mouth, fruity breath odor, drowsiness, dry skin, blurred vision, and weight loss. Check your blood sugar carefully during times of stress, travel, illness, surgery or medical emergency <http://www.drugs.com/humalog.html>, vigorous exercise, or if you drink alcohol or skip meals. These things can affect your glucose levels and your dose needs may also change. If your doctor changes your brand, strength, or type of insulin, your dosage needs may change. Do not change your medication dose or schedule without your doctor's advice." Source dated [DATE]: <http://www.drugs.com/humalog.html> Record review of Resident #4's physician orders dated [DATE] revealed, "Pneumonia [MEDICATION NAME] 20 mg. every day for 5 days, then 10 mg. every day for 5 days, then 5 mg. every day for 5 days. " [MEDICATION NAME] - "If you have diabetes, [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]) may increase your blood sugar level. If you monitor your blood sugar (glucose) at home, test your blood or urine more frequently than usual. Call your doctor if your blood sugar is high or if sugar is present in your urine; your dose of diabetes medication and your diet may need to be changed." Source dated [DATE]: <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 5.html> Record review of Resident #4's physician orders dated [DATE] at 0640 revealed, "[MEDICATION NAME] 14 u/ml every night at bedtime (new order)". Record review of Resident #4's "Insulin MAR" dated [DATE] revealed that Resident #4 received [MEDICATION NAME] 100 /ml, 10 units every night at bedtime (2000) as initialed by the nurse on the following dates: [DATE], [DATE], [DATE]. There was no stop or discontinuation date on the 10 units of [MEDICATION NAME]. The physician's order for [MEDICATION NAME] had changed to 14 units on [DATE]. In an interview on [DATE] at 11:00 a.m. the DON said that she had not been notified that Resident #4 had received the wrong dosage of insulin for three days ([DATE], [DATE], [DATE]). Upon reviewing Resident #4's physician order dated [DATE], she said that Resident #4's physician had written the new order himself for the increased dosage of [MEDICATION NAME]. She said that the nurse who signed off on the order no longer worked for the facility. She said that she would investigate. In an interview on [DATE] at 4:30 p.m. the DON said that she was unable to determine if the correct dose of insulin was given on [DATE] - [DATE] because she could find no other documentation other than the [MEDICATION NAME] was given incorrectly on those days. Record review of Resident #4's "Insulin MAR" dated December, 2014 revealed the following: "Accucheck before meals and at bedtime scheduled for 6:30a.m., 11:30a.m., 4:30p.m. and 8:00p.m. with sliding scale Humalog 100 u/ml .... The blood sugar results were as follows: "[DATE]- 11:30 a.m.-(this was blank indicating no insulin was given. The Nurse's Notes documented that the reading was " HI "). Record review of Resident #4's computer Nurse's Notes dated [DATE] at 4:08 p.m. by LVN K revealed, "Reported by 6am-2pm nurse LVN J that patient's CBG reading HI, Dr. on-call for Dr. was called and notified, new order received to give [MEDICATION NAME] 10 more units at 1500 if CBG readings still HI, rechecked at 1500, still reading HI, [MEDICATION NAME] administered as directed, however, resident alert oriented x2, water was offered, drink 240 cc, accucheck done at 16:30 per orders, CBG 350, ...also new order received to increase PM [MEDICATION NAME] to 20 units ..." Record review of the facility provided "Assure Platinum Meter" (glucometer used to test blood sugars) manufacturer's manual revealed, "High Blood Glucose Readings - If your blood glucose is above 600 mg/dl, you will receive a "HI". Repeat the test with a new test strip. If this message shows again, contact your healthcare professional. " Record review of Resident #4's computer "Medicare Notes" dated [DATE] at 10:30 a.m. by LVN J revealed no information regarding the scheduled 11:30 a.m. Accucheck reading of "HI". Record review of Resident #4's physician orders dated [DATE] at 2:00 p.m. revealed, "Order clarification, Increase [MEDICATION NAME] 100 u/ml Give 20 units subcutaneously every night at bedtime. May give [MEDICATION NAME] 10 units at 3:00 p.m. if blood sugar reading "HI"; time one dose." "[MEDICATION NAME] is a fast-acting form of insulin that works by lowering levels of glucose (sugar) in the blood." Source dated [DATE]: <http://www.drugs.com/[MEDICATION NAME].html> In an interview on [DATE] at 4:00 p.m. LVN K said on [DATE] at 2:00 p.m. she called and spoke with the on-call physician for Resident #4 to clarify the [MEDICATION NAME] order and to notify the physician of the "Hi" blood glucose reading that was reported to her by LVN J at the change of shift. Regarding clarification of the [MEDICATION NAME], LVN K said she notified the physician that Resident #4 had not received the physician ordered [MEDICATION NAME] 14 units for three days, instead had received only 10 units. LVN K said that she had given the wrong dose for three days. LVN K said in her defense that the Insulin MAR for the [MEDICATION NAME] 10 unit at bedtime had not been marked as changed and that the separate Insulin MAR indicated [REDACTED]. LVN K said that she had not notified the DON of the medication error. LVN K said that it was the responsibility of the DON/ADON to check all new orders. Regarding the notification of Resident #4's blood glucose reading of "HI", LVN K said that LVN J reported to her at change of shift (2:00 p.m.) that she had gotten a "HI" reading on the glucometer for Resident #4's scheduled 11:30 a.m. blood sugar test. LVN K said that LVN J had not notified Resident #4's physician of the blood sugar reading of "HI" because LVN J said that she had been very busy and not had time. LVN J had not given any insulin to Resident #4 between 11:30 a.m. and 2:00 p.m. according to the Insulin MAR. In a telephone interview on [DATE] at 2:05 p.m. LVN J said that Resident #4's blood sugars were not consistent, had very high blood sugars at times. LVN J said that she could not remember exactly what she did on [DATE] when Resident #4's 11:30 a.m. blood sugar registered "HI" on the glucometer. LVN J said that she had a lot of very heavy-care residents assigned to her and that often she was unable to complete both resident care and documentation. LVN J said that she knew that if she had not documented, then it was considered not done. Record review of Resident #4's "Insulin MAR" dated December, 2014 revealed the following: "Accucheck before meals and at bedtime scheduled for 6:30a.m., 11:30a.m., 4:30p.m. and 8:00p.m. with sliding scale Humalog 100 u/ml .... The blood sugar results were as follows: [DATE]- 11:30a.m. - 431 (10 units of [MEDICATION NAME] were given); " Record review of physician orders did not reveal an order to give Resident #4 10 units of Humalog for a blood sugar of 431 on [DATE]. The physician order for [REDACTED]. Record review of the computer Nurse's Notes did not reveal that the physician was notified or that an order was received to give Resident #4 10 units of insulin for a blood sugar of 431 at 11:30 a.m. on [DATE]. Review of Resident #4's computer "Medicare Notes" dated [DATE] at 1:59 p.m. signed by LVN J did not mention the 11:30 a.m. blood sugar of 431. In a telephone interview on [DATE] at 2:05 p.m. LVN J said that Resident #4's blood sugars were not consistent, had very high blood sugars at times. LVN J said that she could not remember exactly what she did on [DATE] when Resident #4 had a high blood sugar of 431 mg/dl at 11:30 a.m. LVN J said that she had a lot of very heavy-care residents assigned to her and that often she was unable to complete both resident care and documentation. LVN J said that she knew that if she had not documented, then it was considered not done. LVN J said that she could not remember but she was sure that she would not have given insulin without a physician order but could not recall what she had done. Record review of Resident #4's computer Nurse's Notes dated [DATE] at 8:13 a.m. revealed, "[DATE] 2:00 a.m. Found resident perspiring profusely and skin clammy, CBG (capillary blood glucose) 30 Resident given orange juice. Rechecked X 3 50, 63, 255. Signed by LVN E. In a telephone interview on [DATE] at 4:25 a.m. LVN E said that on [DATE] at 2:00 a.m. Resident #4 had a blood sugar of 30. LVN E said that she gave Resident #4 orange juice with sugar added and checked her blood sugar three times and that her blood sugar level increased. LVN E said that she had charted what she had done in the Nurse's Notes in the computer. LVN E said that she had not notified Resident #4's physician of the critically low blood sugar of 30. She said that she thought she had put the low blood sugar episode on the "___(Resident #4's physician's) Board" . In an interview on [DATE] at 4:30 a.m. LVN F said that the ___Board was a communication sheet that was completed for the physician and kept on a clip board. She said that the completed forms were removed by the physician and that the facility did not retain a copy. In an interview on [DATE] at 12:45 p.m. the DON provided the surveyor with "___Sheets". She said that the ___ Sheets are placed on a clip board and completed by nurses to be reviewed by the physician. The ___ Sheets have the following headings at the top of the page: Residents, Drainage Output, Last Known BM, Meal Intake %, Accu-Checks(CGBs), Vitals. Record review of the "___ Sheet " dated [DATE] provided by the facility and reviewed on [DATE] revealed the following regarding Resident #4: "Accu-checks (CBG's) - 74, 213, 300, 218" and written in at the bottom of the page was "hypoglycemic episode at 0200 orange juice/sugar given". The Accu-check (CBG ' s) blood sugars listed above are from the [DATE] Insulin MAR. Therefore he would not have seen the "___ Sheets" dated [DATE] until the morning of [DATE]. Record review of Resident #4's "Physician's Progress Notes" dated [DATE] revealed, "Glucose ,[DATE]. There was no mention of the critically low blood sugar at 2:00 a.m. that morning. In a telephone interview on [DATE] at 10:20 a.m. Resident #4's physician said that he could not confirm or deny whether the facility notified him regarding the critically low blood sugar episode that occurred at 2:00 a.m. on [DATE]. He said that he probably would have decreased Resident #4's insulin based on a blood sugar that low. He said that he would rather have a high blood sugar than a low blood sugar. He said that the facility does communicate with him by documenting on the "____Board" but he did not read or want access to the computer nurse's notes so would not have seen LVN E ' s documentation regarding Resident #4's critically low blood sugar episode at 2:00 a.m. on [DATE]. Record review of Resident #4's "Daily Skilled Nurse's Notes" dated [DATE] (should be [DATE] because Resident #4 was not in the facility on [DATE]) revealed, "12:15 a.m. CNA reports this resident is perspiring profusely and she is jerking uncontrollably. Resident is pale and clammy. Obtained a blood sugar reading of 23. Attempted to give resident chocolate milk and sugar. Resident became unresponsive and 911 called. CPR (cardio-pulmonary resuscitation) initiated by two nurses and two CNAs. 911 took over with CPR when they arrived. Report called to hospital. Also called resident's son at 12:05 a.m. Spoke with Dr. at 12:00. Informed him of resident's condition. Received order to transfer resident to emergency department for evaluation. Also received call from hospital and nurse states resident has been intubated (tube placed in the resident airway to help them breath)..." Record review Resident #4's "Midland Fire Department Patient Care Record" dated [DATE] at 00:15 revealed, "[MEDICAL CONDITION], unresponsive, unconscious, BG(blood glucose)-23 at 00:15 and 67 at 00:22, [MEDICATION NAME] 50% 25 grams given intravenous ... Further review revealed, " Called to facility for diabetic complications. Arrived on scene to find a [AGE] year old female unconscious unresponsive with agonal respirations at about 20 and CPR in progress. Assessed for pulse palpated at a regular rate. Staff stated patient ' s BSL( blood sugar level) is 23. Moved patient to cot and assisted respirations. Patient loaded into ambulance and placed on monitor. Monitor showed PEA (pulseless electrical activity) no pulse palpable, CPR resumed. IV established in left forearm, D50 given and BGL (blood sugar level) taken and showed 67 with half D50 administered. Transported to ER... Reassessed patient still in PEA ...Arrived at ER with patient still in PEA ..." Record review of Resident #4's local hospital emergency department's records dated [DATE] revealed she was admitted on [DATE] at 12:36 a.m. and discharged on [DATE] at 02:05 a.m. The Disposition was "Expired: Resuscitation efforts were attempted and the patient was pronounced dead at 2:05 a.m." In an interview on [DATE] at 8:45 a.m. the Administrator said that anytime there was a change in condition the staff should contact the physician and the family. She said that Resident #4's physician visited the facility most every morning. She said that the nurse should have notified Resident #4's physician regarding the critically low blood sugar on [DATE] at 2:00 a.m. She said that she would have expected the nurse to also notify her. She said that according to the ADON, the critically low blood sugar was not documented on the 24 hour report or "___Sheets". She said that the facility kept the " __ Sheets". In an interview on [DATE] at 9:15 a.m. the DON said that LVN E failed to notify Resident #4's physician regarding the critically low blood sugar of 30 on [DATE] at 2:00 a.m. She also said that Resident #4 had just completed her physician ordered [MEDICATION NAME] and that the [MEDICATION NAME] increased blood sugars. She said that she was notified on [DATE] that Resident #4 had a critically low blood sugar, had a [MEDICAL CONDITION], and was sent to the ER. She said that she was not notified that Resident #4 had a critically low blood sugar on [DATE] at 2:00 a.m. She said that she had previously disciplined LVN E because she had not notified the physician of another resident who had a change in condition. Record review of Resident #4's MAR indicated [REDACTED]. Record review of the facility provided "Protocol of Care for Diabetic [DIAGNOSES REDACTED] (low blood sugar)", undated, revealed the following: "Purpose: To provide emergency care and treatment of [REDACTED]. The diabetic resident can experience the signs and symptoms of [DIAGNOSES REDACTED] when the blood sugar is less than 60. The signs and symptoms of [DIAGNOSES REDACTED] include headache, dizziness, weakness, agitation, numbness and tingling in the digits, nausea, vomiting, disorderly thinking and loss of consciousness. When the diabetic resident ' s blood sugar is below 50, the resident may experience somulence (sic)(somnolence) and be very difficult to arouse. When the blood sugar is around 40 or less, the resident could experience some type of [MEDICAL CONDITION] activity. The resident whose blood sugar is around or below 30 may become comatose. Blood sugars less than 30 may not be compatible with life. Protocol for Conscious Resident: 1. If the resident ' s blood sugar is less than 60 and he/she is conscious, give the resident ,[DATE] cc of fruit juice with 2 teaspoons of sugar following by a complex carbohydrate source, e.g. 6 vanilla wafers, ,[DATE] graham crackers, 1 slice bread/toast with peanut butter, etc. 2. Recheck the blood sugar in ,[DATE] minutes. (The sugar and fruit juice will be absorbed and should be impacting the blood sugar within ,[DATE] minutes of administration.) 3. If the blood sugar continues to be below 60, repeat the steps ,[DATE] of the procedure. If after repeating the procedure, the resident continues to have a blood sugar less than 60, activate EMS (emergency medical system). 4. Once the resident is stable or EMS has been activated, notify his/her physician and family of the change in condition as soon as possible after stabilizing the resident. (The physician may be contacted at any time during the procedure if time allows and resident is not in immediate jeopardy.) Protocol for Unconscious/Unresponsive Resident: 1. If the resident ' s blood sugar is less than 60 and he/she is unconscious or unresponsive, administer 1 vial/1mg [MEDICATION NAME] IM from the E-Kit. 2. When the resident is alert enough to safely swallow give the resident a complex carbohydrate source, e.g. ,[DATE] vanilla wafers, ,[DATE] graham crackers, 1 slice bread/toast with peanut butter. 3. If the blood sugar continues to be too low (less than 60), activate the EMS. 4. Once the resident is stable or EMS has been activated, notify his/her physician and family of the change of condition as soon as possible after stabilizing the resident. (The physician may be contacted at any time during the procedure if time allows and resident is not in immediate jeopardy.) 5. Thoroughly document the sequence of events into the resident's clinical record. " In an interview on [DATE] at 9:15 a.m. the DON said that the following "Protocol of Care for Diabetic [DIAGNOSES REDACTED] (low blood sugar)" was updated on [DATE]. She said the only change that was made was the addition of " or 1 tube of glucose gel" under the Protocol for the Conscious Resident. Record review of the facility provided protocol for " [MEDICAL CONDITION] (high blood sugar)" undated revealed, "If CBG (capillary blood glucose) is over 400 ... Call the Doctor..." Record review of " Notification of MD when CBGs are out of Parameters " updated [DATE] per DON revealed: "All residents who have orders for accuchecks must have parameters for MD notification. If the CBG is out of range the MD assigned to that resident must be notified. Nursing Practice must be followed for either [DIAGNOSES REDACTED] or [MEDICAL CONDITION] episode. This must also be documented. " Record review of the facility provided policy "Medication Administration" dated ,[DATE] revealed the following: "Medications are administered as prescribed in accordance with manufacturers ' specifications, good nursing principles and practices ... Medication Preparation:.. 3. Prior to administration, the medication and dosage schedule on the resident's MAR indicated [REDACTED]. Apply a "direction change" sticker to label if directions have changed from the current label." Record review of the facility provided policy, " Insulin Administration " dated April, 2007 revealed the following: "...Steps in the Procedure (Insulin Injections via Syringe) ... 8. Check the order for the amount of insulin ... 15. Verify the order and dose to be administered with another licensed nurse; both nurses should then document the administration. Documentation 1. The resident ' s blood glucose result; 2. The dose and concentration of the insulin injection; Reporting 1. Notify your supervisor if the resident refuses the insulin injection. 2. Notify the physician if the resident has signs and symptoms of [DIAGNOSES REDACTED] that are not resolved by following the facility protocol for [DIAGNOSES REDACTED] management ..." The Administrator was informed of the Immediate Jeopardy on [DATE] at 1:30 p.m. Record review of the 2nd draft of the Plan of Removal was accepted on [DATE] at 1100 a.m.: "Please accept this as our plan of abatement to deficiencies leading to citation of Immediate Jeopardy on [DATE]. The following corrections have been completed. 1. The resident identified in this alleged deficient practice is no longer a resident of this facility; therefore, no resident specific action will occur. 2. All resident have the potential to be affected by this alleged deficient practice. 3. The following measures were put into place to ensure the alleged deficiency will not recur. · DON/Designee have identified 28 resident ' s whom reside in this facility and require Accucheck. · DON/Designee have identified 35 resident ' s whom reside in this facility and have physician documented [DIAGNOSES REDACTED]. · All residents with a [DIAGNOSES REDACTED]. · All diet orders have been audited by the DON/Designee on [DATE] · All diabetic snacks have been implemented TID for all diabetic residents. Charge Nurses will be responsible to ensure all identified diabetic residents will be offered snacks three times a day. DON/Designee will make daily random checks to ensure diabetic snacks are being offered. · All Accucheck orders were audited to ensure parameters were in place for MD notification by DON/Designee on [DATE]. This will be monitored and updated weekly in the Standards of Care Meeting and as needed with telephone order changes/admits/readmits by DON/Designee. · A list of diabetic residents and diabetic snack orders were given to the dietary manager to provide diabetic snacks on [DATE]. This will be monitored and updated weekly in the Standards of Care Meeting and as needed with telephone order changes/admits/readmits as well as with registered dietician visits and by the DON/Designee. · DON/Designee audited and updated resident ' s AccuNurse plan of care on [DATE] to ensure CNA ' s were providing/offering diabetic snacks TID per MD orders. This will be monitored Q shift by Charge Nurse and randomly by DON/Designee. · DON/Designee audited all insulin vial ' s to ensure they were correct and in stock on [DATE]. Charge Nurses will be responsible to ensure that correct insulin vials are on cart and in stock. DON/Designee will randomly audit carts to ensure accuracy. · See in-service list below for all licensed staff in-servicing on facility protocols of hypoglycemic care. · A list of diabetic resident was placed on each station in shower book to ensure all staff is aware of diabetic status and care can be monitored. This will be monitored and updated weekly in the Standards of Care Meeting and as needed with telephone order changes/admits/readmits. · An updated Hypoglycemic Protocol of Care was placed in front of each MAR indicated [REDACTED]. · DON/Designee ensured all glucometers were calibrated on [DATE]. · All licensed nurses had in-service training added on Relias Website for [DATE] by the Administrator. · DON/Designee completed lab audit on [DATE] to ensure all diabetic resident have HgA1c ' s ordered by the MD. DON/Designee will monitor chart audit on admission/readmission & randomly as needed with telephone order changes. DON/Designee will continue to fax monthly lab orders to Precision lab to ensure labs correspond with facility lab orders. · DON/Designee added glucose gel to all nurse ' carts on [DATE]. Glucose gel will be monitored by controlled sign out sheet by charge nurse. Charge nurse is responsible for recording glucose gel from the pharmacy. DON/Designee will randomly monitor to ensure glucose gel is available on each cart. · DON/Designee will randomly audit glucometer logs for each nurses ' station. · Daily audits of Accucheck logs will be turned and monitored daily by the DON/Designee RN weekend supervisor will monitor on weekend shifts. · DON/Designee placed second glucometer to each nurse ' s cart on [DATE] for infection control purposes. · DON/Designee will review all insulin orders/changes every day to ensure follow up is accurate. · DON/Designee will ensure all licensed nursing staff will be in-serviced prior to working the floor. · Nurse was suspended on [DATE] following investigation and never returned to work · If recurrent problems occur on any of the above listed items further individualized teaching/in-servicing will occur immediately and will be reviewed by Quality Assurance Committee. In-services Completed: · Diabetic [DIAGNOSES REDACTED] on [DATE] by ADON. · 1 on 1 in-services/[DIAGNOSES REDACTED] protocol of care on [DATE] by DON for LVN ___. · 1 on 1 in-services/[DIAGNOSES REDACTED] protocol of care on [DATE] by DON for LVN ____ Notification of MD when CBGs are out of parameters on [DATE] by DON. · Insulin Administration on [DATE]. · Daily Accucheck log on [DATE]. · Insulin Administration by [MEDICATION NAME] on [DATE] by DON. · Change of Condition Policy on [DATE]. · Change of Condition with Transfer to Hospital on [DATE] by DON. · Identifying in house abuse coordinator on [DATE]. · Offering HS snacks on [DATE] by DON. · Abuse and Neglect Policy on [DATE] by DON. · [MEDICAL CONDITION] Process on [DATE] by DON. · SBAR Documentation on [DATE] by DON. · 24 Hour Report logging of Change of Condition on [DATE] by DON. · Blood Glucose Monitoring System on [DATE] by DON. · Glucometer set up, testing, memory, maintenance and troubleshooting on [DATE] by DON/Designee with follow up post test completed by licensed staff. · Updated Protocol of Care for [DIAGNOSES REDACTED] [DATE] by DON. · Reporting Abuse on [DATE] by Administrator. · Relias Training for [DATE] included: About diabetes, diabetes/what you need to know, Med/diabetes and controlling resident blood glucose. · Relias Course details are as follows: 1. About diabetes: Nurses working with the geriatric population will encounter diabetes frequently. This course covers the basics of the disease and the current medical treatment. The course helps the student be better able to assess the needs of and provide care for diabetic residents as well as problem-solve common medication concerns. 2. MED-Diabetes and Controlling Resident Blood Glucose: Controlling resident blood glucose levels is one of the more challenging responsibilities in healthcare. The current recommended strategies for diabetes management are either oral medications or long acting insulin. Although sliding scale insulin use declining, it is still common in senior care settings. This course will help the student develop essential skills for accurate sliding scale administration and documentation. This course corresponds to the Federal regulations F309, F332, & F333. 3. Diabetes-What you need to know: Diabetes is not an uncommon condition in senior care communities. In fact 40% of people with diabetes are over the age of 65. About half of people age 65 or older with diabetes are hospitalized each year. As a caregiver in a senior care community, you are responsible for providing the care and treatment to your resident with diabetes. It is important for you to know what diabetes is, how it affects residents, and the care you provide." Interviews with 7 LVN's on [DATE] who worked all three shifts revealed they had participated in the in-services that the DON/Administrator had offered regarding the care of residents with diabetes. They all had taken the Relias Computer Training related to the care o

Based on interview and record review, the facility failed to consult the physician of the potential need to alter treatment for one (Resident #4) of 10 residents reviewed who received blood sugar monitoring. The facility failed to: A. Administer insulin in the dosage prescribed by the physician for three days ([DATE], [DATE], and [DATE]). The nursing staff administered 10 units of insulin instead of 14 units which could prevent the blood sugar from being lowered for three days. B. Notify the physician timely of high blood sugars on [DATE] ("HI" which indicated over 600 mg/dl) and [DATE] (431 mg/dl). The physician orders stated he was to be notified for blood sugars over 401. The normal blood sugar is between 70 mg/dl and 120 mg/dl. C. Notify the physician of a critically low blood sugar of 30 mg/dl on [DATE] at 2:00 a.m. On [DATE] at 12:15 a.m. Resident #4 was found perspiring profusely and shaking, pale and clammy. Her blood sugar was 23 mg/dl. She became unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated and she was transported to the hospital where she expired at 2:05 a.m. This failure could place 20 insulin dependent residents at risk for delay in treatment, serious complications and/or death. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE] at 1:30 p.m. While the IJ was removed on [DATE] at 11:00 a.m., the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility continued to monitor the effectiveness of the Plan of Removal. These failures resulted in the physician not being involved in the management of critical medical conditions for Resident #4. The findings included: 1. Review of Resident #4's closed record Face Sheet dated [DATE] revealed a [AGE] year old who was readmitted to the facility on [DATE] with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #4 was discharged on [DATE] to the hospital where she passed away. Review of Resident #4's most recent Minimum Data Set ((MDS) dated [DATE] revealed that she could make herself understood and could understand others, had clear speech, was severely cognitively impaired, required extensive assistance of one person for transfers, dressing, and eating, extensive assistance of two persons for toileting and hygiene, used a walker and wheelchair for mobility, was totally dependent on staff for showers, was frequently incontinent of bowels and bladder, had pressure sores, and had [DIAGNOSES REDACTED]. Review of Resident #4's "Care Plan" dated [DATE] under the problem "Return to community deemed not feasible at this time...unable to care for self on own" revealed Resident receiving [MEDICATION NAME] and Humalog for diabetes. Resident #4's "Care Plan" did not address diabetic care, how to treat low and high blood sugars, blood sugar monitoring before meals and at bedtime, snacks, emergency care, or when to notify the physician and family. Review of Resident #4's physician orders dated [DATE] revealed the following orders: "[MEDICATION NAME] 100 units/ml, inject 10 units at bedtime, Accuchecks (a small amount of blood is taken from a finger and placed in a glucometer to get a blood sugar reading) before meals and at bedtime per sliding scale. Humalog ,[DATE]- 2 units ,[DATE]- 4 units ,[DATE] -6 units ,[DATE]- 8 units ,[DATE]- 10 units Over 401 Notify MD " "[MEDICATION NAME]® is a long-acting insulin used to treat adults with type 2 diabetes and adults and pediatric patients (children 6 years and older) with type 1 diabetes for the control of high blood sugar. " Source dated [DATE]: <http://www.[MEDICATION NAME].com/> "The most common side effect of insulin, including [MEDICATION NAME]®, is low blood sugar ([DIAGNOSES REDACTED]), which may be serious. Some people may experience symptoms such as shaking, sweating, fast heartbeat, and blurred vision. Severe [DIAGNOSES REDACTED] may be serious and life threatening. It may cause harm to your heart or brain." Source dated [DATE]: <http://www.[MEDICATION NAME].com/> "Humalog is a fast-acting insulin that begins to work very quickly. If you use this medication with meal, use it within 15 minutes before or just after you eat... Low blood sugar ([DIAGNOSES REDACTED]) can happen to everyone who has diabetes. Symptoms include headache, hunger, sweating, confusion, irritability, dizziness, or feeling shaky. If you have severe [DIAGNOSES REDACTED] and cannot eat or drink, use a [MEDICATION NAME] injection. Your doctor can prescribe a [MEDICATION NAME] emergency injection kit and tell you how to use it. Also watch for signs of high blood sugar ([MEDICAL CONDITION]) such as increased thirst, increased urination, hunger, dry mouth, fruity breath odor, drowsiness, dry skin, blurred vision, and weight loss. Check your blood sugar carefully during times of stress, travel, illness, surgery or medical emergency <http://www.drugs.com/humalog.html>, vigorous exercise, or if you drink alcohol or skip meals. These things can affect your glucose levels and your dose needs may also change. If your doctor changes your brand, strength, or type of insulin, your dosage needs may change. Do not change your medication dose or schedule without your doctor's advice." Source dated [DATE]: <http://www.drugs.com/humalog.html> Record review of Resident #4's physician orders dated [DATE] revealed, "Pneumonia [MEDICATION NAME] 20 mg. every day for 5 days, then 10 mg. every day for 5 days, then 5 mg. every day for 5 days. " [MEDICATION NAME] - "If you have diabetes, [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]) may increase your blood sugar level. If you monitor your blood sugar (glucose) at home, test your blood or urine more frequently than usual. Call your doctor if your blood sugar is high or if sugar is present in your urine; your dose of diabetes medication and your diet may need to be changed." Source dated [DATE]: <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 5.html> Record review of Resident #4's physician orders dated [DATE] at 0640 revealed, "[MEDICATION NAME] 14 u/ml every night at bedtime (new order)". Record review of Resident #4's "Insulin MAR" dated [DATE] revealed that Resident #4 received [MEDICATION NAME] 100 /ml, 10 units every night at bedtime (2000) as initialed by the nurse on the following dates: [DATE], [DATE], [DATE]. There was no stop or discontinuation date on the 10 units of [MEDICATION NAME]. The physician's order for [MEDICATION NAME] had changed to 14 units on [DATE]. In an interview on [DATE] at 11:00 a.m. the DON said that she had not been notified that Resident #4 had received the wrong dosage of insulin for three days ([DATE], [DATE], [DATE]). Upon reviewing Resident #4's physician order dated [DATE], she said that Resident #4's physician had written the new order himself for the increased dosage of [MEDICATION NAME]. She said that the nurse who signed off on the order no longer worked for the facility. She said that she would investigate. In an interview on [DATE] at 4:30 p.m. the DON said that she was unable to determine if the correct dose of insulin was given on [DATE] - [DATE] because she could find no other documentation other than the [MEDICATION NAME] was given incorrectly on those days. Record review of Resident #4's "Insulin MAR" dated December, 2014 revealed the following: "Accucheck before meals and at bedtime scheduled for 6:30a.m., 11:30a.m., 4:30p.m. and 8:00p.m. with sliding scale Humalog 100 u/ml .... The blood sugar results were as follows: "[DATE]- 11:30 a.m.-(this was blank indicating no insulin was given. The Nurse's Notes documented that the reading was " HI "). Record review of Resident #4's computer Nurse's Notes dated [DATE] at 4:08 p.m. by LVN K revealed, "Reported by 6am-2pm nurse LVN J that patient's CBG reading HI, Dr. on-call for Dr. was called and notified, new order received to give [MEDICATION NAME] 10 more units at 1500 if CBG readings still HI, rechecked at 1500, still reading HI, [MEDICATION NAME] administered as directed, however, resident alert oriented x2, water was offered, drink 240 cc, accucheck done at 16:30 per orders, CBG 350, ...also new order received to increase PM [MEDICATION NAME] to 20 units ..." Record review of the facility provided "Assure Platinum Meter" (glucometer used to test blood sugars) manufacturer's manual revealed, "High Blood Glucose Readings - If your blood glucose is above 600 mg/dl, you will receive a "HI". Repeat the test with a new test strip. If this message shows again, contact your healthcare professional. " Record review of Resident #4's computer "Medicare Notes" dated [DATE] at 10:30 a.m. by LVN J revealed no information regarding the scheduled 11:30 a.m. Accucheck reading of "HI". Record review of Resident #4's physician orders dated [DATE] at 2:00 p.m. revealed, "Order clarification, Increase [MEDICATION NAME] 100 u/ml Give 20 units subcutaneously every night at bedtime. May give [MEDICATION NAME] 10 units at 3:00 p.m. if blood sugar reading "HI"; time one dose." "[MEDICATION NAME] is a fast-acting form of insulin that works by lowering levels of glucose (sugar) in the blood." Source dated [DATE]: <http://www.drugs.com/[MEDICATION NAME].html> In an interview on [DATE] at 4:00 p.m. LVN K said on [DATE] at 2:00 p.m. she called and spoke with the on-call physician for Resident #4 to clarify the [MEDICATION NAME] order and to notify the physician of the "Hi" blood glucose reading that was reported to her by LVN J at the change of shift. Regarding clarification of the [MEDICATION NAME], LVN K said she notified the physician that Resident #4 had not received the physician ordered [MEDICATION NAME] 14 units for three days, instead had received only 10 units. LVN K said that she had given the wrong dose for three days. LVN K said in her defense that the Insulin MAR for the [MEDICATION NAME] 10 unit at bedtime had not been marked as changed and that the separate Insulin MAR indicated [REDACTED]. LVN K said that she had not notified the DON of the medication error. LVN K said that it was the responsibility of the DON/ADON to check all new orders. Regarding the notification of Resident #4's blood glucose reading of "HI", LVN K said that LVN J reported to her at change of shift (2:00 p.m.) that she had gotten a "HI" reading on the glucometer for Resident #4's scheduled 11:30 a.m. blood sugar test. LVN K said that LVN J had not notified Resident #4's physician of the blood sugar reading of "HI" because LVN J said that she had been very busy and not had time. LVN J had not given any insulin to Resident #4 between 11:30 a.m. and 2:00 p.m. according to the Insulin MAR. In a telephone interview on [DATE] at 2:05 p.m. LVN J said that Resident #4's blood sugars were not consistent, had very high blood sugars at times. LVN J said that she could not remember exactly what she did on [DATE] when Resident #4's 11:30 a.m. blood sugar registered "HI" on the glucometer. LVN J said that she had a lot of very heavy-care residents assigned to her and that often she was unable to complete both resident care and documentation. LVN J said that she knew that if she had not documented, then it was considered not done. Record review of Resident #4's "Insulin MAR" dated December, 2014 revealed the following: "Accucheck before meals and at bedtime scheduled for 6:30a.m., 11:30a.m., 4:30p.m. and 8:00p.m. with sliding scale Humalog 100 u/ml .... The blood sugar results were as follows: [DATE]- 11:30a.m. - 431 (10 units of [MEDICATION NAME] were given); " Record review of physician orders did not reveal an order to give Resident #4 10 units of Humalog for a blood sugar of 431 on [DATE]. The physician order for [REDACTED]. Record review of the computer Nurse's Notes did not reveal that the physician was notified or that an order was received to give Resident #4 10 units of insulin for a blood sugar of 431 at 11:30 a.m. on [DATE]. Review of Resident #4's computer "Medicare Notes" dated [DATE] at 1:59 p.m. signed by LVN J did not mention the 11:30 a.m. blood sugar of 431. In a telephone interview on [DATE] at 2:05 p.m. LVN J said that Resident #4's blood sugars were not consistent, had very high blood sugars at times. LVN J said that she could not remember exactly what she did on [DATE] when Resident #4 had a high blood sugar of 431 mg/dl at 11:30 a.m. LVN J said that she had a lot of very heavy-care residents assigned to her and that often she was unable to complete both resident care and documentation. LVN J said that she knew that if she had not documented, then it was considered not done. LVN J said that she could not remember but she was sure that she would not have given insulin without a physician order but could not recall what she had done. Record review of Resident #4's computer Nurse's Notes dated [DATE] at 8:13 a.m. revealed, "[DATE] 2:00 a.m. Found resident perspiring profusely and skin clammy, CBG (capillary blood glucose) 30 Resident given orange juice. Rechecked X 3 50, 63, 255. Signed by LVN E. In a telephone interview on [DATE] at 4:25 a.m. LVN E said that on [DATE] at 2:00 a.m. Resident #4 had a blood sugar of 30. LVN E said that she gave Resident #4 orange juice with sugar added and checked her blood sugar three times and that her blood sugar level increased. LVN E said that she had charted what she had done in the Nurse's Notes in the computer. LVN E said that she had not notified Resident #4's physician of the critically low blood sugar of 30. She said that she thought she had put the low blood sugar episode on the "___(Resident #4's physician's) Board" . In an interview on [DATE] at 4:30 a.m. LVN F said that the ___Board was a communication sheet that was completed for the physician and kept on a clip board. She said that the completed forms were removed by the physician and that the facility did not retain a copy. In an interview on [DATE] at 12:45 p.m. the DON provided the surveyor with "___Sheets". She said that the ___ Sheets are placed on a clip board and completed by nurses to be reviewed by the physician. The ___ Sheets have the following headings at the top of the page: Residents, Drainage Output, Last Known BM, Meal Intake %, Accu-Checks(CGBs), Vitals. Record review of the "___ Sheet " dated [DATE] provided by the facility and reviewed on [DATE] revealed the following regarding Resident #4: "Accu-checks (CBG's) - 74, 213, 300, 218" and written in at the bottom of the page was "hypoglycemic episode at 0200 orange juice/sugar given". The Accu-check (CBG ' s) blood sugars listed above are from the [DATE] Insulin MAR. Therefore he would not have seen the "___ Sheets" dated [DATE] until the morning of [DATE]. Record review of Resident #4's "Physician's Progress Notes" dated [DATE] revealed, "Glucose ,[DATE]. There was no mention of the critically low blood sugar at 2:00 a.m. that morning. In a telephone interview on [DATE] at 10:20 a.m. Resident #4's physician said that he could not confirm or deny whether the facility notified him regarding the critically low blood sugar episode that occurred at 2:00 a.m. on [DATE]. He said that he probably would have decreased Resident #4's insulin based on a blood sugar that low. He said that he would rather have a high blood sugar than a low blood sugar. He said that the facility does communicate with him by documenting on the "____Board" but he did not read or want access to the computer nurse's notes so would not have seen LVN E ' s documentation regarding Resident #4's critically low blood sugar episode at 2:00 a.m. on [DATE]. Record review of Resident #4's "Daily Skilled Nurse's Notes" dated [DATE] (should be [DATE] because Resident #4 was not in the facility on [DATE]) revealed, "12:15 a.m. CNA reports this resident is perspiring profusely and she is jerking uncontrollably. Resident is pale and clammy. Obtained a blood sugar reading of 23. Attempted to give resident chocolate milk and sugar. Resident became unresponsive and 911 called. CPR (cardio-pulmonary resuscitation) initiated by two nurses and two CNAs. 911 took over with CPR when they arrived. Report called to hospital. Also called resident's son at 12:05 a.m. Spoke with Dr. at 12:00. Informed him of resident's condition. Received order to transfer resident to emergency department for evaluation. Also received call from hospital and nurse states resident has been intubated (tube placed in the resident airway to help them breath)..." Record review Resident #4's "Midland Fire Department Patient Care Record" dated [DATE] at 00:15 revealed, "[MEDICAL CONDITION], unresponsive, unconscious, BG(blood glucose)-23 at 00:15 and 67 at 00:22, [MEDICATION NAME] 50% 25 grams given intravenous ... Further review revealed, " Called to facility for diabetic complications. Arrived on scene to find a [AGE] year old female unconscious unresponsive with agonal respirations at about 20 and CPR in progress. Assessed for pulse palpated at a regular rate. Staff stated patient ' s BSL( blood sugar level) is 23. Moved patient to cot and assisted respirations. Patient loaded into ambulance and placed on monitor. Monitor showed PEA (pulseless electrical activity) no pulse palpable, CPR resumed. IV established in left forearm, D50 given and BGL (blood sugar level) taken and showed 67 with half D50 administered. Transported to ER... Reassessed patient still in PEA ...Arrived at ER with patient still in PEA ..." Record review of Resident #4's local hospital emergency department's records dated [DATE] revealed she was admitted on [DATE] at 12:36 a.m. and discharged on [DATE] at 02:05 a.m. The Disposition was "Expired: Resuscitation efforts were attempted and the patient was pronounced dead at 2:05 a.m." In an interview on [DATE] at 8:45 a.m. the Administrator said that anytime there was a change in condition the staff should contact the physician and the family. She said that Resident #4's physician visited the facility most every morning. She said that the nurse should have notified Resident #4's physician regarding the critically low blood sugar on [DATE] at 2:00 a.m. She said that she would have expected the nurse to also notify her. She said that according to the ADON, the critically low blood sugar was not documented on the 24 hour report or "___Sheets". She said that the facility kept the " __ Sheets". In an interview on [DATE] at 9:15 a.m. the DON said that LVN E failed to notify Resident #4's physician regarding the critically low blood sugar of 30 on [DATE] at 2:00 a.m. She also said that Resident #4 had just completed her physician ordered [MEDICATION NAME] and that the [MEDICATION NAME] increased blood sugars. She said that she was notified on [DATE] that Resident #4 had a critically low blood sugar, had a [MEDICAL CONDITION], and was sent to the ER. She said that she was not notified that Resident #4 had a critically low blood sugar on [DATE] at 2:00 a.m. She said that she had previously disciplined LVN E because she had not notified the physician of another resident who had a change in condition. Record review of Resident #4's MAR indicated [REDACTED]. Record review of the facility provided "Protocol of Care for Diabetic [DIAGNOSES REDACTED] (low blood sugar)", undated, revealed the following: "Purpose: To provide emergency care and treatment of the diabetic resident in the event of a hypoglycemic (blood sugar below 60) episode. The diabetic resident can experience the signs and symptoms of [DIAGNOSES REDACTED] when the blood sugar is less than 60. The signs and symptoms of [DIAGNOSES REDACTED] include headache, dizziness, weakness, agitation, numbness and tingling in the digits, nausea, vomiting, disorderly thinking and loss of consciousness. When the diabetic resident ' s blood sugar is below 50, the resident may experience somulence (sic)(somnolence) and be very difficult to arouse. When the blood sugar is around 40 or less, the resident could experience some type of [MEDICAL CONDITION] activity. The resident whose blood sugar is around or below 30 may become comatose. Blood sugars less than 30 may not be compatible with life. Protocol for Conscious Resident: 1. If the resident ' s blood sugar is less than 60 and he/she is conscious, give the resident ,[DATE] cc of fruit juice with 2 teaspoons of sugar following by a complex carbohydrate source, e.g. 6 vanilla wafers, ,[DATE] graham crackers, 1 slice bread/toast with peanut butter, etc. 2. Recheck the blood sugar in ,[DATE] minutes. (The sugar and fruit juice will be absorbed and should be impacting the blood sugar within ,[DATE] minutes of administration.) 3. If the blood sugar continues to be below 60, repeat the steps ,[DATE] of the procedure. If after repeating the procedure, the resident continues to have a blood sugar less than 60, activate EMS (emergency medical system). 4. Once the resident is stable or EMS has been activated, notify his/her physician and family of the change in condition as soon as possible after stabilizing the resident. (The physician may be contacted at any time during the procedure if time allows and resident is not in immediate jeopardy.) Protocol for Unconscious/Unresponsive Resident: 1. If the resident ' s blood sugar is less than 60 and he/she is unconscious or unresponsive, administer 1 vial/1mg [MEDICATION NAME] IM from the E-Kit. 2. When the resident is alert enough to safely swallow give the resident a complex carbohydrate source, e.g. ,[DATE] vanilla wafers, ,[DATE] graham crackers, 1 slice bread/toast with peanut butter. 3. If the blood sugar continues to be too low (less than 60), activate the EMS. 4. Once the resident is stable or EMS has been activated, notify his/her physician and family of the change of condition as soon as possible after stabilizing the resident. (The physician may be contacted at any time during the procedure if time allows and resident is not in immediate jeopardy.) 5. Thoroughly document the sequence of events into the resident's clinical record. " In an interview on [DATE] at 9:15 a.m. the DON said that the following "Protocol of Care for Diabetic [DIAGNOSES REDACTED] (low blood sugar)" was updated on [DATE]. She said the only change that was made was the addition of " or 1 tube of glucose gel" under the Protocol for the Conscious Resident. Record review of the facility provided protocol for " [MEDICAL CONDITION] (high blood sugar)" undated revealed, "If CBG (capillary blood glucose) is over 400 ... Call the Doctor..." Record review of " Notification of MD when CBGs are out of Parameters " updated [DATE] per DON revealed: "All residents who have orders for accuchecks must have parameters for MD notification. If the CBG is out of range the MD assigned to that resident must be notified. Nursing Practice must be followed for either [DIAGNOSES REDACTED] or [MEDICAL CONDITION] episode. This must also be documented. " Record review of the facility provided policy "Medication Administration" dated ,[DATE] revealed the following: "Medications are administered as prescribed in accordance with manufacturers ' specifications, good nursing principles and practices ... Medication Preparation:.. 3. Prior to administration, the medication and dosage schedule on the resident's MAR indicated [REDACTED]. Apply a "direction change" sticker to label if directions have changed from the current label." Record review of the facility provided policy, " Insulin Administration " dated April, 2007 revealed the following: "...Steps in the Procedure (Insulin Injections via Syringe) ... 8. Check the order for the amount of insulin ... 15. Verify the order and dose to be administered with another licensed nurse; both nurses should then document the administration. Documentation 1. The resident ' s blood glucose result; 2. The dose and concentration of the insulin injection; Reporting 1. Notify your supervisor if the resident refuses the insulin injection. 2. Notify the physician if the resident has signs and symptoms of [DIAGNOSES REDACTED] that are not resolved by following the facility protocol for [DIAGNOSES REDACTED] management ..." The Administrator was informed of the Immediate Jeopardy on [DATE] at 1:30 p.m. Record review of the 2nd draft of the Plan of Removal was accepted on [DATE] at 1100 a.m.: "Please accept this as our plan of abatement to deficiencies leading to citation of Immediate Jeopardy on [DATE]. The following corrections have been completed. 1. The resident identified in this alleged deficient practice is no longer a resident of this facility; therefore, no resident specific action will occur. 2. All resident have the potential to be affected by this alleged deficient practice. 3. The following measures were put into place to ensure the alleged deficiency will not recur. · DON/Designee have identified 28 resident ' s whom reside in this facility and require Accucheck. · DON/Designee have identified 35 resident ' s whom reside in this facility and have physician documented [DIAGNOSES REDACTED]. · All residents with a [DIAGNOSES REDACTED]. · All diet orders have been audited by the DON/Designee on [DATE] · All diabetic snacks have been implemented TID for all diabetic residents. Charge Nurses will be responsible to ensure all identified diabetic residents will be offered snacks three times a day. DON/Designee will make daily random checks to ensure diabetic snacks are being offered. · All Accucheck orders were audited to ensure parameters were in place for MD notification by DON/Designee on [DATE]. This will be monitored and updated weekly in the Standards of Care Meeting and as needed with telephone order changes/admits/readmits by DON/Designee. · A list of diabetic residents and diabetic snack orders were given to the dietary manager to provide diabetic snacks on [DATE]. This will be monitored and updated weekly in the Standards of Care Meeting and as needed with telephone order changes/admits/readmits as well as with registered dietician visits and by the DON/Designee. · DON/Designee audited and updated resident ' s AccuNurse plan of care on [DATE] to ensure CNA ' s were providing/offering diabetic snacks TID per MD orders. This will be monitored Q shift by Charge Nurse and randomly by DON/Designee. · DON/Designee audited all insulin vial ' s to ensure they were correct and in stock on [DATE]. Charge Nurses will be responsible to ensure that correct insulin vials are on cart and in stock. DON/Designee will randomly audit carts to ensure accuracy. · See in-service list below for all licensed staff in-servicing on facility protocols of hypoglycemic care. · A list of diabetic resident was placed on each station in shower book to ensure all staff is aware of diabetic status and care can be monitored. This will be monitored and updated weekly in the Standards of Care Meeting and as needed with telephone order changes/admits/readmits. · An updated Hypoglycemic Protocol of Care was placed in front of each MAR indicated [REDACTED]. · DON/Designee ensured all glucometers were calibrated on [DATE]. · All licensed nurses had in-service training added on Relias Website for [DATE] by the Administrator. · DON/Designee completed lab audit on [DATE] to ensure all diabetic resident have HgA1c ' s ordered by the MD. DON/Designee will monitor chart audit on admission/readmission & randomly as needed with telephone order changes. DON/Designee will continue to fax monthly lab orders to Precision lab to ensure labs correspond with facility lab orders. · DON/Designee added glucose gel to all nurse ' carts on [DATE]. Glucose gel will be monitored by controlled sign out sheet by charge nurse. Charge nurse is responsible for recording glucose gel from the pharmacy. DON/Designee will randomly monitor to ensure glucose gel is available on each cart. · DON/Designee will randomly audit glucometer logs for each nurses ' station. · Daily audits of Accucheck logs will be turned and monitored daily by the DON/Designee RN weekend supervisor will monitor on weekend shifts. · DON/Designee placed second glucometer to each nurse ' s cart on [DATE] for infection control purposes. · DON/Designee will review all insulin orders/changes every day to ensure follow up is accurate. · DON/Designee will ensure all licensed nursing staff will be in-serviced prior to working the floor. · Nurse was suspended on [DATE] following investigation and never returned to work · If recurrent problems occur on any of the above listed items further individualized teaching/in-servicing will occur immediately and will be reviewed by Quality Assurance Committee. In-services Completed: · Diabetic [DIAGNOSES REDACTED] on [DATE] by ADON. · 1 on 1 in-services/[DIAGNOSES REDACTED] protocol of care on [DATE] by DON for LVN ___. · 1 on 1 in-services/[DIAGNOSES REDACTED] protocol of care on [DATE] by DON for LVN ____ Notification of MD when CBGs are out of parameters on [DATE] by DON. · Insulin Administration on [DATE]. · Daily Accucheck log on [DATE]. · Insulin Administration by [MEDICATION NAME] on [DATE] by DON. · Change of Condition Policy on [DATE]. · Change of Condition with Transfer to Hospital on [DATE] by DON. · Identifying in house abuse coordinator on [DATE]. · Offering HS snacks on [DATE] by DON. · Abuse and Neglect Policy on [DATE] by DON. · [MEDICAL CONDITION] Process on [DATE] by DON. · SBAR Documentation on [DATE] by DON. · 24 Hour Report logging of Change of Condition on [DATE] by DON. · Blood Glucose Monitoring System on [DATE] by DON. · Glucometer set up, testing, memory, maintenance and troubleshooting on [DATE] by DON/Designee with follow up post test completed by licensed staff. · Updated Protocol of Care for [DIAGNOSES REDACTED] [DATE] by DON. · Reporting Abuse on [DATE] by Administrator. · Relias Training for [DATE] included: About diabetes, diabetes/what you need to know, Med/diabetes and controlling resident blood glucose. · Relias Course details are as follows: 1. About diabetes: Nurses working with the geriatric population will encounter diabetes frequently. This course covers the basics of the disease and the current medical treatment. The course helps the student be better able to assess the needs of and provide care for diabetic residents as well as problem-solve common medication concerns. 2. MED-Diabetes and Controlling Resident Blood Glucose: Controlling resident blood glucose levels is one of the more challenging responsibilities in healthcare. The current recommended strategies for diabetes management are either oral medications or long acting insulin. Although sliding scale insulin use declining, it is still common in senior care settings. This course will help the student develop essential skills for accurate sliding scale administration and documentation. This course corresponds to the Federal regulations F309, F332, & F333. 3. Diabetes-What you need to know: Diabetes is not an uncommon condition in senior care communities. In fact 40% of people with diabetes are over the age of 65. About half of people age 65 or older with diabetes are hospitalized each year. As a caregiver in a senior care community, you are responsible for providing the care and treatment to your resident with diabetes. It is important for you to know what diabetes is, how it affects residents, and the care you provide." Interviews with 7 LVN's on [DATE] who worked all three shifts revealed they had participated in the in-services that the DON/Administrator had offered regarding the care of residents with diabetes. They all had taken the Relias Computer Training related to the care of residents with diabetes. They all could explain the facility's protocol for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] and notification of physician re

Based on observation, interview and record review, the facility failed to ensure that residents are free of any significant medication errors. This failure affected one (Resident #4) of 10 residents reviewed for significant medication errors from insulin. The facility failed to: A. Administer insulin in the dosage prescribed by the physician for three days (12/22/14, 12/23/14, and 12/24/14). The nursing staff administered 10 units of insulin instead of 14 units which could prevent the blood sugar from being lowered for three days. On 12/25/14, Resident #4 experienced a blood glucose reading of " HI " which indicated a blood sugar over 600 mg/dl. B. Obtain a documented physician ' s order for insulin for a blood sugar of 431. LVN J gave 10 units of Humalog without a documented physician ' s order. This failure could affect 20 insulin dependent residents who reside in the facility resulting in increased or decreased blood sugar levels and could prevent the physician from being involved in the medical management of residents. The findings included: 1. Review of Resident #4's closed record Face Sheet dated 12/19/15 revealed a [AGE] year old who was readmitted to the facility on [DATE] with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #4 was discharged on [DATE] to the hospital where she passed away. Review of Resident #4's most recent Minimum Data Set ((MDS) dated [DATE] revealed that she could make herself understood and could understand others, had clear speech, was severely cognitively impaired, required extensive assistance of one person for transfers, dressing, and eating, extensive assistance of two persons for toileting and hygiene, used a walker and wheelchair for mobility, was totally dependent on staff for showers, was frequently incontinent of bowels and bladder, had pressure sores, and had [DIAGNOSES REDACTED]. Review of Resident #4's "Care Plan" dated 12/07/14 under the problem "Return to community deemed not feasible at this time...unable to care for self on own" revealed Resident receiving [MEDICATION NAME] and Humalog for diabetes. Resident #4's "Care Plan" did not address diabetic care, how to treat low and high blood sugars, blood sugar monitoring before meals and at bedtime, snacks, emergency care, or when to notify the physician and family. Review of Resident #4's physician orders dated 12/19/14 revealed the following orders: "[MEDICATION NAME] 100 units/ml, inject 10 units at bedtime, Accuchecks (a small amount of blood is taken from a finger and placed in a glucometer to get a blood sugar reading) before meals and at bedtime per sliding scale. Humalog 150-200- 2 units 201-250- 4 units 251-300 -6 units 301-350- 8 units 351-400- 10 units Over 401 Notify MD " "[MEDICATION NAME]® is a long-acting insulin used to treat adults with type 2 diabetes and adults and pediatric patients (children 6 years and older) with type 1 diabetes for the control of high blood sugar. " Source dated 02/26/15: <http://www.[MEDICATION NAME].com/> "The most common side effect of insulin, including [MEDICATION NAME]®, is low blood sugar ([DIAGNOSES REDACTED]), which may be serious. Some people may experience symptoms such as shaking, sweating, fast heartbeat, and blurred vision. Severe [DIAGNOSES REDACTED] may be serious and life threatening. It may cause harm to your heart or brain." Source dated 02/26/15: <http://www.[MEDICATION NAME].com/> "Humalog is a fast-acting insulin that begins to work very quickly. If you use this medication with meal, use it within 15 minutes before or just after you eat... Low blood sugar ([DIAGNOSES REDACTED]) can happen to everyone who has diabetes. Symptoms include headache, hunger, sweating, confusion, irritability, dizziness, or feeling shaky. If you have severe [DIAGNOSES REDACTED] and cannot eat or drink, use a [MEDICATION NAME] injection. Your doctor can prescribe a [MEDICATION NAME] emergency injection kit and tell you how to use it. Also watch for signs of high blood sugar ([MEDICAL CONDITION]) such as increased thirst, increased urination, hunger, dry mouth, fruity breath odor, drowsiness, dry skin, blurred vision, and weight loss. Check your blood sugar carefully during times of stress, travel, illness, surgery or medical emergency <http://www.drugs.com/humalog.html>, vigorous exercise, or if you drink alcohol or skip meals. These things can affect your glucose levels and your dose needs may also change. If your doctor changes your brand, strength, or type of insulin, your dosage needs may change. Do not change your medication dose or schedule without your doctor's advice." Source dated 02/25/15: <http://www.drugs.com/humalog.html> Record review of Resident #4's physician orders dated 12/22/14 at 0640 revealed, "[MEDICATION NAME] 14 u/ml every night at bedtime (new order)". Record review of Resident #4's "Insulin MAR" dated December 2014 revealed that Resident #4 received [MEDICATION NAME] 100 /ml, 10 units every night at bedtime (2000) as initialed by the nurse on the following dates: 12/22/14, 12/23/14, 12/24/14. There was no stop or discontinuation date on the 10 units of [MEDICATION NAME]. The physician's order for [MEDICATION NAME] had changed to 14 units on 12/22/14. In an interview on 02/20/15 at 11:00 a.m. the DON said that she had not been notified that Resident #4 had received the wrong dosage of insulin for three days (12/22/14, 12/23/14, 12/24/15). Upon reviewing Resident #4's physician order dated 12/22/14, she said that Resident #4's physician had written the new order himself for the increased dosage of [MEDICATION NAME]. She said that the nurse who signed off on the order no longer worked for the facility. She said that she would investigate. In an interview on 02/20/15 at 4:30 p.m. the DON said that she was unable to determine if the correct dose of insulin was given on 12/22/14 - 12/24/14 because she could find no other documentation other than the [MEDICATION NAME] was given incorrectly on those days. Record review of Resident #4's "Insulin MAR" dated December, 2014 revealed the following: "Accucheck before meals and at bedtime scheduled for 6:30a.m., 11:30a.m., 4:30p.m. and 8:00p.m. with sliding scale Humalog 100 u/ml .... The blood sugar results were as follows: "12/25/14- 11:30 a.m.-(this was blank indicating no insulin was given. The Nurse's Notes documented that the reading was " HI "). Record review of Resident #4's computer Nurse's Notes dated 12/25/14 at 4:08 p.m. by LVN K revealed, "Reported by 6am-2pm nurse LVN J that patient's CBG reading HI, Dr. on-call for Dr. was called and notified, new order received to give [MEDICATION NAME] 10 more units at 1500 if CBG readings still HI, rechecked at 1500, still reading HI, [MEDICATION NAME] administered as directed, however, resident alert oriented x2, water was offered, drink 240 cc, accucheck done at 16:30 per orders, CBG 350, ...also new order received to increase PM [MEDICATION NAME] to 20 units ..." Record review of the facility provided "Assure Platinum Meter" (glucometer used to test blood sugars) manufacturer's manual revealed, "High Blood Glucose Readings - If your blood glucose is above 600 mg/dl, you will receive a "HI". Repeat the test with a new test strip. If this message shows again, contact your healthcare professional. " Record review of Resident #4's computer "Medicare Notes" dated 12/25/14 at 10:30 a.m. by LVN J revealed no information regarding the scheduled 11:30 a.m. Accucheck reading of "HI". Record review of Resident #4's physician orders dated 12/25/14 at 2:00 p.m. revealed, "Order clarification, Increase [MEDICATION NAME] 100 u/ml Give 20 units subcutaneously every night at bedtime. May give [MEDICATION NAME] 10 units at 3:00 p.m. if blood sugar reading "HI"; time one dose." "[MEDICATION NAME] is a fast-acting form of insulin that works by lowering levels of glucose (sugar) in the blood." Source dated 03/18/15: <http://www.drugs.com/[MEDICATION NAME].html> In an interview on 03/09/15 at 4:00 p.m. LVN K said on 12/25/14 at 2:00 p.m. she called and spoke with the on-call physician for Resident #4 to clarify the [MEDICATION NAME] order and to notify the physician of the "Hi" blood glucose reading that was reported to her by LVN J at the change of shift. Regarding clarification of the [MEDICATION NAME], LVN K said she notified the physician that Resident #4 had not received the physician ordered [MEDICATION NAME] 14 units for three days, instead had received only 10 units. LVN K said that she had given the wrong dose for three days. LVN K said in her defense that the Insulin MAR for the [MEDICATION NAME] 10 unit at bedtime had not been marked as changed and that the separate Insulin MAR indicated [REDACTED]. LVN K said that she had not notified the DON of the medication error. LVN K said that it was the responsibility of the DON/ADON to check all new orders. Regarding the notification of Resident #4's blood glucose reading of "HI", LVN K said that LVN J reported to her at change of shift (2:00 p.m.) that she had gotten a "HI" reading on the glucometer for Resident #4's scheduled 11:30 a.m. blood sugar test. LVN K said that LVN J had not notified Resident #4's physician of the blood sugar reading of "HI" because LVN J said that she had been very busy and not had time. LVN J had not given any insulin to Resident #4 between 11:30 a.m. and 2:00 p.m. according to the Insulin MAR. In a telephone interview on 03/10/15 at 2:05 p.m. LVN J said that Resident #4's blood sugars were not consistent, had very high blood sugars at times. LVN J said that she could not remember exactly what she did on 12/25/14 when Resident #4's 11:30 a.m. blood sugar registered "HI" on the glucometer. LVN J said that she had a lot of very heavy-care residents assigned to her and that often she was unable to complete both resident care and documentation. LVN J said that she knew that if she had not documented, then it was considered not done. Record review of Resident #4's "Insulin MAR" dated December, 2014 revealed the following: "Accucheck before meals and at bedtime scheduled for 6:30a.m., 11:30a.m., 4:30p.m. and 8:00p.m. with sliding scale Humalog 100 u/ml .... The blood sugar results were as follows: 12/31/14- 11:30a.m. - 431 (10 units of [MEDICATION NAME] were given); " Record review of physician orders did not reveal an order to give Resident #4 10 units of Humalog for a blood sugar of 431 on 12/31/14. The physician order for [REDACTED]. Record review of the computer Nurse's Notes did not reveal that the physician was notified or that an order was received to give Resident #4 10 units of insulin for a blood sugar of 431 at 11:30 a.m. on 12/31/14. Review of Resident #4's computer "Medicare Notes" dated 12/31/14 at 1:59 p.m. signed by LVN J did not mention the 11:30 a.m. blood sugar of 431. In a telephone interview on 03/10/15 at 2:05 p.m. LVN J said that Resident #4's blood sugars were not consistent, had very high blood sugars at times. LVN J said that she could not remember exactly what she did on 12/31/14 when Resident #4 had a high blood sugar of 431 mg/dl at 11:30 a.m. LVN J said that she had a lot of very heavy-care residents assigned to her and that often she was unable to complete both resident care and documentation. LVN J said that she knew that if she had not documented, then it was considered not done. LVN J said that she could not remember but she was sure that she would not have given insulin without a physician order but could not recall what she had done. Record review of the facility provided "Protocol of Care for Diabetic [DIAGNOSES REDACTED] (low blood sugar)", undated, revealed the following: "Purpose: To provide emergency care and treatment of [REDACTED]. The diabetic resident can experience the signs and symptoms of [DIAGNOSES REDACTED] when the blood sugar is less than 60. The signs and symptoms of [DIAGNOSES REDACTED] include headache, dizziness, weakness, agitation, numbness and tingling in the digits, nausea, vomiting, disorderly thinking and loss of consciousness. When the diabetic resident ' s blood sugar is below 50, the resident may experience somulence (sic)(somnolence) and be very difficult to arouse. When the blood sugar is around 40 or less, the resident could experience some type of [MEDICAL CONDITION] activity. The resident whose blood sugar is around or below 30 may become comatose. Blood sugars less than 30 may not be compatible with life. Protocol for Conscious Resident: 1. If the resident ' s blood sugar is less than 60 and he/she is conscious, give the resident 120-180 cc of fruit juice with 2 teaspoons of sugar following by a complex carbohydrate source, e.g. 6 vanilla wafers, 3-4 graham crackers, 1 slice bread/toast with peanut butter, etc. 2. Recheck the blood sugar in 15-20 minutes. (The sugar and fruit juice will be absorbed and should be impacting the blood sugar within 5-10 minutes of administration.) 3. If the blood sugar continues to be below 60, repeat the steps 1-2 of the procedure. If after repeating the procedure, the resident continues to have a blood sugar less than 60, activate EMS (emergency medical system). 4. Once the resident is stable or EMS has been activated, notify his/her physician and family of the change in condition as soon as possible after stabilizing the resident. (The physician may be contacted at any time during the procedure if time allows and resident is not in immediate jeopardy.) Protocol for Unconscious/Unresponsive Resident: 1. If the resident ' s blood sugar is less than 60 and he/she is unconscious or unresponsive, administer 1 vial/1mg [MEDICATION NAME] IM from the E-Kit. 2. When the resident is alert enough to safely swallow give the resident a complex carbohydrate source, e.g. 4-6 vanilla wafers, 3-4 graham crackers, 1 slice bread/toast with peanut butter. 3. If the blood sugar continues to be too low (less than 60), activate the EMS. 4. Once the resident is stable or EMS has been activated, notify his/her physician and family of the change of condition as soon as possible after stabilizing the resident. (The physician may be contacted at any time during the procedure if time allows and resident is not in immediate jeopardy.) 5. Thoroughly document the sequence of events into the resident's clinical record. " In an interview on 03/11/15 at 9:15 a.m. the DON said that the following "Protocol of Care for Diabetic [DIAGNOSES REDACTED] (low blood sugar)" was updated on 01/13/15. She said the only change that was made was the addition of " or 1 tube of glucose gel" under the Protocol for the Conscious Resident. Record review of the facility provided protocol for " [MEDICAL CONDITION] (high blood sugar)" undated revealed, "If CBG (capillary blood glucose) is over 400 ... Call the Doctor..." Record review of " Notification of MD when CBGs are out of Parameters " updated 01/07/15 per DON revealed: "All residents who have orders for accuchecks must have parameters for MD notification. If the CBG is out of range the MD assigned to that resident must be notified. Nursing Practice must be followed for either [DIAGNOSES REDACTED] or [MEDICAL CONDITION] episode. This must also be documented. " Record review of the facility provided policy "Medication Administration" dated 09/08 revealed the following: "Medications are administered as prescribed in accordance with manufacturers ' specifications, good nursing principles and practices ... Medication Preparation:.. 3. Prior to administration, the medication and dosage schedule on the resident's MAR indicated [REDACTED]. Apply a "direction change" sticker to label if directions have changed from the current label." Record review of the facility provided policy, " Insulin Administration " dated April, 2007 revealed the following: "...Steps in the Procedure (Insulin Injections via Syringe) ... 8. Check the order for the amount of insulin ... 15. Verify the order and dose to be administered with another licensed nurse; both nurses should then document the administration. Documentation 1. The resident ' s blood glucose result; 2. The dose and concentration of the insulin injection; Reporting 1. Notify your supervisor if the resident refuses the insulin injection. 2. Notify the physician if the resident has signs and symptoms of [DIAGNOSES REDACTED] that are not resolved by following the facility protocol for [DIAGNOSES REDACTED] management ..." Record review of "Physician Orders List" dated 03/09/15 revealed 20 residents had orders for Accuchecks.