Every finding on record at Georgia Regional Atlanta LTC

Based on record review and staff interviews, the facility failed to follow the plan of care, resulting in an accident for one of nine sampled residents (R)(R1) related to transferring with a mechanical lift. Harm was identified to have occurred on 2/6/2026, when two staff members were transferring the resident with the mechanical lift, and the resident fell, requiring transfer to an acute care hospital. The resident sustained a closed nondisplaced fracture of the sixth cervical vertebra from the fall. It was determined that the resident required three-person assistance with transferring with the mechanical lift.Findings included:A review of the written statement related to the incident that occurred on 2/6/2026 from Certified Nursing Assistant (CNA) TT revealed the following: After she assisted R1 with dressing, they (her and CNA CC) placed the sling underneath him (R1). She stated that they attached the sling to the mechanical lift and began lifting R1 from the bed. Once he was fully lifted, she proceeded to move the [NAME] lift from the bed to the chair. During the transfer from bed to chair, the bottom right hook became detached, and R1 fell out of the sling and onto the floor.A review of the written statement dated 2/6/2026 from CNA AC indicated that R1 was dressed, the sling was placed underneath him, and was attached to the mechanical lift. It was noted that the CNA TT proceeded to lift R1 on the mechanical lift to the chair while (CNA AC) was holding the chair. During the transfer of R1, the bottom right hook became detached, and R1 fell to the floor.A review of the Hospital emergency room After Visit Summary dated 2/6/2026 noted that R1 sustained a closed nondisplaced fracture of the sixth cervical vertebra. The summary further noted that R1 was to wear a C-collar when out of bed and to follow up with outpatient. Inpatient consult to Orthopedic Surgery Reason: GLF: Linear lucency of the C6 spinous process. It was noted that Consult has been discussed with the MD on call, orthopedic spine attending. Diagnosis: 1. Other closed nondisplaced fracture of the sixth cervical vertebra, initial encounter (CMS-HCC).During an interview on 2/12/2026 at 11:45 am with Physical Therapist (PT) FF and Occupational Therapist HH, it was revealed that they do functional training for residents. They revealed that a 24-hour support plan is initiated for all residents and updated as needed. PT FF revealed that R1 has a below-the-knee amputation (BKA) and is unable to transfer himself, so he required manual or mechanical lift with the assistance of three staff members. PT FF revealed that the staff is trained on the 24-hour report, she trains the staff in transferring, and that the staff was trained on how to position themselves during transferring R1. A review of the 24-Hour Support Plan dated 1/13/2026 revealed that R1 required a 3-person manual transfer from bed to wheelchair or a 3-person mechanical lift transfer.A review of the Care Plan dated12/4/2025 revealed that R1 is a paraplegic with bilateral BKA. Measures goals included that R1 would sustain no injury from a fall through the next review. The Plan of Approach/Interventions included that staff would aid R1 with all transfers; a 3-person assist with all transfers.During an interview on 2/12/2026 at 12:25 pm, the Administrator and Nurse Manager II revealed that two people were transferring R1 from his bed to his wheelchair with the mechanical lift, and R1slipped off his sling, hitting his head and shoulder. She revealed that R1 was sent out to the hospital and returned to the facility the same day with a neck brace. She revealed that R1 sustained a closed nondisplaced fracture of the sixth cervical vertebra from the fall. She revealed that the staff involved in the incident had been employed since May 2025 and had done other transfers with no incidents. She revealed that CNA TT had been reassigned to the Kitchen during the investigation. She revealed that the other CNA (CNA AC) who was assisting during the transfer had resigned.During an interview on 2/13/2026 at 8:45 am, CNA TT revealed that on 2/6/2026, she and CNA AC were preparing to lift R1. She stated that she adjusted the height of the mechanical lift to lift R1, and the pad straps were attached to the lift on each side. She said she did not recheck the strap connection when the lift was readjusted because they were in place correctly. She revealed that while transferring R1 from his bed to his wheelchair, the lower right strap came loose, and R1 fell on the floor. She revealed that she, another CNA, and another Nurse picked the resident up. She confirmed that the resident required three people for transferring, but it was only two of them who transferred the resident.During an interview on 2/13/2026 at 9:30 am, R1 revealed that the staff was transferring him from his bed to his chair when the strap came loose at the bottom, and he fell out. He revealed he was sent to the hospital and was diagnosed with a neck injury, and he has to wear a neck brace while he is up. He revealed that he was being transferred by two CNAs.A review of Lifting and Transferring Individual, 03-911 policy dated 2/12/2026, indicated that mechanical lift transfer is where a mechanical lift is used with a sling to move individuals from one surface to another. The Lifting and Transfer Techniques indicated the following: Staff members engage best practice approaches and lifting and transferring techniques included in training (orientation and annually), including but not limited to, preparing the individual.A review of the Mechanical Lifting Procedure, 03-912 policy revision dated 2/12/2026, indicated that, at a minimum, two staff members are required to operate the mechanical lift. One staff member is responsible for operating the lift, and the second staff member is responsible for guiding and supporting the individual. A third person may be used to support the individual's head/neck if they do not have head control and their head is at risk of falling below the sling level.

Based on record review and staff interviews, the facility failed to develop a comprehensive person-centered care plan that addressed oxygen therapy needs for one of 19 sampled residents (R) (R13). This deficient practice had the potential to place the resident at risk for unmet care needs, respiratory complications, and diminished quality of life.Findings include:The facility did not have a policy related to care planning.Review of the care plan revealed the care plan did not include a problem, goal, or interventions related to oxygen (O2) use.Interview conducted on 9/18/2025 at 10:37 am with MDS Coordinator EE stated that O2 use should be triggered and addressed in the care plan. Upon review of R13's care plan, MDS Coordinator EE stated O2 therapy was not included and acknowledged it was omitted in error. She stated the possible negative outcome of not care planning O2 was that the resident might not get the care that they needed.Interview conducted on 9/18/2025 at 2:01 pm with the Administrator stated he did not believe it was necessary to care plan O2, noting the facility had never care planned O2 in 10 years. The Administrator acknowledged that O2 was not included in the resident's care plan.

Based on observations, staff interviews, record review, and review of facility's policy titled, Oxygen Therapy, the facility failed to ensure oxygen (O2) equipment was properly stored when not in use for one of 24 sampled residents (R) (R13). This deficient practice had the potential to place residents at risk of infection. Findings include:A review of the facility's policy titled Oxygen Therapy, reviewed on 7/16/2025 revealed under section titled, Storage and Equipment, all equipment associated with the delivery of oxygen should be discarded and replaced as needed with visible soiling, issues with patency, a defective device, or other issues that interfere with functionality and optimal oxygen delivery.Review of the electronic medical record (EMR) for R13 revealed diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), asthma, and mild neurocognitive disorder due to known physiological condition with behavioral disturbance.A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive decline.A review of the physician's order dated 7/11/2025 revealed an active order for oxygen at 2 liters per minute (LPM) via nasal cannula (NC) as needed for shortness of breath (SOB) or wheezing. The order further directed staff to titrate oxygen to maintain saturations of 92-94% and to check oxygen saturations every six hours and as needed.Observations on 9/16/2025 at 11:00 am, 9/17/2025 at 9:15 am, and 9/17/2025 at 12:43 pm in R13's room revealed the NC was observed uncovered and exposed when not in use.Interview and observation conducted on 9/17/2025 at 12:45 pm with Certified Nursing Assistant (CNA) AA stated the NC should be placed in a plastic bag when not in use to prevent germs and bacteria from contaminating the device. She stated that if the cannula is not covered, bacteria could be inhaled by the resident when the device is reapplied.Interview and observation conducted on 9/17/2025 at 12:49 pm with Registered Nurse (RN) BB stated the NC should have been bagged when not in use. She stated she did not notice it uncovered during the morning and acknowledged the potential negative outcome was infection.Interview conducted on 9/17/2025 at 1:09 pm with Respiratory Therapist (RT) CC stated the O2 equipment should not be stored in the resident's room unless needed, and the NC should be covered. He stated that leaving the cannula uncovered posed an infection control risk and acknowledged.Interview conducted on 9/18/2025 at 12:44 pm with RT Lead DD confirmed all NC's must be stored in a dated, labeled bag when not in use. She stated the potential negative outcome was exposure to germs, which residents could inhale.Interview conducted on 9/18/2025 at 2:01 pm with the Administrator stated his expectations were that NCs must always be covered when not in use. He stated a negative outcome of failure to do so could be infection risk to the resident.

Based on staff interview, record review, and review of the facility's policies titled Infection Prevention And Control and Infection Control Policy Surveillance and Reporting Infections the facility failed to provide evidence that infection control surveillance data was collected for 20 out of 20 months (June 2022 through February 2024) reviewed. The facility had a census of 19 residents. Findings include: Review of the policy titled Infection Prevention And Control dated 9/30/2023 under the section titled POLICY revealed, [Facility name] maintain comprehensive Infection Prevention and Control (IPC) programs that protect hospitalized individuals, visitors, staff, and others from Healthcare Associated Infections (HAIs). Under the section titled, Infection Surveillance revealed, 1. IPC Teams use a line listing form to record and track all infections. IPC data is gathered using multiple sources including, but not limited to: Culture and sensitivity reports, antibiotic dispensing reports, 24-hour nursing reports, infection reporting forms, and nursing rounds. 2. IPC Teams report all HAIs each month. These reports show the number of infections by type, site and service or treatment area. 4. This surveillance approach enables IPC Teams to quickly: (a) Detect infection trends, clusters, and outbreaks. (b) Drill down to identify causative factors. (c) Implement new or additional control measures. (d) Monitor the effect or results of these new or additional control measures. Review of the policy titled Infection Control Policy Surveillance and Reporting Infections dated 12/22/2023 under the section titled PURPOSE revealed, To provide an ongoing system of surveillance, data collection, analysis of data and dissemination of findings in order to identify and control infections/hospital acquired infection and to initiate prevention strategies to minimize the risk of transmission of infections. A. The Infection Control Nurse(s) shall perform surveillance, implement prevention, and control measures, and report infections to the Infection Control Team and appropriate authorities. B. Surveillance is conducted through 1. Review of pertinent laboratory reports. 3. Review of monthly line listings from each client unit. Review of the document titled Skilled Nursing Data revealed no data was obtained for June 2022. Review of the document titled Skilled Nursing Data revealed there was no Line Listing, Mapping, Epidemiology Report Form, and Monthly Surveillance for Tuberculosis Form from June 2022 through February 2024 for a total of 20 months. Interview on 3/16/2024 at 9:23 am with Licensed Practical Nurse (LPN), HH stated the facility followed protocols for infection control. She accumulates a report every month of how many infections there were based on the antibiotic's usage. The LPN stated she obtains the number of antibiotics used for the month from pharmacy. She stated the only source information used is obtained from the residents Electronic Medical Record. She revealed she completed the monthly calculations with the number of infections, daily census, and the resident days per month to arrive at the average facility infection rate. She stated that was the extent of what she did with the infection control. The LPN stated there was no communication with the nursing staff to verify the residents' signs and symptoms or source of infection. The LPN stated she could not provide the surveyor with Line Listing, Mapping, Epidemiology Report Form, or a Monthly Surveillance for Tuberculosis Form.

Based on staff interviews and review of the facility's policy titled, Infection Prevention And Control, the facility failed to designate a qualified Infection Preventionist who completed specialized training in Infection Prevention and Control. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility had a census of 19 residents. Findings include: Review of the policy titled Infection Prevention And Control dated 9/30/2023 under the section titled POLICY revealed, [Facility name] maintain comprehensive Infection Prevention and Control (IPC) programs that protect hospitalized individuals, visitors, staff, and others from Healthcare Associated Infections (HAIs). Under the section titled Procedures revealed, 2 (a) Committee members, representing a variety of departments and clinical services, are appointed by Hospital Leadership. Members include but are not limited to an Infection Prevention and Control (IPC)/Infection Preventionist (IP). 3 (i) The IPC Practitioners are licensee registered nurses with strong clinical nursing backgrounds. The IPC Practitioners are strongly encouraged and supported by Hospital Leadership to obtain Certification in Infection Control (CIC) and membership in the Association for Professionals in Infection Control and Epidemiology (APIC). Interview on 3/16/2024 at 9:23 am with Licensed Practical Nurse (LPN), HH confirmed that she did not have an IP certification or a CIC certification. Interview was conducted on 3/16/2024 at 10:17 am with the Clinical Director of the Hospital responsible for overseeing the infection control program to ensure that the policy and procedures are followed. He stated that he did not have an IP certification or any type of infection control certification. The Clinical Director of the Hospital stated the previous IP abruptly quit in September of 2023. He stated the facility had hired a Registered Nurse (RN) that will be starting on 3/18/2024. He stated the facility will make certain the RN obtained an IP Certification.

Based on staff interviews, record review, and review of the facility's policies titled Infection Prevention And Control the facility failed to provide evidence of a monitoring system to track and trend antibiotic use for 20 out of 20 months (June 2022 through February 2023) of the infection control data reviewed. The facility had a census of 19 residents. Findings include: Review of the policy titled Infection Prevention And Control dated 9/30/2023 under the section titled POLICY revealed, [Facility name] maintain comprehensive Infection Prevention and Control (IPC) programs that protect hospitalized individuals, visitors, staff, and others from Healthcare Associated Infections (HAIs). Under the section titled, Infection Surveillance revealed, 1. IPC Teams use a line listing form to record and track all infections. IPC data is gathered using multiple sources including, but not limited to: Culture and sensitivity reports, antibiotic dispensing reports, 24-hour nursing reports, infection reporting forms, and nursing rounds. 2. IPC Teams report all HAIs each month. These reports show the number of infections by type, site and service or treatment area. 4. This surveillance approach enables IPC Teams to quickly: (a) Detect infection trends, clusters, and outbreaks. (b) Drill down to identify causative factors. (c) Implement new or additional control measures. (d) Monitor the effect or results of these new or additional control measures. Review of the document titled Skilled Nursing Data there was no evidence of antibiotic surveillance data, analysis, documentation of follow up in response to the data or monthly antibiotic reporting for 20 months from June 2022 through February 2023. Interview on 3/16/2024 at 9:15 am with the Administrator stated the last Infection Preventionist abruptly quit in or around December 2023. He stated the facility has a nurse that has been filling in for infection control until the newly hired Registered Nurse starts on 3/18/2024. Interview on 3/16/2024 at 9:23 am with Licensed Practical Nurse (LPN), HH stated she had been filling in for the past 7 months (September 2023) for infection control. She stated the last person that was responsible for the facility's infection control removed all the infection control binders from the office. She stated the facility does not have a policy on the Antibiotic Stewardship Program (ASP). The LPN stated she did not document the percent of residents receiving antibiotics (ABT), percent of new admissions receiving ABT, new [NAME] started, Rate of ABT days of therapy, or the ABT utilization ratio. Interview on 3/17/2024 at 9:43 am with the Director of Nursing stated the facility did not have a policy on the ASP.

Based on staff interview, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report for First Quarter (Q1) of Fiscal Year 2024, the facility failed to submit direct care staffing data to the Centers for Medicare and Medicaid (CMS). The facility census was 19 residents. Findings include: Review of the PBJ Data Staffing Report CASPER Report for Q1 2024, October 1 through December 31, revealed the facility failed to submit data for the quarter. During an interview on 3/16/2024 at 11:00 am with the Director of Nursing (DON) revealed, the facility did send the PBJ information into CMS and that he would look for proof. During an interview on 3/16/2024 at 11:30 am with the Administrator revealed that he had submitted the PBJ information to CMS each quarter. He stated he did not know where the return receipt was located, but he would look for it. During an interview on 3/16/2024 at 1:00 pm with the Administrator revealed, he could not find the return receipt for the information that was sent to CMS and that the facility did not have a policy related to PBJ. During an interview on 3/16/2024 at 3:30 pm with the Administrator, he presented one receipt for the staffing data that was sent to CMS on 10/13/2023. He stated he sent the last report to CMS in January 2024, but was unable to locate the receipt.

Based on staff interviews, record reviews, and review of the facility's documents titled, [name of facility] Skilled Unit Facility Assessment and (LPN) Licensed Practical Nurse: the facility failed to evaluate its resident population and identify the resources needed to provide the necessary care and services to meet the needs of one out of 10 sampled Residents (R) (R16) requiring wound care. In addition, the facility failed to update the Facility Assessment to accurately reflect all required components of an infection control plan. The facility had a census of 19 residents. Findings include: Review of the facility- provided [name of facility] Skilled Unit Facility assessment dated [DATE], revealed the facility provided pressure ulcers services to residents residing in the facility. The care required by the resident population considering types of disease states, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population: wound care. The staff competencies that are required to provide the level and types of care needed for resident population: Wound Nurse. Review of facility-provided job description titled, (LPN) Licensed Practical Nurse undated, revealed the responsibilities includes: administer nursing care to behavioral health patients, communicate with collaborating physicians or specialist regarding patient care, facilitate referrals to other healthcare professionals and medical facilities, maintain accurate documentation and patient medical records, coordinates medical services as needed and required, ensures that each resident receives the required care regarding physical health and dental services within the appropriate timeframes. 1.Review of R16's Face Sheet, dated 3/4/2024, provided by the facility, revealed R16 was admitted with multiple diagnoses that included but not limited to a pressure ulcer to his right ischium. Review of R16's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/2023, revealed a Brief Interview Mental Status (BIMS) without a score, which indicated R16 was severely cognitively impaired; Further review revealed the resident was at risk for developing pressure ulcers. During an interview 3/16/2024 at 9:59 am with Licensed Practical Nurse (LPN) DD, revealed she had worked at the facility for nine years and she had not received training related to wound care and was not sure how often the wound needed to be assessed or measured. She further revealed she was not sure who was responsible for staging the wound. She only changed the dressings as ordered by the physician. During an interview 3/16/2024 at 3:27 pm with LPN EE revealed she had worked at the facility for seven years. She further stated the facility had provided her with training related to wound care when she was first hired. LPN EE stated she was aware that the physician order for dressing changes must be followed, and she had to assess the resident for nonverbal signs of pain. She stated she was aware that the color of the wound bed, odor, drainage of the wound needed to be documented. LPN EE then stated she received that training prior to coming to the facility at the facility. During a follow up interview on 3/16/2024 at 3:39 pm with the Director of Nursing (DON) and Administrator revealed the facility did not have a policy related to wounds and nurses had not been trained to care for wounds that they were aware of. DON stated he had not conducted any nurse competencies or skill checkoffs to ensure nurses were competent in performing wound care. During an interview on 3/17/2024 at 9:10 am the Administrator revealed there was not a policy related to wound care, therefore the competency and education related to wound care for the nurse would not be completed. The Administrator verified that the Facility Assessment provided indicated that nurses would have the skills, training, and competency to provide wound care. A policy was requested related to the Facility Assessment. The Administrator informed surveyor the facility did not have a policy. 38997 2. Review of the Facility assessment dated [DATE] did not include its policies or protocols to include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents. An interview on 3/16/2024 at 1:56 pm with the Administrator stated the facility does not have a policy for the Facility Assessment. He stated the facility follows the state and federal guidelines as it relates to the facility assessment. The Administrator stated he was not aware that the facility assessment did not address infection control or the infection preventionist.

Based on staff interviews and record review, the facility failed to assess, measure, and document the status of a pressure wound and obtain a physician's order for treatments for one out of 10 sampled Residents (R) (R16) reviewed for pressure ulcer/injury. This deficient practice had the potential to result in complications of the wound and further impair the resident's skin integrity and infection. Findings include: Record review revealed R16 was admitted with the diagnoses that included cerebral palsy, profound mental retardation, congenital quadriplegia, and contractures of multiple joints. Record review revealed R16's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/2023, revealed a Brief Interview Mental Status (BIMS) without a score, which indicated R16 was severely cognitively impaired. Further review of the MDS revealed the resident was at risk for developing pressure ulcers. Record review revealed R16 had an order with a start date of 11/16/2023 and a discontinued effective date of 12/13/2023 for wound care to right ischium wound - once daily, cleanse with normal saline, apply Hydrogel to open wound only, cover with non-stick gauze, overlay with Duoderm, continue until clear. This order was discontinued by the facility's physician. Record review of a physician progress note date 12/13/2023 did not reflect the wound status or reasoning for the discontinuation of the order for the Hydrogel to the right ischium wound. Record review of physician progress note dated 12/21/2023 revealed the right ischium decubitus was healing gradually. Continue Hydrogel topical application, until clear. There was not a current order for Hydrogel in the record which was verified by the Director of Nursing (DON). Further review of the record revealed R16 was discharged from the facility to the hospital on 1/4/2024 and readmitted to the facility on [DATE]. Review of the facility's document titled Resident Extremity Check Sheet Suite 2 dated 1/10/2024 3pm-11 pm Shift indicated R16 had a wound on buttock. Record review revealed a physician progress note dated 1/10/2024 that read the right ischial decubitus was open. Continue other routine medications and wound care. Further review of the record revealed residents did not have an active order for wound care which was verified by the DON. Review of nurse's progress note dated 1/14/2024 that read wound dressing change to right hip and sacral area, skin remains excoriated. There was no evidence of an order related to this dressing change. Further review of the record revealed progress notes dated 1/15/2024, 1/17/2024, 1/18/2024 that indicated right buttock was noted with padded dry dressing in place for protection. There was no evidence of an order related to this dressing in place for protection. Record review revealed a physician progress note dated 1/19/2024 at 4:20 pm that read: Patient has a decubitus wound on right ischial, which is open. Will Apply Hydrogel ointment to open wound once daily until clear. Continue wound care. Record review revealed Client Doctor Orders for active orders between 1/1/2024 and 3/15/2024 that indicated an order for Hydrogel wound care apply to open wound on right ischium, once daily until clear. Start date 1/19/2024. Order status active. Further review of the record revealed there was no evidence of documentation in the record related to measurements of the pressure wound, staging of the wound, or wound characteristics such as wound bed, odor, drainage, or peri wound. Review of R16's electronic and paper record revealed there was no evidence of documentation related to the status of the wound on resident's right ischium which was verified by the DON. Record review revealed there was no evidence of a treatment for R16's right ischium wound from 12/13/2023 until 1/19/2024. There was no evidence of documentation in the record to indicate whether the wound was healed during this period. Record review revealed R16 had a current physician order with a start date of 1/19/2024 for hydrogel wound care - apply to open wound on right ischium and cover with non-stick gauze once daily until clear. During an interview on 3/16/2024 at 9:59 am with Licensed Practical Nurse (LPN) DD revealed R16 had a wound on his right ischium for a while and she was not exactly sure when the wound first appeared, but she was aware that resident returned from the hospital with the wound. LPN DD further stated that she did not stage or document the characteristics such as drainage, odor, appearance of wound bed or peri wound. LPN DD further stated she documents daily related to the dressing being intact and the dressing was changed. LPN verified there was not an order in the record for wound care upon residents return from the hospital on 1/9/2024 until 1/19/2024. LPN DD also further stated that skin assessment should be documented every day on a paper document and scanned into the electronic record. LPN DD stated the wound on resident's right ischium was much larger at one time. LPN DD retrieved a skin assessment dated [DATE] that indicated resident had a wound on his right buttock. LPN DD verified there were not any assessments in the record or box of files dated from 1/9/2024 until the one she found dated 1/15/2024. LPN DD stated she had worked at the facility for nine years and she had not received training related to wound care at the facility and was not certain how often wounds needed to be measured or the characteristics of the wound assessed and documented. During an interview on 3/16/2024 at 11:39 am with the DON verified R16 returned to facility from the hospital on the evening of 1/9/2024. After reviewing the record, DON verified the progress note from the physician on 1/10/2024 that stated resident had right ischium decubitus that was open. DON also verified the physician orders did not have a treatment order for the right ischium wound until 1/19/2024. DON further stated the wound to resident's right ischium was an old area, resident had the area prior to discharging from the facility to the hospital on 1/4/2024. DON further stated that it was the physician's responsibility to write a treatment order for the residents wound if she wanted it treated. DON also verified there was not any documentation in the record related to measurements of the wound or documentation related to the wound status. DON stated that the nurses only document wounds as needed, and the measurements are not done routinely on a schedule. DON stated he had not visualized the wound since resident's readmission and was not sure of the R16's wound status. During a telephone interview on 3/16/2024 at 3:09 pm with the Facility's physician FF revealed the wound on resident's right ischium was not a new wound and she did not write an order for the wound care to area when she assessed him on 1/10/2024 after readmission to the facility because the resident should have had an order already in place. The Facility's physician FF further stated she could not recall if there was an order on the chart or not but there should have been an order to treat the wound because the resident had the wound for a while, and it was not new. The Facility's physician FF stated the nurses are responsible for measuring and staging wounds in the facility. She stated she was not sure how often the wounds are measured or how often the nurse should document the wounds' status. During a follow up interview on 3/17/2024 at 7:53 am with the DON revealed, that at one-point R16 wound healed and the order was discontinued. DON stated, apparently there was something there but was not sure of the size and that the nurses were doing the treatments during the time there were no orders. DON stated if there was a wound, there should have been an order in place prior to applying a dressing. DON stated the RN service Director oversees the wound and was responsible for measuring, staging, and documenting the characteristics of the wound. DON verified after the wound treatment was discontinued on 12/13/2023 there was not another order written until 1/19/204. DON further stated that he does not know that much about wound himself and there needs to be an education over wound treatment. The DON and Administrator revealed the facility did not have policies related to wound care or treatment of a pressure ulcer.

Based on staff interviews and record review, the facility failed to develop a comprehensive person-centered plan for one out of 10 sampled Residents (R) (R3). Specifically, the facility failed to address the resident's medical needs related to the use of an antiviral medication. Findings include: Review of the medical records for R3 revealed that she had a physician's order for Acyclovir (an antiviral) 10 ml every eight hours for recurring Herpes Simplex of right gluteus with a start date of 3/11/2024, and a stop date of 3/18/2024. Interview with Licensed Practical Nurse (LPN) DD on 3/16/2024 at 10:50 am revealed she was familiar with R3 and her care. She stated that R3 was taking an antiviral for Herpes. LPN DD stated that there was no care plan for the antiviral. She confirmed that there should be a care plan, and that the Minimum Data Set (MDS) Coordinator was responsible for care plans. She stated that the MDS coordinator was not working today because she does not work on the weekend. Interview with LPN EE on 3/16/2024 at 10:59 am revealed R3 was on an antiviral for Herpes. She stated that R3 started on it on 3/11/2024. LPN EE stated that R3 has break outs sometimes, but it has been a while since the last break out. She stated that there was not a care plan for the antiviral. She confirmed that there should be a care plan, but she did not see one. LPN EE further stated that the MDS Coordinator was responsible for care plans. Interview with the Director of Nursing (DON) on 3/16/2024 at 11:15 am revealed the MDS coordinator was responsible for adding diagnoses. DON verified that there was not a diagnosis of herpes listed on R3 medication list. He stated that they do not do care plans for medications unless it is a psychotropic medication. DON stated that they did not have a care plan policy. DON confirmed that there was not a care plan to address the antiviral order. Interview with the DON on 3/16/2024 at 12:51 pm revealed the facility has never developed care plans pertaining to a resident's diagnosis that requires care and services such as medications to manage the condition. DON stated the MDS Coordinator was responsible for care plans and surveyor needed to speak with her. Additionally, the DON stated again that the facility did have a policy related to care plans. Telephone interview on 3/16/2024 at 12:58 pm with the Registered Nurse (RN) AA, MDS Coordinator revealed that she developed care plans related to residents' medical diagnosis and/or medication usage. She stated she only does a general care plan for a resident who have orders for psychotropic medications. RN AA, MDS Coordinator stated she had not been informed that a care plan was required for diagnosis and medications but if she was required to do so, she would follow through with getting it done.

Based on observations, record review, and staff interviews the facility failed to accurately assess one(1) resident ( #1), for [MEDICAL CONDITION] medication use on the Admission Minimum Data Set (MDS) assessment from a sample of seventeen (17) residents. Findings Include: Review of the clinical record revealed that resident # 1 was admitted to the facility on [DATE] from Central State Hospital with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated ,[DATE] revealed that the resident was assessed as severely cognitively impaired, totally dependent on staff for all care and receiving Insulin injections daily during the seven (7) day look back period. Further review revealed that he exhibited verbal behaviors one to three (1-3) days during the seven (7) day look back period but there was no evidence of the resident receiving an antipsychotic and/or antidepressant medications. Review of the electronic Physicians Orders dated 07/01/14 revealed that the resident was prescribed [MEDICATION NAME] ([MEDICATION NAME]) 3 milligrams (mgs) every evening by Gastrostomy tube (G tube) for Depression/Mood, and [MEDICATION NAME] ([MEDICATION NAME]) 50 mgs every morning by G tube for Depression. Review of the July, August, and September 2014 Medication Administration Records (MAR) revealed that the resident continued to receive these medications daily as ordered. Review of a Psychiatric Review, completed on 08/15/14, revealed that the resident had an Axis I [DIAGNOSES REDACTED]. His medications include the [MEDICAL CONDITION] medications of [MEDICATION NAME] ([MEDICATION NAME]) 3 milligrams daily and [MEDICATION NAME] ([MEDICATION NAME]) 50 milligrams daily. The recommendation of the Interdisciplinary Team ( IDT) was to keep him on his [MEDICAL CONDITION] medications at this time and to continue to monitor the effectiveness of these medications. Interview with Registered Nurse "BB" Minimum Data Set (MDS) Coordinator on 09/11/14 at 12:00 p.m., revealed that she completed the Admission MDS assessment for resident # 1, and that she does recall that he was on [MEDICATION NAME]. "BB" revealed that she could not recall why she did not accurately assess him as receiving antipsychotic, and antidepressant medications during the look back period.

Based on observations and staff interview the facility failed to monitor the temperature of the medication storage refrigerator on one (1) of three (3) units (unit 4). Findings include: Observations on 9/10/14 at 10:33 a.m. and 11:32 a.m. of the medication storage refrigerator on unit four (4) revealed there was no thermometer in the refrigerator to record the temperature. Continued observation revealed that the stored medications were sitting on a small plate in a pool of water. There was a wet towel in the refrigerator also. The stored medications included: two (2) vials of Humulin Insulin 70/30, one (1) vial of Humulin R Insulin, one (1) vial of Levemir Insulin 100 units/milliliter (u/ml), and Novolog Insulin 100u/ml. Staff Interview on 9/10/14 at 10:35 a.m. with Registered Nurse (RN) "AA" revealed that since the unit opened around a month ago there has been no thermometer in the refrigerator and this has been reported to her supervisors.. Continued interview revealed that the refrigerator had a wet towel in it because staff defrosted the freezer. Staff Interview on 9/10/14 at 10:45 a.m. with the Director of Nursing ( DON )revealed that she was unaware that there was no thermometer in the refrigerator until yesterday. Continued interview revealed that without a thermometer, there was no way for the refrigerator temperature to be monitored to ensure that the medications were stored within a safe temperature range.

Based on record review and staff interviews the facility failed to ensure that resident trust funds were disbursed within thirty (30) days of death for one of three (1 of 3) accounts reviewed. Findings include: Review of three (3) expired residents with trust fund accounts for the last six (6) months revealed that resident #3 expired on [DATE]. A payment of $4923.72 was paid to the Funeral Home on [DATE] leaving a balance of $1332.00 which was not disbursed to the responsible party until [DATE]. Interview with the Financial Operation Generalist on [DATE] at 11:00 a.m., revealed that she has held the position since July, 2014, and when reviewing the records realized that the outstanding balance was not paid, and sent the payment to the family. Continued interview revealed that she was aware that funds should be disbursed within 30 days.

Based on clinical record review, facility Investigative Report review, and facility staff interview, the facility failed to prevent neglect during the provision of Activities of Daily Living (ADL) Care for one (1) resident (#1), who was totally dependent on staff for ADL care and who received a second degree burn from staff's unsafe use of a hair dryer, on the total survey sample of seven (7) residents. After Resident #1 received a shower and as direct-care staff dried her hair utilizing an electric hair dryer, the resident sustained [REDACTED]. Resident #1's second degree burn wound later developed slough, the resident was transferred to the Burn Center for treatment, and she received antibiotic drug therapy for the treatment of [REDACTED]. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during the provision of ADL care to Resident #1 resulted in neglect, as the resident received a second degree burn to the left flank measuring twelve (12) inches by six (6) inches with peeling skin and bullous blistering which caused the resident to groan in pain and exhibit facial grimacing, and resulted in referral to the Burn Center and receipt of antibiotic drug therapy for the treatment of [REDACTED].#1 had sustained the second degree burn while receiving care on July 09, 2014, the direct-care staff member, who was drying the resident's hair with a hair dryer after a shower, propped the running hair dryer on a towel as she repositioned the resident, causing a large burn to the resident's left flank. An allegation of jeopardy removal was received on August 06, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 07, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued staff in-service training related to the newly-implemented ADL Care/Body Checks Protocol which included procedures to ensure the safe use of hair dryers when providing resident care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's Protocol and procedures related to the provision of Activities of Daily Living Care to residents, including the safe use of resident hair dryers. Resident records were reviewed to ensure that resident assessments and Plans of Care accurately reflected the Activities of Daily Living Care provided to residents. Findings include: Resident #1's Quarterly Minimum Data Set assessment of 05/08/2014 documented in Section C - Cognitive Patterns that the resident had short-term and long-term memory problems and severe impairment in cognitive skills for daily decision-making. Section I - Active [DIAGNOSES REDACTED]. A Nursing/HST (Health Service Technician) Notes entry of 07/09/2014 at 9:31 a.m. for Resident #1 documented that at 2:40 a.m., Licensed Practical Nurse (LPN) "AA" was called to the shower and observed Resident #1 laying on the right side on the shower trolley. The LPN documented redness to Resident #1's left flank and back, with peeling skin and fluid-filled blistering, and that the physician, when notified, came to the unit to assess the resident. During an interview with the Service Director conducted on 07/18/2014 at 1:25 p.m., the Service Director acknowledged that on 07/09/2014, Resident #1 had received a burn (a second degree burn to the left flank) while two HSTs were providing ADL care, as indicated in the 07/09/2014, 9:31 a.m. Nursing/HST Notes entry above. The Service Director stated that on 07/09/2014, Resident #1 had experienced a large bowel movement (after having received an earlier bowel preparation) and needed a shower. The Service Director further stated that as one of the HSTs was drying the resident's hair with a hair dryer after the shower, the HST propped the hair dryer on a towel, left it running, and caused the left flank burn. Further review of Resident #1's clinical record revealed that Physician "EE" documented in a 07/09/2014, 3:56 a.m. Physician Notes-Medical entry that she had been called to the facility for Resident #1's significant burn, and documented Resident #1 to be groaning in pain, having facial grimacing and appearing distressed. The physician documented an area on Resident #1's left flank approximately twelve (12) inches by six (6) inches with bright red skin, an overlay of peeling skin and bullous blistering, and ordered the resident's hospital transfer. A Nursing/HST Notes entry of 07/09/2014 at 6:33 a.m. by Registered Nurse "BB" documented Resident #1's hospital transport for a second degree left flank burn, and a 07/09/2014, 9:54 p.m. Nursing/HST Notes entry documented Resident #1's 8:00 p.m. return from the hospital with a left flank burn eight (8) inches by four (4) inches in size. A 07/09/2014, 8:07 p.m. Physician Notes-Medical form entry completed by Physician "FF" documented the physician's examination of Resident #1 after her return from the hospital, revealing an eight (8) inch by five (5) inch burn. Physician "FF" ordered silver [MEDICATION NAME] cream to the burn twice daily, and Tylenol 650 milligrams (mgs) every 6 hours for 72 hours. A 07/10/2014, 1:21 p.m. Physician Notes-Medical form entry completed by Physician "GG" documented the physician's examination of Resident #1 on that date, and noted a left lateral trunk burn with no bleeding or drainage, but noted a six (6) by three (3) inch area with all skin gone. During an interview conducted on 08/05/2014 at 2:00 p.m., Physician "GG" stated that the silver [MEDICATION NAME] cream ordered for Resident #1's burn was being applied to the area of the burn measuring six (6) inches by three (3) inches. Further record review for Resident #1 revealed a Nursing/HST Notes entry of 07/12/2014 at 1:16 p.m. which documented treatment of [REDACTED]. A subsequent 07/14/2014, 9:47 p.m. Nursing/HST Notes entry documented that Resident #1 was scheduled for an appointment at the Burn Center on 07/15/2014. A 07/15/2014, 1:59 p.m. Physician Notes-Medical entry documented Resident #1's return from the Burn Center with orders to continue silver [MEDICATION NAME] cream twice daily and to administer the antibiotic Keflex 500 mgs four (4) times daily, and the Client Doctor Orders form documented a 07/15/2014 order for Keflex 500 mgs every 6 hours for infection. A facility Investigative Report (IR) of 07/15/2014 documented the facility's investigation of Resident #1's second degree, twelve (12) by six (6) inch left flank burn, which had peeling skin, bullous blistering, and caused the resident to groan and show facial grimacing, and to later develop slough and require antibiotic drug therapy. The IR Summary of Allegation(s)/Incident section documented that on 07/09/2014, HST "CC" assisted HST "DD" to shower Resident #1, and HST "DD" was standing behind the resident blow drying her hair with an electric blow dryer. HST "CC" was facing Resident #1 and observed the resident crying, walked around to Resident #1's back, noted redness to the back, and informed LPN "AA" of this observation. In a 07/09/14 statement by HST "DD" documented in the IR referenced above, HST "DD" indicated that on 07/09/14, she and HST "CC" placed Resident #1 on the bath trolley, took the resident to the shower room, and washed her body and hair. HST "DD" indicated she was standing behind Resident #1 drying her hair, laid the blow dryer down while it was still running to reposition the resident's head, then resumed blow drying the resident's hair. HST "DD" then heard Resident #1 moaning and noted that the resident's back and side were really red. In a statement of 07/10/2014 documented in the facility IR, LPN "AA" indicated that on 07/09/2014, HST "CC" and HST "DD" took Resident #1 to the shower around 2:30 a.m. LPN "AA" indicated that later, in response to a page, she entered the shower, heard Resident #1 moaning, and was told by HST "DD" that the resident had been burned with a blow dryer after HST "DD" propped the blow dryer on a towel to untangle and brush Resident #1's hair. LPN "AA" indicated she observed Resident #1 lying on the right side having a burn from the axillary breast area to the waist, with an area of elongated water-filled blistering, and with most of the elongated area on the back beet-red in color. LPN "AA" indicated that Resident #1 continued to moan and groan, and that the doctor was called. The facility's IR referenced above documented, in the Findings/Conclusions section, that allegations of neglect against HST "DD" were substantiated. HST "DD" admitted that while drying Resident #1's hair, she propped a blow dryer, while still running, on a towel to reposition the resident's head, resulting in a twelve (12) inch by six (6) inch burn, and failed to notice Resident #1's condition prior to the formation of the elongated twelve (12) inch by six (6) inch reddened, blistered area. The IR documented that HST "DD"'s actions caused Resident #1 physical harm and mental anguish. This IR Findings/Conclusions section also indicated the allegation of neglect was substantiated against HST "CC", in that HST "CC" was in direct view of the blow dryer being used by HST "DD" when Resident #1 was burned. During an interview conducted on 08/05/2014 at 10:00 a.m., the Service Director acknowledged that during the 07/09/2014 incident which resulted in Resident #1 sustaining a second degree burn to the left flank measuring twelve (12) by six (6) inches with peeling skin and bullous blistering causing the resident to groan in pain, exhibit facial grimacing, and to subsequently develop slough and receive antibiotic drug therapy for infection The Service Director stated that while drying Resident #1's hair, HST "DD" had propped the hair dryer on a towel, with the hair dryer still running, as the HST repositioned the resident, thus allowing the hair dryer to point directly at the resident's skin and cause the resident to sustain the second degree burn. Based on the above, despite Resident #1 having severe cognitive impairment and [DIAGNOSES REDACTED]. The HST staff member layed the hair dryer down, while still in the on position and in close proximity to Resident #1. This exposed Resident #1's left flank to direct heat from the hair dryer, causing a second degree burn to the left flank measuring twelve (12) inches by six (6) inches with peeling skin and bullous blistering, causing the resident to groan in pain and exhibit facial grimacing. Resident #1's left flank second degree burn required treatment with silver [MEDICATION NAME] cream, later developed yellow slough, resulted in the resident's transfer to the Burn Center, and required administration of Keflex antibiotic drug therapy for an infection of the wound. Cross refer to F323 for more information regarding Resident #1. The immediate jeopardy was determined to have been removed on 08/07/2014, at which time the facility had developed and implemented a credible allegation of jeopardy removal which included the following interventions: 1. On 07/09/2014, upon learning of the incident involving Resident #1 when the resident sustained [REDACTED]. The Protocol included the requirements that staff place residents in the upright position in the wheelchair and towel dry residents' hair prior to using hair dryers. This Protocol also specified that hair dryers were not to be used longer than 2 minutes at a time, and that the hair dryer must be shut off for 1 minute before resuming the process of drying a resident's hair. 2. On 08/01/2014, the HSTs who were providing care to Resident #1 at the time the resident sustained [REDACTED]. 3. On 08/05/2014, the facility again revised the ADL Protocol to include the stipulation that hair dryers could only be used in resident rooms with the resident fully clothed, and that hair dryers will always be shut off when laid down and not in use for any reason. The previously developed ADL Protocol requirements (towel drying resident hair prior to using hair dryers; ensuring hair dryers were set at the lowest setting; limiting hair dryer use to no longer than 2 minutes at a time; leaving the hair dryer shut off for 1 minute before resuming drying resident hair) remained in use. 4. On 08/06/2014, the facility initiated a Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents. This per-shift HST staff monitoring will be documented on the Daily Bath Observation Form, and would note the following: hair dryers were used on the lowest setting; hair was not dried while on the bath trolley; excess moisture was removed from the hair with a towel prior to the use of the dryer; residents were completely dressed and in the upright position (when feasible) prior to drying hair with a dryer; hair dryers were not used for more than 2 minutes at a time and then turned off, and drying with the hair dryer was not resumed until at least 1 minute had elapsed; the hair dryer was not directed at one spot for more than five seconds and the dryer was in constant motion; the hair dryer was off when not in use. This Daily Bath Observation Form would be maintained in a binder at each nurse's station. 5. On 08/06/2014, the facility initiated a procedure specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager will provide management staff oversight of the Charge Nurse/Unit Nurse per-shift observations of HST staff while providing ADL care to residents by reviewing the Daily Bath Observation Forms for each unit to ensure Charge Nurse/Unit Nurse compliance with this shift-by-shift monitoring of resident baths/shampoos. On Saturday and Sunday, this management oversight function will be conducted by daily reviews of the Daily Bath Observation Forms by the Designated Charge Nurse. Problems/deficiencies identified by management staffs' daily oversight audits of the Daily Bath Observation Forms will be documented on this Form, in the Comments/Deficiencies section. 6. On 08/06/2014, the facility continued the process of staff in-service training, originally initiated on 07/09/2014, regarding the facility's new protocols and procedures, including the revised ADL Protocol, the new Bath Observation Guide Protocol, and the new Daily Bath Observation Form. As of 08/06/2014, eight (8) of the facility's eleven (11) licensed nursing staff had received this in-service training. Two (2) of the three (3) remaining licensed nursing staff members were on Family and Medical Leave Act (FMLA) leave, and the one (1) remaining licensed nursing staff member was on annual leave. In addition, thirty-nine (39) of the facility's fifty-two (52) HST staff had received this in-service training as of 08/06/2014, with thirteen (13) HST staff being unavailable for training at that time due to off work-status or being on FMLA or annual leave. The three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff, who were unavailable for training as of 08/06/2014, will receive this in-service training regarding the new Protocols and Observation Form upon their reporting for work, before being allowed to provide direct resident care. Going forward, newly hired nursing staff will receive this in-service training related to the new Protocols and Observation Form during the period of orientation, prior to providing direct care to residents. Additionally, all nursing staff will receive updated training annually during the Annual Skilled Competency Fair, with the next Fair scheduled to occur in September 2014. 7. On 08/06/2014, the facility initiated a procedure by which the results of the Charge Nurse/Unit Nurse monitoring each shift of HST staff during the provision of resident baths/shampoos, and the results of management staffs' oversight of this shift-by-shift monitoring via daily audits of the Daily Bath Observation Forms, would be presented by the Service Director to the facility's QA Committee at the Committee's quarterly meetings. This was to allow for the QA Committee's evaluation and ongoing oversight of direct care staffs' conformance with the facility's Protocols and procedures regarding resident baths/showers, including hair dryer use, to thus allow the Committee to assess the need for policy revision or additional staff training. 8. On 08/06/2014, the facility conducted a called Quality Assurance (QA) Committee meeting to review the revised ADL Protocol, Bath Observation Guide Protocol, and Daily Bath Observation Form. The QA Committee approved the Protocols and the Observation Form. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On 08/06/2014, the facility's revised ADL Protocol was reviewed and it was confirmed that the facility had revised this Protocol on 07/09/2014, as indicated in step #1 of the facility's credible allegation of jeopardy removal referenced above. The Protocol was revised to add guidance governing the use of hair dryers, requiring that staff position residents in the upright position in the wheelchair and towel-dry residents' hair prior to hair dryer use, and limiting hair dryer use to period of no longer than 2 minutes at a time. - On 08/06/2014, it was confirmed via review of termination letters dated 08/01/2014 that the facility had released HSTs "CC" and "DD" from employment on that date, as indicated in step #2 of the facility's credible allegation of jeopardy removal, due to substantiated findings of neglect related to Resident #1's second degree burn. - On 08/06/2014, the facility's revised ADL Protocol was again reviewed and it was confirmed that the facility had revised the Protocol on 08/05/2014, as indicated in step #3 of the credible allegation of jeopardy removal, to specify that hair dryers only be used in resident rooms with the resident fully clothed, and that hair dryers always be shut off when laid down. - On 08/06/2014, it was confirmed via interview with the Administrator and Service Director, policy review, and document review that the facility had initiated, per step #4 of the credible allegation of jeopardy removal, the new procedure involving the use of the Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents, to be documented on the Daily Bath Observation Form, and would note the multiple criteria as indicated on the credible allegation of jeopardy removal. - On 08/06/2014, it was confirmed via Administrator and Service Director interview, and by policy review and document review, that the facility had initiated the new protocol, as indicated in step #5 of the credible allegation of jeopardy removal, specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager will provide management staff oversight of this process by reviewing this Daily Bath Observation Form, and on Saturday and Sunday, management oversight would be conducted by Designated Charge Nurse. - On 08/07/2014, it was confirmed via Administrator and Service Director interview and review of facility inservice records that the facility had provided in-service training to the licensed nursing staff and HST staff regarding the newly revised/implemented ADL Protocols and Daily Bath Observation Form, as indicated in step #6 of the facility's credible allegation of jeopardy removal. - On 08/07/2014, it was confirmed via Administrator interview and policy review that the findings of management staff audits of shift-by-shift monitoring of HST staff while providing resident baths/shampoos would be reviewed at each quarterly QA Committee meeting, and that the QA Committee would monitor staff compliance with the Protocols and procedures regarding resident ADL care, to ensure resident safety, as indicated in step #7 of the credible allegation of jeopardy removal. - On 08/07/2014, it was verified via Service Director interview that the QA Committee met on 08/06/2014 and reviewed the newly revised/implemented Protocols and Daily Bath Observation Form, as indicated in step #8 of the credible allegation of jeopardy removal. Additionally, survey staff was present in the facility on 08/06/2014 at the time of QA Committee meeting. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure of facility staff to use safe technique while utilizing the blow dryer during the provision of ADL care, was removed on August 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed at the time of survey completion to ensure ongoing application and completion, based on the following: On 08/05/2014, the facility revised the ADL Protocol related to the use of hair dryers to include multiple metrics to instruct staff regarding the safe use of hair dryers during the provision of resident care, and initiated a Bath Observation Guide Protocol which outlined a process of supervisory nursing staff to provide shift-by-shift monitoring of HST staff during resident showering and shampooing procedures. This monitoring was to be documented on the Daily Bath Observation Form. In addition, the Daily Bath Observation Form would be audited daily by facility management staff to ensure oversight of this process. By 08/06/2014, the facility had provided in-service training regarding the new Protocols and the new Daily Bath Observation Form, with eight (8) of the facility's eleven (11) licensed nursing staff, and thirty-nine (39) HST staff having received this training as of that date. However, three (3) licensed nursing staff and thirteen (13) HST staff were currently unavailable for training due to being off work-status or being on leave. These three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff who had not received training as of the 08/07/2014 exit date of this survey will need to receive this in-service training upon their return to work, and their completion of this required training will need assessment on a future date. In addition, on 08/06/2014, the facility initiated a procedure by which the results of the supervisory staff monitoring, per shift, of HST staff during resident baths/shampoos, and of management staffs' oversight of this shift-by-shift monitoring via daily audits, would be presented to the facility's QA Committee at the Committee's quarterly meetings to allow for the Committee's ongoing oversight of staff conformance with facility Protocols and procedures regarding resident baths/showers. However, the next scheduled QA Committee meeting was not scheduled to occur until 09/09/2014, and thus the QA Committee's process of oversight regarding these new facility Policies, procedures, and monitoring processes will need evaluation on a future date. Therefore, to allow for the assessment of the facility's completion of pending licensed nursing staff/HST staff in-service training and the QA Committee's ongoing oversight of the newly enacted Protocol and procedures as outlined above, the noncompliance continues at a decreased scope/severity of "D".

Based on clinical record review, facility Investigative Report review, and facility staff interview, the facility failed to ensure the provision of care in accordance with the Plan of Care to meet the Activities of Daily Living (ADL) needs of one (1) resident (#1), whose Plan of Care identified to be totally dependent for ADL care due to decreased mobility and deficits in cognition and communication, and whose Plan of Care further specified the provision of personal care to meet the resident's needs, on the total survey sample of seven (7) residents. As Resident #1's hair was dried with an electric hair dryer after a shower, the resident sustained [REDACTED]. Resident #1's second degree burn wound later developed slough, and the resident was treated at the Burn Center and received antibiotic drug therapy for the treatment of [REDACTED]. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during Activities of Daily Living care resulted in Resident #1 sustaining a second degree burn to the left flank measuring twelve (12) inches by six (6) inches with peeling skin and bullous blistering, causing the resident to groan in pain and exhibit facial grimacing, to later develop slough, require transfer to the Burn Center, and require treatment with antibiotic drug therapy for infection of the wound. During the August 5, 2014, 3:00 p.m. interview referenced above, the Service Director acknowledged the July 09, 2014 incident which had resulted in Resident #1 obtaining a second degree burn from a hair dryer when a Health Service Technician failed to use safe technique during the provision of Activities of Daily Living Care to the resident. An allegation of jeopardy removal was received on August 06, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 07, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the provision of staff in-service training related to the newly-implemented ADL Care/Body Checks Protocol which included procedures to ensure the safe use of hair dryers when providing resident care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's Protocol and procedures related to the provision of Activities of Daily Living Care to residents, including the safe use of resident hair dryers. Resident records were reviewed to ensure that resident assessments and Plans of Care accurately reflected the Activities of Daily Living Care provided to residents. Findings include: Resident #1's Quarterly Minimum Data Set assessment of 05/08/14 documented in Section C-Cognitive Patterns severe impairment in cognitive skills for decision-making, and documented diagnoses, in Section I-Active Diagnoses, including [MEDICAL CONDITIONS] Disorder, and [MEDICAL CONDITION]. Section G-Functional Status documented bilateral impairment in the upper/lower extremities and total dependence for all ADL care. Review of Resident #1's Plan of Care revealed a Needs/Problems entry, originally dated 08/08/2013, which identified the resident to be totally dependent for all ADL care related to decreased mobility, communication, and cognition. The Measurable Goals section of this Plan of Care indicated that care would be provided such that Resident #1's ADL needs would be met, and the Plan of Care identified Interventions which included baths daily and as needed, and that personal care would be provided to the resident as needed. A 07/09/2014, 9:31 a.m. Nursing/HST (Health Service Technician) Notes entry documented that at 2:40 a.m., Licensed Practical Nurse (LPN) "AA" was called to the shower room and observed Resident #1 to have redness to the left flank and back, with peeling skin and a fluid-filled blistered area. LPN "AA" documented the physician was notified and came to assess the resident. In a 07/09/2014, 3:56 a.m. Physician Notes - Medical form entry, Physician "EE" documented that upon assessment, she noted Resident #1 to be groaning in pain, with facial grimacing and appearing distressed, and noted an area approximately twelve (12) by six (6) inches on the left flank with bright red, peeling skin and blistering at the edges. Physician "EE" ordered hospital transfer. A 07/09/14, 9:54 p.m. Nursing/HST Notes entry documented Resident #1's return from the hospital with a left flank burn measuring about eight (8) inches by four (4) inches. A 07/09/14, 8:07 p.m. Physician Notes - Medical form entry documented that Physician "FF" examined Resident #1 after her return from the hospital and ordered silver [MEDICATION NAME] cream to the burned area twice daily. A 07/15/2014, 1:59 p.m. Physician Notes - Medical form documented Resident #1's examination at the Burn Center, and Resident #1's Client Doctor Orders form referenced a physician's orders [REDACTED]. A 07/15/14 facility Investigative Report (IR) documented that on 07/09/14 at around 2:40 a.m., after HSTs "CC" and "DD" showered Resident #1, HST "DD" was behind the resident blow drying her hair, and HST "CC" was facing the resident. HST "CC" observed Resident #1 crying, walked around and noted redness to her back, and informed LPN "AA". In a 07/10/2014 statement documented in the IR referenced above, LPN "AA" indicated that on 07/09/2014 at around 2:30 a.m., HSTs "CC" and "DD" had taken Resident #1 to the shower. LPN "AA" was then summoned via page, entered the shower and heard Resident #1 moaning. LPN "AA" was told by HST "DD" that Resident #1 was accidentally burned with a blow dryer, and that HST "DD" had propped the blow dryer on a towel while untangling and brushing the resident's hair. LPN "AA" indicated she observed a burn extending from Resident #1's axillary breast area to the waist with an elongated water-filled blister, with most of the elongated area beet-red in color. In 07/09/2014 statement documented in the IR, HST "DD" indicated she and HST "CC" had showered Resident #1 and washed her hair. HST "DD" began blow drying Resident #1's hair while behind the resident, laid the blower dryer down for about 10 seconds while in the "on" position to reposition the resident, and continued blow drying the resident's hair. HST "DD" then heard Resident #1 moaning and saw that the resident's back and side were red. The IR documented, in the Findings/Conclusions section, that HST "DD" caused Resident #1 physical harm and mental anguish for reasons which included HST "DD"'s admission that she propped a running blow dryer on a towel while drying Resident #1's hair and caused a 12 by 6 inch burn. This Findings/Conclusions section also documented that HST "CC" had been present and had seen, or was aware, that HST "DD" had placed the blow dryer on a towel when Resident #1 received the burn. During an 08/05/14, 11:30 a.m. interview, the Service Director acknowledged the 07/09/2014 incident when Resident #1 received a second degree burn to the left flank from a hair dryer. The Service Director acknowledged Resident #1's dependence on staff for ADL care, per the Plan of Care, and acknowledged HST staffs' unsafe use of the hair dryer while providing ADL care for the resident. Based on the above, Resident #1 had severe cognitive impairment, had [DIAGNOSES REDACTED]. However, facility HST staff failed to provide ADL care to meet the needs of Resident #1, as specified in the Plan of Care, by failing to use a hair dryer in a safe manner while drying the resident's hair during ADL care. Resident #1 sustained a second degree burn measuring twelve (12) by six (6) inches with blistering and yellow slough to the left flank, required treatment at the Burn Center, received silver [MEDICATION NAME] cream for the burn and Keflex antibiotic therapy for wound infection. Cross refer to F323 for more information regarding Resident #1. The immediate jeopardy was determined to have been removed on 08/07/2014, at which time the facility had developed and implemented a credible allegation of jeopardy removal which included the following interventions: 1. On 07/09/2014, upon learning of the incident involving Resident #1 when the resident sustained [REDACTED]. The Protocol included the requirements that staff place residents in the upright position in the wheelchair and towel dry residents' hair prior to using hair dryers. This Protocol also specified that hair dryers were not to be used longer than 2 minutes at a time, and that the hair dryer must be shut off for 1 minute before resuming the process of drying a resident's hair. 2. On 08/01/2014, the HSTs who were providing care to Resident #1 at the time the resident sustained [REDACTED]. 3. On 08/05/2014, the facility again revised the ADL Protocol to include the stipulation that hair dryers could only be used in resident rooms with the resident fully clothed, and that hair dryers will always be shut off when laid down and not in use for any reason. The previously developed ADL Protocol requirements (towel drying resident hair prior to using hair dryers; ensuring hair dryers were set at the lowest setting; limiting hair dryer use to no longer than 2 minutes at a time; leaving the hair dryer shut off for 1 minute before resuming drying resident hair) remained in use. 4. On 08/06/2014, the facility initiated a Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents. This per-shift HST staff monitoring will be documented on the Daily Bath Observation Form, and would note the following: hair dryers were used on the lowest setting; hair was not dried while on the bath trolley; excess moisture was removed from the hair with a towel prior to the use of the dryer; residents were completely dressed and in the upright position (when feasible) prior to drying hair with a dryer; hair dryers were not used for more than 2 minutes at a time and then turned off, and drying with the hair dryer was not resumed until at least 1 minute had elapsed; the hair dryer was not directed at one spot for more than five seconds and the dryer was in constant motion; the hair dryer was off when not in use. This Daily Bath Observation Form would be maintained in a binder at each nurse's station. 5. On 08/06/2014, the facility initiated a procedure specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager will provide management staff oversight of the Charge Nurse/Unit Nurse per-shift observations of HST staff while providing ADL care to residents by reviewing the Daily Bath Observation Forms for each unit to ensure Charge Nurse/Unit Nurse compliance with this shift-by-shift monitoring of resident baths/shampoos. On Saturday and Sunday, this management oversight function will be conducted by daily reviews of the Daily Bath Observation Forms by the Designated Charge Nurse. Problems/deficiencies identified by management staffs' daily oversight audits of the Daily Bath Observation Forms will be documented on this Form, in the Comments/Deficiencies section. 6. On 08/06/2014, the facility continued the process of staff in-service training, originally initiated on 07/09/2014, regarding the facility's new Protocol and procedures, including the revised ADL Protocol, the new Bath Observation Guide Protocol, and the new Daily Bath Observation Form. As of 08/06/2014, eight (8) of the facility's eleven (11) licensed nursing staff had received this in-service training. Two (2) of the three (3) remaining licensed nursing staff members were on Family and Medical Leave Act (FMLA) leave, and the one (1) remaining licensed nursing staff member was on annual leave. In addition, thirty-nine (39) of the facility's fifty-two (52) HST staff had received this in-service training as of 08/06/2014, with thirteen (13) HST staff being unavailable for training at that time due to off work-status or being on FMLA or annual leave. The three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff, who were unavailable for training as of 08/06/2014, will receive this in-service training regarding the new Protocols and Observation Form upon their reporting for work, before being allowed to provide direct resident care. Going forward, newly hired nursing staff will receive this in-service training related to the new Protocols and Observation Form during the period of orientation, prior to providing direct care to residents. Additionally, all nursing staff will receive updated training annually during the Annual Skilled Competency Fair, with the next Fair scheduled to occur in September 2014. 7. On 08/06/2014, the facility initiated a procedure by which the results of the Charge Nurse/Unit Nurse monitoring each shift of HST staff during the provision of resident baths/shampoos, and the results of management staffs' oversight of this shift-by-shift monitoring via daily audits of the Daily Bath Observation Forms, would be presented by the Service Director to the facility's QA Committee at the Committee's quarterly meetings. This was to allow for the QA Committee's evaluation and ongoing oversight of direct care staffs' conformance with the facility's Protocols and procedures regarding the resident baths/showers, including hair dryer use, to thus allow the Committee to assess the need for policy revision or additional staff training. 8. On 08/06/2014, the facility conducted a called Quality Assurance (QA) Committee meeting to review the revised ADL Protocol, Bath Observation Guide Protocol, and Daily Bath Observation Form. The QA Committee approved the Protocols and the Observation Form. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On 08/06/2014, the facility's revised ADL Protocol was reviewed and it was confirmed that the facility had revised this Protocol on 07/09/2014, as indicated in step #1 of the facility's credible allegation of jeopardy removal referenced above. The Protocol was revised to add guidance governing the use of hair dryers, requiring that staff position residents in the upright position in the wheelchair and towel-dry residents' hair prior to hair dryer use, and limiting hair dryer use to period of no longer than 2 minutes at a time. - On 08/06/2014, it was confirmed via review of termination letters dated 08/01/2014 that the facility had released HSTs "CC" and "DD" from employment on that date, as indicated in step #2 of the facility's credible allegation of jeopardy removal, due to substantiated findings of neglect related to Resident #1's second degree burn. - On 08/06/2014, the facility's revised ADL Protocol was again reviewed and it was confirmed that the facility had revised the Protocol on 08/05/2014, as indicated in step #3 of the credible allegation of jeopardy removal, to specify that hair dryers only be used in resident rooms with the resident fully clothed, and that hair dryers always be shut off when laid down. - On 08/06/2014, it was confirmed via interview with the Administrator and Service Director, policy review, and document review that the facility had initiated, per step #4 of the credible allegation of jeopardy removal, the new procedure involving the use of the Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents, to be documented on the Daily Bath Observation Form, and would note the multiple criteria. - On 08/06/2014, it was confirmed via Administrator and Service Director interview, and by policy review and document review, that the facility had initiated the new protocol, as indicated in step #5 of the credible allegation of jeopardy removal, which specified that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager will provide management staff oversight of this process by reviewing this Daily Bath Observation Form, and on Saturday and Sunday, management oversight would be conducted by Designated Charge Nurse. - On 08/07/2014, it was confirmed via Administrator and Service Director interview and review of facility inservice records that the facility had provided in-service training to the licensed nursing staff and HST staff regarding the newly revised/implemented ADL Protocols and Daily Bath Observation Form, as indicated in step #6 of the facility's credible allegation of jeopardy removal. - On 08/07/2014, it was confirmed via Administrator interview and policy review that the findings of management staff audits of shift-by-shift monitoring of HST staff while providing resident baths/shampoos would be reviewed at each quarterly QA Committee meeting, and that the QA Committee would monitor staff compliance with the Protocols and procedures regarding resident ADL care, to ensure resident safety, as indicated in step #7 of the credible allegation of jeopardy removal. - On 08/07/2014, it was verified via Service Director interview that the QA Committee met on 08/06/2014 and reviewed the newly revised/implemented Protocols and Daily Bath Observation Form, as indicated in step #8 of the credible allegation of jeopardy removal. Additionally, survey staff was present in the facility on 08/06/2014 at the time of QA Committee meeting. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure of facility staff to use safe technique while utilizing the blow dryer during the provision of ADL care was removed on August 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed at the time of survey completion to ensure ongoing application and completion, based on the following: On 08/05/2014, the facility revised the ADL Protocol related to the use of hair dryers to include multiple metrics to instruct staff regarding the safe use of hair dryers during the provision of resident care, and initiated a Bath Observation Guide Protocol which outlined a process of supervisory nursing staff to provide shift-by-shift monitoring of HST staff during resident showering and shampooing procedures. This monitoring was to be documented on the Daily Bath Observation Form. In addition, the Daily Bath Observation Form would audited daily by facility management staff to ensure oversight of this process. By 08/06/2014, the facility had provided in-service training regarding the new Protocols and the new Daily Bath Observation Form, with eight (8) of the facility's eleven (11) licensed nursing staff, and thirty-nine (39) HST staff having received this training as of that date. However, three (3) licensed nursing staff, and thirteen (13) HST staff were currently unavailable for training due to being off work-status or being on leave. These three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff who had not received training as of the 08/07/2014 exit date of this survey will need to receive this in-service training upon their return to work, and their completion of this required training will need assessment on a future date. In addition, on 08/06/2014, the facility initiated a procedure by which the results of the supervisory staff monitoring, per shift, of HST staff during resident baths/shampoos, and of management staffs' oversight of this shift-by-shift monitoring via daily audits, would be presented to the facility's QA Committee at the Committee's quarterly meetings to allow for the Committee's ongoing oversight of staff conformance with facility Protocols and procedures regarding resident baths/showers. However, the next scheduled QA Committee meeting was not scheduled to occur until 09/09/2014, and thus the QA Committee's process of oversight regarding these new facility Policies, procedures, and monitoring processes will need evaluation on a future date. Therefore, to allow for the assessment of the facility's completion of pending licensed nursing staff/HST staff in-service training and the QA Committee's ongoing oversight of the newly enacted Protocol and procedures as outlined above, the noncompliance continues at a decreased scope/severity of "D".

Based on clinical record review, observation, facility Investigative Report review, Occupational Therapy Evaluation review, physician interview, and facility staff interview, the facility failed to ensure the supervision necessary to prevent an accident resulting in a second degree burn during Activities of Daily Living (ADL) Care for one (1) resident (#1), who was totally dependent on staff for ADL care, on the total survey sample of seven (7) residents. As direct-care staff dried Resident #1's hair using an electric hair dryer after the resident had received a shower, Resident #1 sustained a second degree burn to the left flank measuring twelve (12) inches by six (6) inches with peeling skin and bullous blistering at the edges, causing the resident to groan in pain and exhibit facial grimacing. Resident #1's second degree burn wound later developed slough, and the resident was transferred to the Burn Center for evaluation and treatment and was treated with antibiotic drug therapy for infection. This resulted in a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during the provision of Activities of Daily Living care to Resident #1 resulted in the resident sustaining a second degree burn, and the resident's subsequent referral to the Burn Center for treatment and receipt of antibiotic drug therapy for treatment of [REDACTED].#1 sustained a second degree burn to her left flank when Health Service Technician staff used a hair dryer in an unsafe manner while drying the resident's hair after a bath. An allegation of jeopardy removal was received on August 06, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 07, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued staff in-service training related to the newly-implemented ADL Care/Body Checks Protocol which included procedures to ensure the safe use of hair dryers when providing resident care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's Protocol and procedures related to the provision of Activities of Daily Living Care to residents, including the safe use of resident hair dryers. Resident records were reviewed to ensure that resident assessments and Plans of Care accurately reflected the Activities of Daily Living Care provided to residents. Findings include: Record review for Resident #1 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 05/08/2014 which documented in Section C - Cognitive Patterns that the Brief Interview for Mental Status not be conducted due to the resident being rarely/never understood, that the resident had both short-term and long-term memory problems, and that the resident had severe impairment in cognitive skills for daily decision-making. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section G - Functional Status documented impairment of Resident #1's upper and lower extremities on both sides, and documented total dependence on staff for all ADLs, to include bathing and hair care. An Occupational Therapy Evaluation (OTE) for Resident #1 dated 07/02/2014 documented the resident to have an additional [DIAGNOSES REDACTED]. This OTE for Resident #1 further defined the resident's [DIAGNOSES REDACTED]. This OTE also documented that Resident #1 had generalized hypertonicity and exhibited no functional gross motor mobility skills. A Nursing/HST (Health Service Technician) Notes entry of 07/09/2014 timed at 9:31 a.m. for Resident #1 documented that at 2:40 a.m., Licensed Practical Nurse (LPN) "AA" had been called to the shower room by HSTs and observed Resident #1 lying on the right side on the shower trolley, and also observed a hair dryer which was present but turned off. LPN "AA" documented she noted redness to Resident #1's left flank and back, with peeling skin and a fluid-filled blistered area, and that the resident was transferred from the shower trolley to the bed. LPN "AA" documented the physician was notified, came to the unit to assess Resident #1, and ordered that the resident be transported to the hospital for evaluation and treatment. A Physician Notes - Medical form entry of 07/09/2014 timed at 3:56 a.m. completed by Physician "EE" for Resident #1 documented that at approximately 2:45 a.m. on 07/09/2014, this physician had been called to the facility due to Resident #1 having a significant burn. The physician documented that she had been informed by staff that while receiving a bath, Resident #1 had sustained a significant burn to the left flank caused by a hair dryer. The physician documented that upon her arrival to the unit, Resident #1 was groaning in pain, with facial grimacing and appearing to be distressed. Physician "EE" also documented that Resident #1 had an area measuring approximately twelve (12) inches by six (6) inches on the left flank with bright red skin and an overlay of peeling skin and bullous blistering at the edges, and documented the plan to transfer the resident to the hospital emergency room . A Nursing/HST Notes entry of 07/09/2014 timed at 6:33 a.m. by Registered Nurse (RN) "BB" for Resident #1 documented the resident's transport to the hospital at 3:45 a.m. following a second degree burn to the left flank area measuring approximately twelve (12) inches long and six (6) inches wide. RN "BB" documented that the burned area appeared to be moist and was reddened with blisters. RN "BB" further documented that Resident #1 was making moaning sounds for which Tylenol was administered. A Nursing/HST Notes entry of 07/09/2014 timed at 9:54 p.m. for Resident #1 documented that the resident had returned from the hospital at 8:00 p.m. on that date and was noted to have a burn on the left flank measuring about eight (8) inches by four (4) inches in size at that time. This Notes entry further documented that the facility physician was notified and came to evaluate the resident. A Physician Notes - Medical form entry of 07/09/2014 timed at 8:07 p.m. completed by Physician "FF" for Resident #1 documented the physician's examination of the resident after her return from the hospital, with the examination revealing a burn measuring eight (8) inches by five (5) inches. Physician "FF" gave orders for silver sulfadiazine cream to be applied to the burned area twice daily, and Tylenol 650 milligrams every six (6) hours for seventy-two (72) hours. A subsequent Physician Notes - Medical form entry of 07/10/2014 timed at 1:21 p.m. completed by Physician "GG" for Resident #1 documented the physician had examined the resident on that date and noted the resident's burn of the left lateral trunk to have no bleeding or drainage, but also noted a six (6) by three (3) inch area of the burn with all the skin gone. The physician referenced Resident #1's use of the silver sulfadiazine cream dressing and Tylenol for pain, related to the burn. During an interview with Physician "GG" conducted on 08/05/2014 at 12:00 noon, Physician "GG" acknowledged he had examined Resident #1 the day following the resident's return from the hospital (as documented in the 07/10/2014, 1:21 p.m. Physician Notes-Medical form entry referenced above), and stated that Resident #1 had experienced a second degree burn with blistering and slough. During a subsequent 08/05/2014, 2:00 p.m. interview, when asked about the actual size of Resident #1's burn wound, Physician "GG" stated that the area of Resident #1's burn wound measuring six (6) inches by three (3) inches (as documented in his 07/10/2014, 1:21 p.m. Physician Notes-Medical form), was the specific area of the burn to which the silver sulfadiazine cream was applied. The physician further stated that the resident's initial burn wound when new would likely have had a larger area of redness. Further record review for Resident #1 revealed a Nursing/HST Notes entry of 07/12/2014 timed at 12:00 a.m. which documented the resident's left flank burn wound was noted with a minimal amount of greenish pus drainage, and documented the burn was cleaned with wound cleanser and the silver sulfadiazine cream dressing was applied as ordered. A Nursing/HST Notes entry of 07/12/2014 timed at 1:16 p.m. for Resident #1 documented that during the treatment of [REDACTED]. A subsequent Nursing/HST Notes entry of 07/14/2014 timed at 9:47 p.m. documented that the resident was scheduled for an appointment at the hospital Burn Center on the following day of 07/15/2014. A 07/15/2014, 1:59 p.m. Physician Notes - Medical form for Resident #1 documented that the resident had returned from the Burn Center with an order to continue the silver sulfadiazine wound dressing twice daily, and also documented an additional order specifying the administration of the antibiotic Keflex 500 milligrams four (4) times daily. Review of Resident #1's Client Doctor Orders form revealed a physician's orders [REDACTED]. A 07/19/2014 Nursing/HST Notes entry timed at 3:14 p.m. for Resident #1 documented that the resident's left axillary (flank) wound dressing change (silver sulfadiazine) had been done as ordered on that date. This Notes entry also documented that Resident #1's burn wound appeared red, having light green slough in the middle of the wound bed at that time. A subsequent Nursing/HST Notes entry of 07/25/2014 timed at 3:58 p.m. for Resident #1 documented that the resident's left axillary wound dressing change had been performed earlier that morning, and documented that the wound continued to have green slough in the middle. A Nursing/HST Notes entry of 07/27/2014 timed at 3:05 p.m. for Resident #1 documented that the resident's wound care had been provided and that resident's left side flank wound had noticeable improvement at that time. During an observation of Resident #1 conducted on 08/05/2014 at 2:30 p.m., Resident #1 was noted with a burn wound to the left flank measuring approximately six (6) inches by three (3) inches, and having scar tissue to the left flank. Resident #1 was observed to be total immobile, having significantly decreased movement of the bilateral upper and lower extremities, and having no ability to speak. A facility Investigative Report (IR) dated 07/15/2014 documented the facility's investigation into the 07/09/2014 incident during which Resident #1 sustained a second degree burn to the left flank. The IR documented in the Chronology of Incident section that at around 1:00 a.m. to 1:30 a.m. on 07/09/2014, Resident #1 received a bowel preparation and then had a bowel movement, and thus needed a bath. The IR then documented in the Summary of Allegation(s)/Incident section that on 07/09/2014 at around 2:40 a.m., HST "CC" was assisting HST "DD" in showering Resident #1. The IR further documented that following the shower, HST "DD" was standing behind the resident blow drying her hair with an electric blow dryer, and then HST "CC", who was standing facing the resident, observed the resident to be crying. HST "CC" walked around to the back of Resident #1 and noted redness to her back, at which time HST "CC" informed LPN "AA" of this observation. In a statement provided by HST "DD" dated 07/09/2014 and documented in the facility IR referenced above, HST "DD" indicated that between 2:00 a.m. and 2:15 a.m. (on 07/09/2014), she and HST "CC" went to Resident #1's room to prepare the resident for a shower. HST "DD" indicated that she and HST "CC" placed the resident on her right side on the bath trolley and proceeded into the shower room, undressed the resident and washed her body and hair. HST "DD" indicated that she began blow drying Resident #1's hair while standing behind her, and that in order to maneuver the resident's head to pull her hair from beneath her body, HST "DD" laid the blow dryer down, while it was still on, for about ten (10) seconds and then resumed blow drying the resident's hair. HST "DD" indicated she then heard Resident #1 moaning, looked at the resident's back and side, and saw that the residents back and side were really red. In a statement provided by HST "CC" dated 07/09/2014 and documented in the facility IR referenced above, HST "CC" indicated that at around 2:30 a.m. (on 07/09/2014), HST "DD" had requested her to assist in showering Resident #1. HST "CC" indicated that after the bath was completed, HST "DD" began blow drying Resident #1's hair, and the HSTs placed the resident on her left side, with the resident lying on her left arm. HST "CC" indicated that she then heard Resident #1 moaning, walked around to the back side of the resident and observed pink skin on the left side of the resident's body. LPN "AA" was then summoned and responded to the shower room. In a statement provided by LPN "AA" dated 07/10/2014 and documented the facility IR referenced above, LPN "AA" indicated that during the 11:00 p.m. to 7:00 a.m. shift of 07/08/2014, resident bowel preparations were scheduled, and that Resident #1 had received a bowel preparation on 07/09/2014 at 1:30 a.m. HST "CC" and HST "DD" had taken Resident #1 to the shower room around 2:30 a.m., and that later, the nurse overhead a page requesting her to respond. LPN "AA" indicated she entered the doorway of the shower room and heard Resident #1 moaning, and was told by HST "DD" that the HSTs had accidentally burned the resident with the blow dryer. LPN "AA" indicated that she was told by HST "DD" that while drying Resident #1's hair, HST "DD" had propped the blow dryer up on a towel for a moment while she untangled and brushed Resident #1's hair. LPN "AA" indicated she observed Resident #1 lying on the right side, having a burn extending from the axillary breast area down to the waist, with an area on the skin that had an elongated water-filled blister, with most of the elongated area on the back being beet-red and having one dark circular spot. LPN "AA" indicated that during this observation, Resident #1 continued to moan and groan, and the LPN then called the doctor to inform the doctor of the resident's burn. The IR referenced above further documented, in the Findings/Conclusions section, that upon conclusion of the facility's investigation into the 07/09/2014 incident during which Resident #1 sustained the second degree burn to the left flank, the facility concluded that HST "DD"'s actions had directly caused Resident #1 physical harm and mental anguish. The IR documented this conclusion was based on reasons which included HST "DD"'s admission to LPN "AA" that while drying Resident #1's hair, HST "DD" had propped the blow dryer, while it was still running, on a towel while she repositioned the resident's head, resulting in the twelve (12) inch by six (6) inch burn; also, HST "DD" had failed to notice Resident #1's condition prior to the formation of an elongated twelve (12) inch by six (6) inch reddened area with blisters. This Findings/Conclusions section of the IR also documented the facility concluded that HST "CC" had been present and in direct view of the blow dryer being utilized by HST "DD" when drying Resident #1's hair, thus indicating she had seen, or was aware, that HST "CC" placed the blow dryer on a towel, after which Resident #1 sustained the burn. During an interview with the Service Director conducted on 08/05/2014 at 10:00 a.m., the Service Director acknowledged the 07/09/2014 incident during which Resident #1 sustained a second degree burn wound to her left flank, twelve (12) by six (6) inches in size, with peeling skin, bullous blistering and slough, later requiring Burn Center transfer and antibiotic treatment. The Service Director acknowledged that as the HST staff was preparing to dry Resident #1's hair, the HST propped the hairdryer on a towel, with the hair dryer still in the on-position, as the HST paused to reposition the resident to allow better access to her hair. The Service Director acknowledged that the HST failed to turn the hair dryer off as she repositioned Resident #1, and placed the hair dryer in a position that allowed it to point directly at the resident's skin for a long enough period to cause the resident to get burned. In the 08/05/2014, 12:00 noon interview with Physician "GG" referenced above during which Physician "GG" acknowledged Resident #1 having experienced the second degree burn to the left flank, the physician further stated that when the HST laid the hair dryer down while the dryer was still on, it would have taken only a few seconds to cause a lot of damage. During an interview with the Service Director conducted on 08/05/2014 at 11:30 a.m., the Service Director stated that prior to the 07/09/2014 incident during which Resident #1 received the burn due to staffs' unsafe use of a hair dryer, the facility had not provided specific training to direct-care staff related to the use of hair dryers for drying residents' hair. The Service Director further stated, however, that the use of a hairdryer for a person such as Resident #1, who was totally dependent and could not speak-out or move, would be different than hair dryer use for a nondependent person. The Service Director further acknowledged that after Resident #1's burn injury resulting from staffs' unsafe use of a hair dryer, the facility had identified the need for staff training in the use of hair dryers for residents. Based on the above, despite Resident #1 having severe cognitive impairment and [DIAGNOSES REDACTED].#1 in a safe manner while drying her hair. HST "DD" laid the hair dryer down, while the dryer was in the on position, in close proximity to Resident #1 who was laying on a shower trolley, thus exposing the resident's left flank to direct heat from the hair dryer. Resident #1 sustained a second degree burn with blistering and yellow slough to the left flank, required treatment by the Burn Center, received silver sulfadiazine cream treatment for [REDACTED]. The immediate jeopardy was determined to have been removed on 08/07/2014, at which time the facility had developed and implemented a credible allegation of jeopardy removal which included the following interventions: 1. On 07/09/2014, upon learning of the incident involving Resident #1 when the resident sustained [REDACTED]. The Protocol included the requirements that staff place residents in the upright position in the wheelchair and towel dry residents' hair prior to using hair dryers. This Protocol also specified that hair dryers were not to be used longer than 2 minutes at a time, and that the hair dryer must be shut off for 1 minute before resuming the process of drying a resident's hair. 2. On 08/01/2014, the HSTs who were providing care to Resident #1 at the time the resident sustained [REDACTED]. 3. On 08/05/2014, the facility again revised the ADL Protocol to include the stipulation that hair dryers could only be used in resident rooms with the resident fully clothed, and that hair dryers will always be shut off when laid down and not in use for any reason. The previously developed ADL Protocol requirements (towel drying resident hair prior to using hair dryers; ensuring hair dryers were set at the lowest setting; limiting hair dryer use to no longer than 2 minutes at a time; leaving the hair dryer shut off for 1 minute before resuming drying resident hair) remained in use. 4. On 08/06/2014, the facility initiated a Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents. This per-shift HST staff monitoring will be documented on the Daily Bath Observation Form, and would note the following: hair dryers were used on the lowest setting; hair was not dried while on the bath trolley; excess moisture was removed from the hair with a towel prior to the use of the dryer; residents were completely dressed and in the upright position (when feasible) prior to drying hair with a dryer; hair dryers were not used for more than 2 minutes at a time and then turned off, and drying with the hair dryer was not resumed until at least 1 minute had elapsed; the hair dryer was not directed at one spot for more than five seconds and the dryer was in constant motion; the hair dryer was off when not in use. This Daily Bath Observation Form would be maintained in a binder at each nurse's station. 5. On 08/06/2014, the facility initiated a procedure specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager will provide management staff oversight of the Charge Nurse/Unit Nurse per-shift observations of HST staff while providing ADL care to residents by reviewing the Daily Bath Observation Forms for each unit to ensure Charge Nurse/Unit Nurse compliance with this shift-by-shift monitoring of resident baths/shampoos provided by HST staff. On Saturday and Sunday, this management oversight function will be conducted by daily reviews of the Daily Bath Observation Forms by the Designated Charge Nurse. Problems/deficiencies identified by management staffs' daily oversight audits of the Daily Bath Observation Forms will be documented on this Form, in the Comments/Deficiencies section. 6. On 08/06/2014, the facility continued the process of staff in-service training, originally initiated on 07/09/2014, regarding the facility's new Protocols and procedures, including the revised ADL Protocol, the new Bath Observation Guide Protocol, and the new Daily Bath Observation Form. As of 08/06/2014, eight (8) of the facility's eleven (11) licensed nursing staff had received this in-service training. Two (2) of the three (3) remaining licensed nursing staff members were on Family and Medical Leave Act (FMLA) leave, and the one (1) remaining licensed nursing staff member was on annual leave. In addition, thirty-nine (39) of the facility's fifty-two (52) HST staff had received this in-service training as of 08/06/2014, with thirteen (13) HST staff being unavailable for training at that time due to off work-status or being on FMLA or annual leave. The three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff, who were unavailable for training as of 08/06/2014, will receive this in-service training regarding the new Protocols and Observation Form upon their reporting for work, before being allowed to provide direct resident care. Going forward, newly hired nursing staff will receive this in-service training related to the new Protocols and Observation Form during the period of orientation, prior to providing direct care to residents. Additionally, all nursing staff will receive updated training annually during the Annual Skilled Competency Fair, with the next Fair scheduled to occur in September 2014. 7. On 08/06/2014, the facility initiated a procedure by which the results of the Charge Nurse/Unit Nurse monitoring each shift of HST staff during the provision of resident baths/shampoos, and the results of management staffs' oversight of this shift-by-shift monitoring via daily audits of the Daily Bath Observation Forms, would be presented by the Service Director to the facility's QA Committee at the Committee's quarterly meetings. This was to allow for the QA Committee's evaluation and ongoing oversight of direct care staffs' conformance with the facility's Protocols and procedures regarding the resident baths/showers, including hair dryer use, to thus allow the Committee to assess the need for policy revision or additional staff training. 8. On 08/06/2014, the facility conducted a called Quality Assurance (QA) Committee meeting to review the revised ADL Protocol, Bath Observation Guide Protocol, and Daily Bath Observation Form. The QA Committee approved the Protocols and the Observation Form. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On 08/06/2014, the facility's revised ADL Protocol was reviewed and it was confirmed that the facility had revised this Protocol on 07/09/2014, as indicated in step #1 of the facility's credible allegation of jeopardy removal referenced above. The Protocol was revised to add guidance governing the use of hair dryers, requiring that staff position residents in the upright position in the wheelchair and towel-dry residents' hair prior to hair dryer use, and limiting hair dryer use to period of no longer than 2 minutes at a time. - On 08/06/2014, it was confirmed via review of termination letters dated 08/01/2014 that the facility had released HSTs "CC" and "DD" from employment on that date, as indicated in step #2 of the facility's credible allegation of jeopardy removal, due to substantiated findings of neglect related to Resident #1's second degree burn. - On 08/06/2014, the facility's revised ADL Protocol was again reviewed and it was confirmed that the facility had revised the Protocol on 08/05/2014, as indicated in step #3 of the credible allegation of jeopardy removal, to specify that hair dryers only be used in resident rooms with the resident fully clothed, and that hair dryers always be shut off when laid down. - On 08/06/2014, it was confirmed via interview with the Administrator and Service Director, policy review, and document review that the facility had initiated, per step #4 of the credible allegation of jeopardy removal, the new procedure involving the use of the Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents, to be documented on the Daily Bath Observation Form, and would note the multiple criteria. - On 08/06/2014, it was confirmed via Administrator and Service Director interview, and by policy review and document review, that the facility had initiated the new protocol, as indicated in step #5 of the the credible allegation of jeopardy removal, specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager would provide management staff oversight of this process by reviewing the Daily Bath Observation Forms, and on Saturday and Sunday, management oversight would be conducted by the Designated Charge Nurse. - On 08/07/2014, it was confirmed via Administrator and Service Director interview and review of facility inservice records that the facility had provided in-service training to the licensed nursing staff and HST staff regarding the newly revised/implemented ADL Protocols and Daily Bath Observation Form, as indicated in step #6 of the facility's credible allegation of jeopardy removal. - On 08/07/2014, it was confirmed via Administrator interview and policy review that the findings of management staff audits of shift-by-shift monitoring of HST staff while providing resident baths/shampoos would be reviewed at each quarterly QA Committee meeting, and that the QA Committee would monitor staff compliance with the Protocols and procedures regarding resident ADL care, to ensure resident safety, as indicated in step #7 of the credible allegation of jeopardy removal. - On 08/07/2014, it was verified via Service Director interview that the QA Committee met on 08/06/2014 and reviewed the newly revised/implemented Protocols and Daily Bath Observation Form, as indicated in step #8 of the credible allegation of jeopardy removal. Additionally, survey staff was present in the facility on 08/06/2014 at the time of QA Committee meeting. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure of facility staff to use safe technique while utilizing the blow dryer during the provision of ADL care was removed on August 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed at the time of survey completion to ensure ongoing application and completion, based on the following: On 08/05/2014, the facility revised the ADL Protocol related to the use of hair dryers to include multiple metrics to instruct staff regarding the safe use of hair dryers during the provision of resident care, and initiated a Bath Observation Guide Protocol which outlined a process of supervisory nursing staff to provide shift-by-shift monitoring of HST staff during resident showering and shampooing procedures. This monitoring was to be documented on the Daily Bath Observation Form. In addition, the Daily Bath Observation Form would be audited daily by facility management staff to ensure oversight of this process. By 08/06/2014, the facility had provided in-service training regarding the new Protocols and the new Daily Bath Observation Form, with eight (8) of the facility's eleven (11) licensed nursing staff, and thirty-nine (39) HST staff having received this training as of that date. However, three (3) licensed nursing staff and thirteen (13) HST staff were currently unavailable for training due to being off work-status or being on leave. These three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff who had not received training as of the 08/07/2014 exit date of this survey will need to receive this in-service training upon their return to work, and their completion of this required training will need assessment on a future date. In addition, on 08/06/2014, the facility initiated a procedure by which the results of the supervisory staff monitoring, per shift, of HST staff during resident baths/shampoos, and of management staffs' oversight of this shift-by-shift monitoring via daily audits, would be presented to the facility's QA Committee at the Committee's quarterly meetings to allow for the Committee's ongoing oversight of staff conformance with facility Protocols and procedures regarding resident baths/showers. However, the next scheduled QA Committee meeting was not scheduled to occur until 09/09/2014, and thus the QA Committee's process of oversight regarding these new facility Policies, procedures, and monitoring processes will need evaluation on

Based on observation, record review, and staff interview, facility administration failed to ensure a system by which to assess and monitor direct-care staffs' provision of Activities of Daily Living (ADL) Care, to thereby ensure resident safety during the use of electric hair dryers, after one (1) resident (#1) who was totally dependent for ADL care sustained a second degree burn to the left flank as direct-care staff used an electric hair dryer in an unsafe manner. The survey sample was seven (7) residents. For Resident #1, direct-care staff failed to utilize a hair dryer in a safe manner while drying Resident #1's hair after the resident received a bath. Resident #1 sustained a second degree burn to the left flank twelve (12) by six (6) inches in size, with peeling skin and bullous blistering, causing the resident to groan in pain and exhibit facial grimacing. Resident #1's second degree burn developed slough, the resident was transferred to the Burn Center and treated with antibiotic drug therapy for wound infection. In response to this incident involving Resident #1 receiving a second degree burn due to staff's unsafe use of a hair dryer, the facility implemented a corrective plan involving Policy revision and staff in-service training; however, the facility failed to develop and implement a protocol to allow for the ongoing monitoring of staffs' use of hair dryers when providing resident care, to ensure ongoing resident safety. This resulted in a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during the provision of Activities of Daily Living care to Resident #1 resulted in the resident sustaining a second degree burn, and the resident's subsequent referral to the Burn Center for treatment, and receipt of antibiotic drug therapy for treatment of [REDACTED].#1's burn with a hair dryer, but acknowledged that she had developed no system to ensure the ongoing monitoring of direct-care staff regarding hair dryer use. An allegation of jeopardy removal was received on August 06, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 07, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued staff in-service training related to the newly-implemented ADL Care/Body Checks Protocol which included procedures to ensure the safe use of hair dryers when providing resident care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's Protocol and procedures related to the provision of Activities of Daily Living Care to residents, including the safe use of resident hair dryers. Resident records were reviewed to ensure that resident assessments and Plans of Care accurately reflected the Activities of Daily Living Care provided to residents. Findings include: Cross refer to F323. Based on record review, observation, and staff interview, the facility failed to ensure safety during Activities of Daily Living (ADL) Care for one (1) resident (#1), who was totally dependent on staff for ADL care, on the total survey sample of seven (7) residents. Direct-care nursing staff failed to use safe procedure as Resident #1's hair was dried with an electric hair dryer after a bath, and the resident sustained [REDACTED]. Resident #1's second degree burn wound later developed slough, the resident was examined at the Burn Center, and received antibiotic drug therapy for infection. During an interview with the facility's Administrator conducted on 08/07/2014 at 1:30 p.m., the Administrator was questioned regarding the 07/09/2014 incident during which Resident #1 sustained the second degree burn to the left flank measuring twelve (12) inches by six (6) inches with peeling skin and bullous blistering at the edges, which later developed slough and which caused the resident to groan in pain and exhibit facial grimacing. During this interview, the Administrator was questioned about her response to, and the corrective action plan put into place since, the 07/09/2014 incident resulting in Resident #1 receiving the left flank burn from a hair dryer. The Administrator stated that on the 07/09/2014 date of the incident, she reviewed and revised the facility's ADL Policy related to ADL care, and in addition, a copy of the new policy and in-service training were provided to direct-care staff on that date. During the 08/07/2014, 1:30 p.m. interview referenced above, the Administrator was also questioned to determine if a system or process had been put into place after the 07/09/2014 burn incident involving Resident #1, and the resulting in-service training regarding hair dryer use provided to direct-care staff related to the revised ADL Policy, to ensure direct-care staffs' conformance with the new Policy. The Administrator stated that prior to the 07/09/2014 incident involving Resident #1 which resulted in the second degree burn, there had been no system for monitoring for the safe use of hair dryers by facility staff. The Administrator further stated that after the 07/09/2014 burn incident involving Resident #1, and after the additional training provided to staff on the revised ADL Policy related to hair dryer use, she had still put no system in place for monitoring staffs' use of electric blow dryers during resident ADL care to ensure that blow dryers were used safely. The Administrator further acknowledged that prior to the previous day of 08/06/2014 (approximately one (1) month after the 07/09/1024 incident involving Resident #1's second degree burn from a hair dryer), there had been no system to monitor direct-care staff use of hair dryers to ensure the correct and safe use of hair dryers during resident care. Based on the above, despite Resident #1 sustaining a left flank second degree burn measuring twelve (12) by six (6) inches, having peeling skin, bullous blistering, slough, and requiring antibiotic therapy for infection, and despite facility administration's subsequent revision of the facility's ADL Policy and the provision of staff in-service training, facility administration failed to develop and implement a process by which to monitor direct-care staff as they provided resident care using hair dryers. Facility administration therefore failed to ensure direct-care staffs' understanding of, and conformance with, the revised policy related to the use of electric hair dryers to ensure safe hair dryer use. The immediate jeopardy was determined to have been removed on 08/07/2014, at which time the facility had developed and implemented a credible allegation of jeopardy removal which included the following interventions: 1. On 07/09/2014, upon learning of the incident involving Resident #1 when the resident sustained [REDACTED]. The Protocol included the requirements that staff place residents in the upright position in the wheelchair and towel dry residents' hair prior to using hair dryers. This Protocol also specified that hair dryers were not to be used longer than 2 minutes at a time, and that the hair dryer must be shut off for 1 minute before resuming the process of drying a resident's hair. 2. On 08/01/2014, the HSTs who were providing care to Resident #1 at the time the resident sustained [REDACTED]. 3. On 08/05/2014, the facility again revised the ADL Protocol to include the stipulation that hair dryers could only be used in resident rooms with the resident fully clothed, and that hair dryers will always be shut off when laid down and not in use for any reason. The previously developed ADL Protocol requirements (towel drying resident hair prior to using hair dryers; ensuring hair dryers were set at the lowest setting; limiting hair dryer use to no longer than 2 minutes at a time; leaving the hair dryer shut off for 1 minute before resuming drying resident hair) remained in use. 4. On 08/06/2014, the facility initiated a Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents. This per-shift HST staff monitoring will be documented on the Daily Bath Observation Form, and would note the following: hair dryers were used on the lowest setting; hair was not dried while on the bath trolley; excess moisture was removed from the hair with a towel prior to the use of the dryer; residents were completely dressed and in the upright position (when feasible) prior to drying hair with a dryer; hair dryers were not used for more than 2 minutes at a time and then turned off, and drying with the hair dryer was not resumed until at least 1 minute had elapsed; the hair dryer was not directed at one spot for more than five seconds and the dryer was in constant motion; the hair dryer was off when not in use. This Daily Bath Observation Form would be maintained in a binder at each nurse's station. 5. On 08/06/2014, the facility initiated a procedure specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager will provide management staff oversight of the Charge Nurse/Unit Nurse per-shift observations of HST staff while providing ADL care to residents by reviewing the Daily Bath Observation Forms for each unit to ensure Charge Nurse/Unit Nurse compliance with this shift-by-shift monitoring of resident baths/shampoos. On Saturday and Sunday, this management oversight function will be conducted by daily reviews of the Daily Bath Observation Forms by the Designated Charge Nurse. Problems/deficiencies identified by management staffs' daily oversight audits of the Daily Bath Observation Forms will be documented on this Form, in the Comments/Deficiencies section. 6. On 08/06/2014, the facility continued the process of staff in-service training, originally initiated on 07/09/2014, regarding the facility's new Protocols and procedures, including the revised ADL Protocol, the new Bath Observation Guide Protocol, and the new Daily Bath Observation Form. As of 08/06/2014, eight (8) of the facility's eleven (11) licensed nursing staff had received this in-service training. Two (2) of the three (3) remaining licensed nursing staff members were on Family and Medical Leave Act (FMLA) leave, and the one (1) remaining licensed nursing staff member was on annual leave. In addition, thirty-nine (39) of the facility's fifty-two (52) HST staff had received this in-service training as of 08/06/2014, with thirteen (13) HST staff being unavailable for training at that time due to off work-status or being on FMLA or annual leave. The three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff, who were unavailable for training as of 08/06/2014, will receive this in-service training regarding the new Protocols and Observation Form upon their reporting for work, before being allowed to provide direct resident care. Going forward, newly hired nursing staff will receive this in-service training related to the new Protocols and Observation Form during the period of orientation, prior to providing direct care to residents. Additionally, all nursing staff will receive updated training annually during the Annual Skilled Competency Fair, with the next Fair scheduled to occur in September 2014. 7. On 08/06/2014, the facility initiated a procedure by which the results of the Charge Nurse/Unit Nurse monitoring each shift of HST staff during the provision of resident baths/shampoos, and the results of management staffs' oversight of this shift-by-shift monitoring via daily audits of the Daily Bath Observation Forms, would be presented by the Service Director to the facility's QA Committee at the Committee's quarterly meetings. This was to allow for the QA Committee's evaluation and ongoing oversight of direct care staffs' conformance with the facility's Protocols and procedures regarding resident baths/showers, including hair dryer use, to thus allow the Committee to assess the need for policy revision or additional staff training. 8. On 08/06/2014, the facility conducted a called Quality Assurance (QA) Committee meeting to review the revised ADL Protocol, Bath Observation Guide Protocol, and Daily Bath Observation Form. The QA Committee approved the Protocols and the Observation Form. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On 08/06/2014, the facility's revised ADL Protocol was reviewed and it was confirmed that the facility had revised this Protocol on 07/09/2014, as indicated in step #1 of the facility's credible allegation of jeopardy removal referenced above. The Protocol was revised to add guidance governing the use of hair dryers, requiring that staff position residents in the upright position in the wheelchair and towel-dry residents' hair prior to hair dryer use, and limiting hair dryer use to period of no longer than 2 minutes at a time. - On 08/06/2014, it was confirmed via review of termination letters dated 08/01/2014 that the facility had released HSTs "CC" and "DD" from employment on that date, as indicated in step #2 of the facility's credible allegation of jeopardy removal, due to substantiate findings of neglect related to Resident #1's second degree burn. - On 08/06/2014, the facility's revised ADL Protocol was again reviewed and it was confirmed that the facility had revised the Protocol on 08/05/2014, as indicated in step #3 of the credible allegation of jeopardy removal, to specify that hair dryers only be used in resident rooms with the resident fully clothed, and that hair dryers always be shut off when laid down. - On 08/06/2014, it was confirmed via interview with the Administrator and Service Director, policy review, and document review that the facility had initiated, per step #4 of the credible allegation of jeopardy removal, the new procedure involving the use of the Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents, to be documented on the Daily Bath Observation Form, and would note the multiple criteria. - On 08/06/2014, it was confirmed via Administrator and Service Director interview, and by policy review and document review, that the facility had initiated the new protocol, as indicated in step #5 of the the credible allegation of jeopardy removal, specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager would provide management staff oversight of this process by reviewing the Daily Bath Observation Forms, and on Saturday and Sunday, management oversight would be conducted by the Designated Charge Nurse. - On 08/07/2014, it was confirmed via Administrator and Service Director interview and review of facility inservice records that the facility had provided in-service training to the licensed nursing staff and HST staff regarding the newly revised/implemented ADL Protocols and Daily Bath Observation Form, as indicated in step #6 of the facility's credible allegation of jeopardy removal. - On 08/07/2014, it was confirmed via Administrator interview and policy review that the findings of management staff audits of shift-by-shift monitoring of HST staff while providing resident baths/shampoos would be reviewed at each quarterly QA Committee meeting, and that the QA Committee would monitor staff compliance with the Protocols and procedures regarding resident ADL care, to ensure resident safety, as indicated in step #7 of the credible allegation of jeopardy removal. - On 08/07/2014, it was verified via Service Director interview that the QA Committee met on 08/06/2014 and reviewed the newly revised/implemented Protocols and Daily Bath Observation Form, as indicated in step #8 of the credible allegation of jeopardy removal. Additionally, survey staff was present in the facility on 08/06/2014 at the time of QA Committee meeting. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure of facility staff to use safe technique while utilizing the blow dryer during the provision of ADL care was removed on August 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed at the time of survey completion to ensure ongoing application and completion, based on the following: On 08/05/2014, the facility revised the ADL Protocol related to the use of hair dryers to include multiple metrics to instruct staff regarding the safe use of hair dryers during the provision of resident care, and initiated a Bath Observation Guide Protocol which outlined a process of supervisory nursing staff to provide shift-by-shift monitoring of HST staff during resident showering and shampooing procedures. This monitoring was to be documented on the Daily Bath Observation Form. In addition, the Daily Bath Observation Form would be audited daily by facility management staff to ensure oversight of this process. By 08/06/2014, the facility had provided in-service training regarding the new Protocols and the new Daily Bath Observation Form, with eight (8) of the facility's eleven (11) licensed nursing staff, and thirty-nine (39) HST staff having received this training as of that date. However, three (3) licensed nursing staff and thirteen (13) HST staff were currently unavailable for training due to being off work-status or being on leave. These three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff who had not received training as of the 08/07/2014 exit date of this survey will need to receive this in-service training upon their return to work, and their completion of this required training will need assessment on a future date. In addition, on 08/06/2014, the facility initiated a procedure by which the results of the supervisory staff monitoring, per shift, of HST staff during resident baths/shampoos, and of management staffs' oversight of this shift-by-shift monitoring via daily audits, would be presented to the facility's QA Committee at the Committee's quarterly meetings to allow for the Committee's ongoing oversight of staff conformance with facility Protocols and procedures regarding resident baths/showers. However, the next scheduled QA Committee meeting was not scheduled to occur until 09/09/2014, and thus the QA Committee's process of oversight regarding these new facility Policies, procedures, and monitoring processes will need evaluation on a future date. Therefore, to allow for the assessment of the facility's completion of pending licensed nursing staff/HST staff in-service training and the QA Committee's ongoing oversight of the newly enacted Protocol and procedures as outlined above, the noncompliance continues at a decreased scope/severity of "D".

Based on observation, record review, and staff interview, the facility failed to ensure Quality Assurance (QA) Committee's participation in, and oversight of, the development of a corrective action plan developed by the facility in response to a incident involving one (1) resident (#1), related to a second degree burn sustained during Activities of Daily Living (ADL) Care. The total survey sample was seven (7) residents. Resident #1 sustained a left flank second degree burn resulting from direct-care staff's unsafe use of a hair dryer after the resident received a bath. Resident #1 sustained a second degree burn to the left flank measuring twelve (12) inches by six (6) inches, which had peeling skin and bullous blistering, and caused the resident to groan in pain and exhibit facial grimacing. Resident #1's left flank second degree burn wound later developed slough, the resident was transferred to the Burn Center for treatment, and received antibiotic drug therapy for infection of the wound. This resulted in a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during the provision of Activities of Daily Living care to Resident #1 resulted in the resident sustaining a second degree burn, and the resident's subsequent referral to the Burn Center and receipt of antibiotic drug therapy for treatment of [REDACTED].#1's second degree left flank burn caused by direct care staff's unsafe use of an electric hair dryer. The Administrator stated that revisions had been made to the ADL Policy instructing direct-care staff on the use of hair dryers, and that the facility had provided staff in-service training regarding these policy revisions. However, the Administrator acknowledged that the QA Committee had not been involved in the formulation of this corrective action plan, nor had the Committee provided oversight of the implementation of this corrective action plan. An allegation of jeopardy removal was received on August 06, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on August 07, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued staff in-service training related to the newly-implemented ADL Care/Body Checks Protocol which included procedures to ensure the safe use of hair dryers when providing resident care. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's Protocol and procedures related to the provision of Activities of Daily Living Care to residents, including the safe use of resident hair dryers. Resident records were reviewed to ensure that resident assessments and Plans of Care accurately reflected the Activities of Daily Living Care provided to residents. Findings include: During an interview with the Service Director conducted on 08/05/2014 at 3:00 p.m., the Service Director was questioned about the 07/09/2014 incident during which Resident #1 sustained a left flank second degree burn, twelve (12) by six (6) inches in size, with peeling skin and bullous blistering, which caused the resident to groan and show facial grimacing, and resulted in the resident's treatment with antibiotic drug therapy for wound infection. The Service Director was questioned about the QA Committee's knowledge of the 07/09/2014 incident during which Resident #1 had received the second degree burn, and of any actions initiated by the QA Committee in response to this incident. The Service Director stated that as of the 08/05/2014 date of this interview, the QA Committee had not been informed of the 07/09/2014 incident involving Resident #1 sustaining a burn. During a subsequent interview with the Administrator and Service Director conducted on 08/06/2014 at 11:15 a.m., the Administrator and Service Director were again questioned regarding the 07/09/2014 incident during which Resident #1 received the second degree left flank burn as direct care staff utilized an electric hair dryer in an unsafe manner, and of the QA Committee's involvement in the corrective action plan the facility had developed in response to this incident. The Administrator stated that when Resident #1 sustained the left flank burn on 07/09/2014, she immediately conducted a review, on 07/09/2014, of the facility's ADL Policy and added procedures which instructed direct-care staff on the use of hair dryers. The Administrator further stated that upon this 07/09/2014 revision of the ADL Policy, the facility immediately implemented in-service training for health service technician (HST) staff to instruct them on the new ADL Policy protocols for hair dryer use with residents. The Administrator acknowledged, however, that even though the ADL Policy was modified on 07/09/2014, and again on 08/06/2014, related to hair dryer use in response to the 07/09/2014 incident during which Resident #1 sustained the second degree left flank burn due to HST staffs' unsafe use of a hair dryer, the QA Committee had not been involved in the formulation of this corrective action plan. The Administrator further acknowledged that the QA Committee had not reviewed the corrective action plan which involved the 07/09/2014 and 08/06/2014 modifications to the ADL Policy, and also HST staff training regarding these Policy modifications, as of the 08/06/2014 date of this interview. The Administrator also acknowledged that the QA Committee had provided no oversight during the development and implementation of this corrective action plan. Based on the above, Resident #1 sustained a left flank second degree burn, twelve (12) by six (6) inches in size, with peeling skin and bullous blistering, causing the resident to groan, show facial grimacing, and undergo antibiotic drug therapy for wound infection. Facility administration then developed a corrective action plan involving 07/09/2014 and 08/05/2014 reviews of the ADL Policy, modifications to this Policy regarding direct-care staffs' hair dryer use during resident care, and in-service training to instruct direct-care staff on the new procedures governing hair dryer use during resident care. The facility, however, failed to ensure the QA Committee's involvement in the formulation of the corrective action plan, including policy revision and staff training, which was developed in response to the identified quality deficiency related to Resident #1's second degree left flank burn. The facility also failed to ensure the QA Committee's involvement in monitoring the effect of the policy changes, and the monitoring of staffs' conformance with these new policies, to therefore ensure that the Committee identified the potential need for revision of this corrective action plan, or the need for additional staff training. The immediate jeopardy was determined to have been removed on 08/07/2014, at which time the facility had developed and implemented a credible allegation of jeopardy removal which included the following interventions: 1. On 07/09/2014, upon learing of the incident involving Resident #1 when the resident sustained [REDACTED]. The Protocol included the requirements that staff place residents in the upright position in the wheelchair and towel dry residents' hair prior to using hair dryers. This Protocol also specified that hair dryers were not to be used longer than 2 minutes at a time, and that the hair dryer must be shut off for 1 minute before resuming the process of drying a resident's hair. 2. On 08/01/2014, the HSTs who were providing care to Resident #1 at the time the resident sustained [REDACTED]. 3. On 08/05/2014, the facility again revised the ADL Protocol to include the stipulation that hair dryers could only be used in resident rooms with the resident fully clothed, and that hair dryers will always be shut off when laid down and not in use for any reason. The previously developed ADL Protocol requirements (towel drying resident hair prior to using hair dryers; ensuring hair dryers were set at the lowest setting; limiting hair dryer use to no longer than 2 minutes at a time; leaving the hair dryer shut off for 1 minute before resuming drying resident hair) remained in use. 4. On 08/06/2014, the facility initiated a Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents. This per-shift HST staff monitoring will be documented on the Daily Bath Observation Form, and would note the following: hair dryers were used on the lowest setting; hair was not dried while on the bath trolley; excess moisture was removed from the hair with a towel prior to the use of the dryer; residents were completely dressed and in the upright position (when feasible) prior to drying hair with a dryer; hair dryers were not used for more than 2 minutes at a time and then turned off, and drying with the hair dryer was not resumed until at least 1 minute had elapsed; the hair dryer was not directed at one spot for more than five seconds and the dryer was in constant motion; the hair dryer was off when not in use. This Daily Bath Observation Form would be maintained in a binder at each nurse's station. 5. On 08/06/2014, the facility initiated a procedure specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager will provide management staff oversight of the Charge Nurse/Unit Nurse per-shift observations of HST staff while providing ADL care to residents by reviewing the Daily Bath Observation Forms for each unit to ensure Charge Nurse/Unit Nurse compliance with this shift-by-shift monitoring of resident baths/shampoos. On Saturday and Sunday, this management oversight function will be conducted by daily reviews of the Daily Bath Observation Forms by the Designated Charge Nurse. Problems/deficiencies identified by management staffs' daily oversight audits of the Daily Bath Observation Forms will be documented on this Form, in the Comments/Deficiencies section. 6. On 08/06/2014, the facility continued the process of staff in-service training, originally initiated on 07/09/2014, regarding the facility's new Protocols and procedures, including the revised ADL Protocol, the new Bath Observation Guide Protocol, and the new Daily Bath Observation Form. As of 08/06/2014, eight (8) of the facility's eleven (11) licensed nursing staff had received this in-service training. Two (2) of the three (3) remaining licensed nursing staff members were on Family and Medical Leave Act (FMLA) leave, and the one (1) remaining licensed nursing staff member was on annual leave. In addition, thirty-nine (39) of the facility's fifty-two (52) HST staff had received this in-service training as of 08/06/2014, with thirteen (13) HST staff being unavailable for training at that time due to off work-status or being on FMLA or annual leave. The three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff, who were unavailable for training as of 08/06/2014, will receive this in-service training regarding the new Protocols and Observation Form upon their reporting for work, before being allowed to provide direct resident care. Going forward, newly hired nursing staff will receive this in-service training related to the new Protocols and Observation Form during the period of orientation, prior to providing direct care to residents. Additionally, all nursing staff will receive updated training annually during the Annual Skilled Competency Fair, with the next Fair scheduled to occur in September 2014. 7. On 08/06/2014, the facility initiated a procedure by which the results of the Charge Nurse/Unit Nurse monitoring each shift of HST staff during the provision of resident baths/shampoos, and the results of management staffs' oversight of this shift-by-shift monitoring via daily audits of the Daily Bath Observation Forms, would be presented by the Service Director to the facility's QA Committee at the Committee's quarterly meetings. This was to allow for the QA Committee's evaluation and ongoing oversight of direct care staffs' conformance with the facility's Protocols and procedures regarding resident baths/showers, including hair dryer use, to thus allow the Committee to assess the need for policy revision or additional staff training. 8. On 08/06/2014, the facility conducted a called Quality Assurance (QA) Committee meeting to review the revised ADL Protocol, Bath Observation Guide Protocol, and Daily Bath Observation Form. The QA Committee approved the Protocols and the Observation Form. During this complaint survey, on the following referenced dates, each newly developed policy, procedure, and system included the facility's credible allegation of jeopardy removal was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On 08/06/2014, the facility's revised ADL Protocol was reviewed and it was confirmed that the facility had revised this Protocol on 07/09/2014, as indicated in step #1 of the facility's credible allegation of jeopardy removal referenced above. The Protocol was revised to add guidance governing the use of hair dryers, requiring that staff position residents in the upright position in the wheelchair and towel-dry residents' hair prior to hair dryer use, and limiting hair dryer use to period of no longer than 2 minutes at a time. - On 08/06/2014, it was confirmed via review of termination letters dated 08/01/2014 that the facility had released HSTs "CC" and "DD" from employment on that date, as indicated in step #2 of the facility's credible allegation of jeopardy removal, due to substantiate findings of neglect related to Resident #1's second degree burn. - On 08/06/2014, the facility's revised ADL Protocol was again reviewed and it was confirmed that the facility had revised the Protocol on 08/05/2014, as indicated in step #3 of the credible allegation of jeopardy removal, to specify that hair dryers only be used in resident rooms with the resident fully clothed, and that hair dryers always be shut off when laid down. - On 08/06/2014, it was confirmed via interview with the Administrator and Service Director, policy review, and document review that the facility had initiated, per step #4 of the credible allegation of jeopardy removal, the new procedure involving the use of the Bath Observation Guide Protocol by which the Designated Charge Nurse/Designated Unit Nurse would conduct one (1) observation on each shift of HST staff while providing baths and shampoos to residents, to be documented on the Daily Bath Observation Form, and would note the multiple criteria. - On 08/06/2014, it was confirmed via Administrator and Service Director interview, and by policy review and document review, that the facility had initiated the new protocol, as indicated in step #5 of the the credible allegation of jeopardy removal, specifying that on a daily basis, Monday through Friday, the Administrator/Service Director/Designated Nurse Manager would provide management staff oversight of this process by reviewing the Daily Bath Observation Forms, and on Saturday and Sunday, management oversight would be conducted by the Designated Charge Nurse. - On 08/07/2014, it was confirmed via Administrator and Service Director interview and review of facility inservice records that the facility had provided in-service training to the licensed nursing staff and HST staff regarding the newly revised/implemented ADL Protocols and Daily Bath Observation Form, as indicated in step #6 of the facility's credible allegation of jeopardy removal. - On 08/07/2014, it was confirmed via Administrator interview and policy review that the findings of management staff audits of shift-by-shift monitoring of HST staff while providing resident baths/shampoos would be reviewed at each quarterly QA Committee meeting, and that the QA Committee would monitor staff compliance with the Protocols and procedures regarding resident ADL care, to ensure resident safety, as indicated in step #7 of the credible allegation of jeopardy removal. - On 08/07/2014, it was verified via Service Director interview that the QA Committee met on 08/06/2014 and reviewed the newly revised/implemented Protocols and Daily Bath Observation Form, as indicated in step #8 of the credible allegation of jeopardy removal. Additionally, survey staff was present in the facility on 08/06/2014 at the time of QA Committee meeting. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the failure of facility staff to use safe technique while utilizing the blow dryer during the provision of ADL care was removed on August 7, 2014. However, the effectiveness of the corrective action plans could not be fully assessed at the time of survey completion to ensure ongoing application and completion, based on the following: On 08/05/2014, the facility revised the ADL Protocol related to the use of hair dryers to include multiple metrics to instruct staff regarding the safe use of hair dryers during the provision of resident care, and initiated a Bath Observation Guide Protocol which outlined a process of supervisory nursing staff to provide shift-by-shift monitoring of HST staff during resident showering and shampooing procedures. This monitoring was to be documented on the Daily Bath Observation Form. In addition, the Daily Bath Observation Form would be audited daily by facility management staff to ensure oversight of this process. By 08/06/2014, the facility had provided in-service training regarding the new Protocols and the new Daily Bath Observation Form, with eight (8) of the facility's eleven (11) licensed nursing staff, and thirty-nine (39) HST staff having received this training as of that date. However, three (3) licensed nursing staff, and thirteen (13) HST staff were currently unavailable for training due to being off work-status or being on leave. These three (3) remaining licensed nursing staff and thirteen (13) remaining HST staff who had not received training as of the 08/07/2014 exit date of this survey will need to receive this in-service training upon their return to work, and their completion of this required training will need assessment on a future date. In addition, on 08/06/2014, the facility initiated a procedure by which the results of the supervisory staff monitoring, per shift, of HST staff during resident baths/shampoos, and of management staffs' oversight of this shift-by-shift monitoring via daily audits, would be presented to the facility's QA Committee at the Committee's quarterly meetings to allow for the Committee's ongoing oversight of staff conformance with facility Protocols and procedures regarding resident baths/showers. However, the next scheduled QA Committee meeting was not scheduled to occur until 09/09/2014, and thus the QA Committee's process of oversight regarding these new facility Policies, procedures, and monitoring processes will need evaluation on a future date. Therefore, to allow for the assessment of the facility's completion of pending licensed nursing staff/HST staff in-service training and the QA Committee's ongoing oversight of the newly enacted Protocol and procedures as outlined above, the noncompliance continues at a decreased scope/severity of "D".

Based on observation, staff interviews, and policy review, the facility failed to ensure that expired medications were discarded appropriately after twenty-eight (28) days on two (2) of two (2) facility medication carts. Findings Include: 1. Observation on 12/12/12 at 2:10 p.m. of the Suite Three (3) Medication Cart revealed six (6) eye drop medications on the medication cart that had not been appropriately discarded after being opened for more than 28 (twenty-eight) days. The medication included the following: - Artificial Tears one-half (1/2) fluid ounce bottle was opened and dated 4/06/12. - Erythromycin Ophthalmic ointment 0.5% one-eighth (1/8) ounce tube was opened and dated 10/09/12. - Dexamethasone/Tobramycin 0.05% - 0.3% sterile five (5) milliliter (ml) bottle was opened and dated 11/05/12. - Gentamicin Sulfate 0.3% three (3) milligrams (mg) per milliliter (ml) eye drops in The stop date was 10/22/12. There was no opening date written on the outside label or on the bottle of eye drops. - Erythromycin ophthalmic ointment 0.5% (one-eighth)1/8 ounce tube was opened 9/19/12 with a stop date of 9/26/12. - Neomycin and Polymyxin B Sulfates, Bacitracin Zinc, and Hydrocortisone ophthalmic ointment one-eighth (1/8) per ounce tube was opened 11/07/12.daily. Interview on 12/12/12 at 2:15 p.m. with Licensed Practical Nurse (LPN) "BB" confirmed the opening dates of the six (6) medications and verified the medications should have been discarded after twenty-eight (28) days. Interview on 12/12/12 at 2:22 p.m. with Registered Nurse (RN) "AA" revealed the medications open beyond twenty-eight (days) should have been discarded. Review of the facility's medication storage policy dated June, 2012 revealed all multi-dose vials will expire (twenty-eight) days once the vial is opened. All eye drops expire twenty-eight (28) days once it is opened. 2. Observation on 12/12/12 at 1:30 p.m. of the medication cart for Suite 2 revealed two (2) eye drop medications on the medication cart that had not been appropriately discarded after being opened for more than 28 (twenty-eight) days The medication were as follows: - Timolol Maleate ophthalmic solution opened 10/19/12. -Dorzolamide HCL-Timolol Maleate ophthalmic solution opened 10/10/12. 3. Observation on 12/12/12 at 1:50 p.m. of the medication storage refrigerator, on Suite 2 revealed two (2) Promethazine HCL (hydrochloride) suppositories that expired 5/11/12, 4 (four) that expired 4/11/12 and one Acetaminophen three hundred and twenty five (325) milligrams (mgs) suppository expired 7/11/10. Interview on 12/12/12 at 2:00 p.m. with LPN "CC" confirmed that the expired medications stored in the medication cart and refrigerator should have been discarded .

Based on observation, staff interview, and facility policy review, the facility failed to properly flush gastrostomy and jejunostomy tubes during medication administration for three (3) residents (#18, #8, #11) from a sample of seventeen (17) residents. Findings include: 1. Observation on 12/12/12 from 8:02 a.m. until 8:27 a.m. of medication administration to Resident #18 revealed Licensed Practical Nurse (LPN) "BB" administering six (6) medications via the resident's gastrostomy-tube ([DEVICE]). The LPN did not flush the [DEVICE] after the final medication was given. Observation on 12/12/12 at 12:18 p.m. revealed that the LPN administered a medication via the [DEVICE] without flushing the [DEVICE] before or after the medication was administered. 2. Observation on 12/12/12 from 8:30 a.m. until 8:50 a.m of medication administration for Resident #8 revealed LPN "BB" administer nine (9) medications via the resident's jejunostomy tube. The LPN did not flush the jejunostomy tube (j-tube) prior to administering the medications and did not flush the j-tube after the final medication was given. Continued observation revealed that the LPN checked the j-tube for residual prior to medication administration 3. Observation on 12/12/12 from 9:05 a.m. until 9:55 a.m. of medication administration for Resident #11 revealed LPN administer eleven (11) medications via the resident's [DEVICE]. The LPN did not flush the [DEVICE] after the final medication was given. Review of the facility protocol for Medical Administration via Enteral Tube Feeding revealed instructions to flush the feeding tube with thirty (30) cubic centimeters (cc) of water prior to administering medication and flush the tube with thirty (30) cc of water after administering medication. Review of the policy revealed jejunostomy tubes are checked for patency only (DO NOT check residual in Jejunostomy tube) and flushed with five (5) to thirty (30) cc of water prior to administering medication, unless otherwise ordered by the physician. Interview on 12/13/12 at 2:26 p.m. with LPN "BB" confirmed she did not flush the gastrostomy or jejunostomy tubes before administering medications via the tubes. Interview on 12/12/12 at 2:37 PM with LPN "CC" revealed the procedure for administering medications via gastrostomy and jejunostomy tubes includes flushing the tubes with thirty (30) cubic centimeters (cc) of water before and after administering the medications. Interview on 12/13/12 at 8:58 am with Registered Nurse (RN) "AA" confirmed that Resident #8 has a jejunostomy tube which is not checked for residual prior to medication administration. Interview on 12/13/12 at 9:09 am with Registered Nurse (RN), Director of Nursing (DON) revealed medication administration via gastrostomy and jejunostomy tubes included: Flush the tubes with thirty (30) cubic centimeters of water prior to the medication administration; flush with five (5) or more cc of water between each medication, and flush with thirty (30) cc of water at the end of the medication administration. Jejunostomy tubes should not be checked for residual .